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Healthcare AI agent · Member services

Member-Services Copilot (Payer Benefits)

Give a representative the benefit, claim and cost-share answer with the governing document cited beside it, and capture grievances and appeals to the clock — adverse determinations stay with qualified staff.

Typical delivery
4–6 weeks
Deployment
Your stack
Who speaks
Your rep
After launch
Agent Care

What this agent does

Drafts the answer the representative gives

In

  1. 01

    Take the member's question as the representative typed or heard it, beside the contact record already open.

  2. 02

    Resolve the enrolment to one plan year, benefit package, group and rider set before any document is opened.

Reason

  1. 03

    Retrieve the governing document for that enrolment — evidence of coverage or benefit booklet, riders and carve-outs.

  2. 04

    Read claim, accumulator and eligibility state so a cost-share figure carries the accrual it was calculated against.

  3. 05

    Check network status for the named provider on the date, product and location asked about, not the default row.

Decide

  1. 06

    Detect where an answer would function as a coverage decision and send the request to the determination path instead.

  2. 07

    Detect a grievance or an appeal in what the member said, and open intake against the deadline it starts.

Out

  1. 08

    Present the draft to the representative with the document, section and effective date cited beside every figure.

  2. 09

    Retain the question, the sources read, the draft, what the representative actually said and every correction.

Product statement

The agent retrieves, drafts and cites. The representative speaks, and any adverse determination is made and communicated by qualified staff on the determination path.

Example workflow

One member question, end to end

  1. 1Contact openedCall, secure message or portal chat, with the member record already on the representative's desktop
  2. 2Identity verifiedChecked on the plan's agreed fields before any benefit, claim or accumulator detail is read back
  3. 3Enrolment resolvedOne plan year, benefit package, group, rider set and effective date — ambiguity is shown, not guessed
  4. 4Answer drafted with sourcesThe governing document and section, the claim and accumulator read, and network status on the date asked

No human action required

Stages 1 to 4 run before the representative says anything — verification, resolution and retrieval finish while the member is still explaining. A request that is really a determination ends that stretch on the spot.

5DecisionSplits on whether the answer is information or a determination
Information, sources agree

Reaches the representative as a cited draft.

Determination, conflict or gap

Leaves for the queue that owns it, with what is missing.

Representative

Reads the draft and the section it cites, then speaks to the member — or hands the request to the staff qualified to decide it.

Speak · Correct · Route to determination

Answered — handed back

  1. 6Answer given, disposition writtenThe representative speaks; intake, routing and the date of receipt are written where policy allows
  2. 7Outcome evaluatedAnswer accuracy against the document, plan-variant correctness, routing fit, intake completeness and call-backs by cohort

Corrections

What the representative changed before speaking is counted in the evaluation.

What should not run autonomously

Human approval stays in control

Outside the boundary — human approval required

8 items

  • Telling a member a service is not covered.
    • Making or communicating an adverse determination.
    • Deciding an appeal, or who reviews it.
    • Issuing a binding network-status confirmation.

  • Automation boundary

    Agent acts unaided

    • ✓Retrieve the governing document for the resolved enrolment and cite the section.
    • ✓Read claim status, accumulators and eligibility, and show the accrual behind a figure.
    • ✓Draft the representative's answer, and mark where two sources disagree.
    • ✓Open grievance and appeal intake with the date of receipt and the deadline it starts.

    Write actions run only inside the approval boundaries agreed during implementation. Determination and denial notices are not among them.

    • Quoting benefits for an unresolved enrolment.
    • Closing a grievance, or deciding it is not one.
    • Advising a member clinically or on treatment choice.
  • Changing benefit rules, directory data or approved wording.

Example output

One member question, annotated

Everything the agent drafts is attached to the contact and the document it came from.

