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Healthcare AI agent · Eligibility & benefits

Eligibility, Benefits-Verification & Insurance-Discovery AI Agent

Run the coverage check, read the response into the fields registration needs, propose the payer sequence, search self-pay patients for undisclosed coverage, and flag what will deny — a registrar accepts each result.

Typical delivery
4–6 weeks
Deployment
Your stack
Registrar accepts
Pre-service
After launch
Agent Care

What this agent does

Reads the response, not the payment

In

  1. 01

    A check runs at scheduling and registration, and the agent submits the 270 and reads back what the payer returns.

  2. 02

    Normalise payer names, plan identifiers and response fields across clearinghouse and payer sources.

Reason

  1. 03

    Read the 271 response into the fields registration needs — plan status, network and the prior-authorisation flag.

  2. 04

    Apply the payer, plan and state Medicaid rules configured for the site, never inferred from one response.

  3. 05

    Bind each field to the payer response it came from, and mark what the payer left unanswered.

Decide

  1. 06

    A payer answers with more than one active plan; propose the coordination-of-benefits sequence and flag it.

  2. 07

    Route every response, sequence and discovery result to the registrar for acceptance.

Out

  1. 08

    Retain the payer response, the proposed sequence, the registrar's corrections and what went unanswered.

  2. 09

    Execute write actions only inside the approval boundaries agreed during implementation.

Product statement

The agent reads and proposes; the registrar accepts each result, and prior authorisation stays a separate agent's determination, never this one's.

Example workflow

One check, scheduling to registrar

  1. 1Check triggeredScheduling entry, registration intake, self-pay flag or a manual re-check request
  2. 2Response gathered270 submitted, 271 returned, MSP questionnaire answers, plan history and discovery results
  3. 3Response readPlan status, network, proposed sequence, prior-authorisation flag and confidence
  4. 4Controls appliedResponse-completeness checks, sequencing checks, discovery-scope checks and confidence threshold

No human action required

Stages 1 to 4 run unaided, and nothing posts to billing at any of them — the agent is checking, and the registrar's lane opens at the confidence gate.

5DecisionBranches at the confidence threshold
High confidence

Goes to the registrar to accept.

Low confidence

Adds a patient-access supervisor read first.

Registrar acceptance

The check is held with its response, its proposed sequence and the confidence.

Accept · Edit · Send for supervisor review

Accepted — ready to bill

  1. 6Registration and billing systems updatedOnly where write access and approval policy allow it
  2. 7Outcome evaluatedResponse accuracy, registrar edits, downstream denials and sequencing outcomes

Edits

Every registrar edit is counted in the evaluation.

What should not run autonomously

Human approval stays in control

Outside the boundary — human approval required

8 items

  • Determining whether a service requires prior authorisation.
    • Confirming a payer sequence and posting it to billing.
    • Billing or posting a claim to any payer.
    • Changing what care is offered based on a discovery search.

  • Automation boundary

    Agent acts unaided

    • ✓Run the coverage check and read the payer's response.
    • ✓Apply the payer, plan and state Medicaid rules configured for the site.
    • ✓Search configured sources for unbilled coverage under a minimum-necessary, logged scope.
    • ✓Propose the payer sequence, flag what will deny,.

    Any write happens inside the boundaries agreed at implementation, never ahead of acceptance.

    • Approving financial assistance or a presumptive-eligibility determination.
    • Assuming a state's Medicaid retroactive-coverage window applies.
    • Widening an insurance-discovery search beyond its configured, logged scope.
  • Changes to payer, plan or discovery-scope configuration.

Example output

One eligibility check, annotated

Everything the agent reads is attached to the response it came from.

Eligibility output · single encounter

Illustrative example
Encounter
Dual-coverage office visit
Result line
271 returns two active plans; sequence proposed with the employer plan primary
Plan status
Active — dual coverage
Sequencing basis
MSP questionnaire on file
Confidence
87%
Attribution
Payer ID and NPI included

As received

Taken from the 271 response and the MSP questionnaire on file — nothing on this side is decided by the agent.

