Substrate Eligibility Agent

From front end denial to resolution

How does it work?

The Eligibility agent combines patient eligibility (270/271) with real time claim status (276/277), payer portals, payor policies and EOBs to determine exactly what steps to take to fix a claim. Then it fixes the claim and rebills it for you.

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Claim Ingestion

We start with your full AR Queue or worklist. This can be via an SFTP feed, report your team generates, spreadsheet, or your data warehouse.

Claim Status Check

The Substrate Claim Status Agent kicks off the claim research just like a biller would. It checks for the latest status of all claims, across your clearinghouse, the 276/277 RTCS, each payor portal, or EOB. This step determines which claims have been denied and why.

Payer Resolution

Next, we perform Payer Resolution: doing a coverage discovery check on all patient insurances to ensure we have correct payers for eligibility and claim submission.

Benefit Verification

The Substrate Eligibiltiy Agent verifies patient benefits, checks for coordination of benefits, prior auth and referral requirements, demographic mismatches and more.

Bringing it all together

The Substrate Eligibility Agent combines results from all sources: the Claim Status, Payer Resolution, and Eligibility Check into a discrete list of actions required to fix the claim and get paid. This action set can be customized per your SOPs.

Action Completion & Write-back

The specific actions are then executed on, including
1. Rebilling the claim
2. Submitting a corrected claim
3. Submitting a claim to a different payer
4. Writing back to your PM system

The only Eligibility Agent built to fight denials

Payer Resolution using real-time eligibility data to determine the correct payer, plan and submission path prior to claim status.

Primary & secondary payer identification

Active coverage confirmation

Plan-level benefit details

Fill coordination of benefits by pulling eligibility across multiple payers to resolve COB gaps & ensure claims are billed to the right plan in the right order.

Multi-payer eligibility checks

COB order determination

COB updates to your PM

Resolve eligibility denials by combining denial reasons and benefits verification. Fixes common eligibility issues like

Demographic errors

Missing referrals or prior auth

Incorrect payer, TPAs, IPAs or Carve Out Plans

FAQ

What does the Eligibility Agent do?

It autonomously verifies patient eligibility for claim routing, coordination of benefits and resolving eligibility-based denials.

How does it check eligibility?

Through a combination of EDI transactions, direct payer APIs and browser-based portal agents — the same infrastructure that powers our claim status agent.

Does it handle coordination of benefits?

Yes. It checks eligibility across multiple payers, determines COB order and updates your PM with the correct billing sequence.

Can it resolve eligibility denials?

Yes. When a claim is denied for eligibility, the agent retrieves current eligibility documentation and feeds it into the Appeals Agent for resubmission.

How fast does it run?

Eligibility checks run in real time as claims enter the system. Most results are returned within seconds.

Does it integrate with my PM?

Yes. Results are pushed directly into your practice management system. No exports, no manual data entry.

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Enterprise-grade AI that actually works and gets smarter at scale

Full Audit Trail

Complete visibility into every agent action with screenshots and video recordings. Know exactly what happened, when, and why.

Human-in-the-Loop

When our agent is uncertain, it escalates to your team for verification. These cases get logged and learned from, so they rarely happen twice.

Predictive Insights

Track payer trends, denial patterns, and agent performance across your entire revenue cycle. Surface the signals that matter across your entire AR.

Security first, from the ground-up

End-to-end encryption protects sensitive data in transit and at rest, ensuring complete confidentiality.

Zero-trust architecture verifies every request, reducing attack surfaces and preventing unauthorized access.

Regular security audits and compliance checks keep our infrastructure resilient against evolving threats.

Granular access controls allow precise permission management, securing data at every level of the system.

Trust & Security →

HIPAA

SOC2

The Substrate Eligibility Agent tells you exactly how to fix denials caused by frontend errors

Put your revenue cycle on Autopilot