Source facts used

  • 271 response from the payer
  • MSP questionnaire on file
  • Configured COB rule

Why this sequence

The order comes from the MSP questionnaire and the 271 response on file.

What the score decides

Below the configured threshold the check picks up a supervisor read before the registrar sees it.

Action

AcceptEditSend for supervisor review

Value

Where AI adds value

The same four claims, placed at the point in the workflow where each one applies.

Where the value lands

Value 01 – 04

Every coverage check

From the 270/271 exchange

03Verification

Check against payer and plan rules

Weigh the payer response against the plan, state Medicaid and coordination-of-benefits rules configured for the site.

01Approved path

Eligible is not the same as covered

The response that cleared a check travels with it — the record is the deliverable, not just the status.

02Human review

Point the registrar at what needs

Multiple active plans and low-confidence responses are marked, so the registrar's read starts where the sequence is least certain.

04

Build an evidence trail

The response, the payer it came from and the registrar who accepted it stay on the encounter.

Integrations

Typical integrations

Five system groups connect to the same agent. Which of them are in scope is decided in discovery.

  • Registration and scheduling

    • Epic Prelude
    • Cerner
    • MEDITECH
    • patient access systems

  • Clearinghouse connectivity

    • Availity
    • Change Healthcare
    • Payer 270/271 gateways

  • Coverage discovery

    • Coverage-discovery vendors
    • MSP and coordination-of-benefits sources

Agent

Eligibility, benefits & insurance discovery

  • Reads the response
  • Proposes the sequence
  • Holds for acceptance

  • Billing systems

    • Patient billing and collections systems
    • Prior-authorisation agent

  • Observability & evaluation

    • OpenTelemetry
    • Langfuse
    • Supported monitoring/evaluation sources

Integration availability depends on the client's existing systems and API access.

Agent controls

Six layers between the model and the encounter

Controls nest inward. What the stack misses is set out in the map beneath it.

L6 · Outermost — last line of defence

Inward → L1 · closest to the model

L6Rollback / safe modeHold the encounter at unverified only when evaluation or production signals degrade.Roll back
L5Version monitoringTrack model, prompt, payer-rule and plan-configuration changes.Track
L4TraceabilityRecord the payer response, the proposed sequence, the flags and the registrar's acceptance.Record
L3Registrar acceptanceHold checks for the named registrar; it governs release, not whether the response is right.Gate
L2Policy guardrailsTest checks against payer, plan and state Medicaid rules; a failure returns the item.Restrict
L1Confidence thresholdsRoute low-confidence checks to a supervisor read before the registrar sees them.Require review
Model coreCheck produced — response, proposed sequence, flags and confidence
L1 – L2
Test whether a check may stand
L3
Puts the acceptance in a registrar's hands
L4 – L5
Keep the response and the payer behind it
L6
Holds the encounter at unverified when signals degrade

How Nestack evaluates it

Evaluate the verification workflow — not only the final response.

Coverage runs the whole depth of the workflow, and every layer is cut by slice.

Surface — the status the registrar sees

  1. E1Final-output evaluationDid the proposed sequence match the MSP questionnaire and the response on file?
  2. E2Step-level evaluationDid the agent use the right payer, plan and state Medicaid configuration?
  3. E3Tool evaluationDid it read and write the correct encounter, payer and plan field?
  4. E4Confidence calibrationDo low-confidence responses actually draw more registrar edits?
  5. E5Slice evaluationHow does performance change across specific payer mixes?
  6. E6Business outcomeHow many checks needed a registrar edit or a downstream denial?

Floor — the outcome the health system answers for

Failure modes

Where each failure originates in the agent

Seven failure modes, placed at the stage each one starts.

Agent lifecycle

Direction of processing →

  1. 01 · Retrieval

    1 mode

    • EB-03

      Stale coverage signal

      A discovery vendor's match is used without a fresh 271 to confirm it's still active.

    Stage gathers

    270 request, payer response and plan data

  2. 02 · Reasoning

    2 modes

    • EB-04

      Authorisation read as cleared

      A prior-authorisation flag on the response is treated as the authorisation itself.

    • EB-06

      Sequence assumed, not confirmed

      A coordination-of-benefits order reaches billing before a registrar confirms it.

    Stage proposes

    Response, the proposed sequence and confidence

  3. 03 · Tool / write

    2 modes

    • EB-02

      Coverage read as payment

      An active-coverage response is surfaced as though it guarantees the service is paid.

    • EB-05

      Discovery scope exceeded

      A self-pay search pulls more identifiers than the payment purpose requires.

    Stage writes

    Only where write access and approval policy allow it

  4. 04 · Output

    1 mode

    • EB-01

      Plan type not distinguished

      Medicare Advantage is recorded as traditional Medicare, so referral and authorisation rules follow the wrong plan.

    Stage returns

    The status the registrar accepts and billing relies on

  5. 05 · Change / Version

    1 mode

    • EB-07

      Silent rule drift

      A payer or state Medicaid rule changes and configuration doesn't follow, so a response assumes coverage the update removed.

    Stage tracks

    Model, prompt, payer rules and plan configuration

  • Sev-1 · posts outside the boundary
  • Sev-2 · a wrong status reaches billing
  • Sev-3 · response degrades, goes to review
See the complete Healthcare failure-mode catalogue

Affected slices

One verification rate can hide the risk underneath it

A single verification rate can look acceptable while one payer mix carries most of the downstream denials. Nestack reports the rate by slice, not only in total Nestack reports it by slice rather than in aggregate..

Slice performance — reported separately, not only in aggregate

Illustrative example
SliceFailure rateLiftLift vs. thresholdStatus
Patients presenting as self-pay7.3%3.8×Review
Members with more than one active plan5.6%2.9×Review
Medicare Advantage read as traditional Medicare3.5%1.8×Watch
Single commercial plan, active coverage1.9%0.7×Normal

Bar: downstream-denial rate lift vs. the single-plan baseline · scale 0–4.0× · tick at 2.0×

2 of 4 slices over threshold

Evidence-linked improvement

The loop closes on the sequence, not the status

A cycle closes when the wrong payer is a case the next release has to catch. That suite is what the next check run is measured against.

Improvement cycle · five stages

Switchback — the path turns at Improve and returns at Learn

  1. 01

    Detect

    Downstream-denial rate rises in a payer-mix slice.

  2. 02

    Diagnose

    The 271 that said active and meant nothing is traced to the payer rule, the sequence, or the workflow that missed it.

  3. 03

    Improve

    The correction is versioned, with the encounters that motivated it attached.

  4. 04

    Verify

    A failing verification case holds the release until it passes.

  5. 05

    Learn

    The case is added permanently, and the payer rules move with it.

  6. Learn → Detect

    The return edge. The next check runs against a suite one case longer.

Typical build scope

Twelve workstreams across six weeks

The build scope read against the delivery timeline. Week structure follows the six-week plan — discovery, sources, verification workflow, evaluation, integration, then production validation and handover.

Workstream

Week 1Week 2Week 3Week 4Week 5Week 6

  1. 01Check workflow and boundary definition and it is logged..Week 1
  2. 02Clearinghouse and payer-source assessment.Week 1, Week 2
  3. 03Payer, plan and Medicaid rule mapping and rule mapping.Week 1, Week 2
  4. 04270/271 ingestion and normalisation.Week 2
  5. 05Response retrieval and sequencing logic.Week 2, Week 3
  6. 06Confidence scoring and flag routing.Week 3
  7. 07Registrar acceptance workflow.Week 3, Week 4
  8. 08Clearinghouse and registration integration.Week 5
  9. 09Response and sequencing cases.Week 4, Week 5
  10. 10Guardrails and verification controls.Week 4
  11. 11Encounter-trail instrumentation.Week 5, Week 6
  12. 12Deployment, documentation and Agent Care handover.Week 6

12 workstreams · 6 weeks · bar shows the weeks a workstream is active — several run in parallel

Final scope and sequence confirmed in discovery

Engagement tiers

What each tier includes

Rows are the capabilities named in each tier's scope. Higher tiers include everything below them.

Capability✓ in scope · — not at this tierPilotOne payer, one siteProductionProduction clearinghouse integrationAdvancedMultiple payers / sites
Introduced at Pilot
Verification recommendations✓✓✓
Registrar acceptance✓✓✓
Verification-accuracy baseline✓✓✓
Introduced at Production
Reporting by payer—✓✓
Acceptance workflow in your systems—✓✓
Approved encounter write-back—✓✓
Clearinghouse integration—✓✓
Introduced at Advanced
Multi-payer verification rules——✓
Multi-stage acceptance chains——✓
High verification volume——✓
Multi-payer verification controls——✓
Build priceFrom $5,000From $8,000Custom quote
Final build price
Confirmed after discovery based on integrations, workflow complexity, transaction volume, approval controls and deployment requirements.
Separate from build
Build pricing is separate from recurring Agent Care, which covers managed monitoring, evaluations, incidents and verified improvements after launch.

What we need from you

What you bring, and what we build with it

Each input maps to a piece of build scope and a week in the delivery timeline.

  1. 01Your payer mix, clearinghouse and registration system

    Clearinghouse ingestion and payer mapping

    Week 1

  2. 02Representative recent checks and encounters

    Verification baseline and sequencing-rule extraction

    Week 2

  3. 03Your payer, plan and state Medicaid rules

    Payer, plan and Medicaid-rule mapping

    Week 1

  4. 04Access to relevant APIs, feeds or exports

    Clearinghouse and registration assessment, then integration setup

    Week 2

  5. 05Coverage you would not want billed

    Sequencing cases and the evaluation suite

    Week 4

  6. 06What no response may be read as

    Confidence scoring, flag routing, guardrails and verification controls

    Week 3

  7. 07Named registrars to accept checks

    Registrar acceptance workflow, then pilot and production validation

    Weeks 5–6

Nothing else is required

Deployment, documentation and Agent Care handover are ours.

Delivery timeline

Four phases across six weeks

Weeks are drawn where the work sits, so the fifth carries both evaluation and the first live checks.

Phase

W1

W2

W3

W4

W5

W6

  1. DiscoveryW1
  2. BuildW2 – W3
  3. EvaluateW4 – W5
  4. Pilot & LaunchW5 – W6

Week focus

W1Verification-workflow discovery, rule mapping and boundary

W2Clearinghouse integration and the verification baseline

W3Sequencing logic, confidence scoring and acceptance controls

W4Evaluation suite, guardrails and failure-mode testing

W5Registration integration, pilot checks and corrections

W6One registration cycle verified under the access lead, then handover

Reading the band
A bar covers the weeks its work is named in, and nothing else. The week 5 overlap is real, not padding.
At the end of W6
Validation closes on live encounters, and Agent Care takes over monitoring.
Duration
Six-week plan shown · typical delivery 4–6 weeks depending on scope confirmed in discovery.

Next step · Healthcare AI agent

Build an eligibility and benefits agent around your payer mix.

Show us your payer mix, your registration workflow and who accepts a check. What does a 271 actually confirm? We'll map it against what registration needs, set the automation boundary, and name what stays with the registrar.

Typical delivery
4–6 weeks
Deployment
Your clearinghouse and payer mix
Registrar acceptance
Pre-service
After launch
Agent Care available

Nestack Agents · Eligibility, benefits & insurance discovery

AGT-HC-15 · Agent Care available after launch

Build an eligibility and benefits agent

Four questions so the call starts from your actual setup — then pick a time that suits you.

About you
Your checks

No obligation. We’ll map the workflow, name the automation boundary and tell you if an agent is the wrong answer.