Answer draft · single member contact

Illustrative example
Member asked
What do I owe for an MRI?
Channel
Phone, interpreter on line
Identity
Verified, 3 fields
Drafted for
Representative — not sent
Confidence
88%
Coverage decision
Not made by the agent

As received

The member's question as the representative logged it, and the channel it arrived on — including that an interpreter was on the line.

Evidence used

  • Evidence of coverage, §5
  • Outpatient imaging rider
  • Deductible accrued to date

Why a figure and not a yes

The cost share is quoted against the deductible already accrued. It estimates what the member would owe.

What the score decides

Confidence decides how much the representative checks before speaking, not whether the member is covered.

Action

SpeakCorrectRoute to determination

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 member contact

Phone, secure message or portal chat

03Retrieval & citation

Apply the member's own plan documents

Use the evidence of coverage, riders, carve-outs and medical policy for the enrolment actually in force.

01Approved path

Take the document search off the call

The representative starts from a cited draft instead of searching three systems while the member waits.

02Human review

Send determinations down the right path

A request that needs a coverage decision reaches the staff qualified to make it, instead of being settled at the desk.

04

Build an evidence trail

Retain the question, the enrolment resolved, the document and section cited, the draft, what was said and the correction — on both paths.

Integrations

Typical integrations

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

  • Core claims & benefits

    • HealthEdge
    • Facets
    • QNXT
    • Benefit configuration
    • plan documents

  • CRM & contact centre

    • Salesforce Health Cloud
    • Pega
    • Genesys
    • Telephony and IVR

  • Provider directory

    • Directory of record
    • credentialing
    • Network status
    • fee schedules

Agent

Member-services copilot

  • Resolves enrolment
  • Cites the document
  • Routes determinations

  • Care & documents

    • Care management
    • referral queues
    • Document management
    • member portal

  • 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 member

Each control wraps the one inside it. An answer clears every layer before a representative reads it, and the coverage decision sits outside all six.

L6 · Outermost — last line of defence

Inward → L1 · closest to the model

L6Rollback / safe modeReturn the queue to unaided representatives if evaluations or production signals degrade.Roll back
L5TraceabilityRecord the question, sources read, the draft, what was said and the correction.Record
L4Identity and scopeVerify on the plan's agreed fields, and disclose only what the question needs.Verify
L3Determination gateAnything that would function as a coverage decision leaves this path.Gate
L2Citation requirementNo governing document and section behind a statement, no statement.Require source
L1Plan-variant lockBound to one plan year, benefit package and rider set, or not drafted.Bind
Model coreAnswer drafted — cited passage, cost-share figure, claim or network status and confidence
L1 – L2
Decide whether an answer may be drafted
L3
Decides what is information and what is not
L4 – L5
Keep disclosure minimal and the trail intact
L6
Pulls automation back when signals degrade

How Nestack evaluates it

Evaluate the whole contact — not only the answer the member hears.

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

Surface — the draft the representative reads

  1. E1Final-output evaluationWas the answer correct against the governing benefit document?
  2. E2Plan-variant evaluationWas it the right plan year, benefit package, rider and effective date?
  3. E3Citation evaluationDoes the cited section support the sentence it is attached to?
  4. E4Routing evaluationDid determinations, grievances and appeals leave on the right path?
  5. E5Slice evaluationHow does answer quality change across specific contact cohorts?
  6. E6Business outcomeDid the member call back, was intake complete, did handle time move?

Floor — the answer the member acts on

Failure modes

Where each failure originates in the agent

Seven failure modes plotted against the five stages of the agent lifecycle.

Agent lifecycle

Direction of processing →

  1. 01 · Identity / enrolment

    1 mode

    • MS-01

      Wrong plan variant

      Last year's document, or the plan named almost the same.

    Stage resolves

    The member, the plan year, the package and its riders

  2. 02 · Retrieval

    2 modes

    • MS-02

      Rider not applied

      The base document is right and incomplete.

    • MS-03

      Stale network status

      The directory says in network; the contract ended.

    Stage gathers

    The plan document, the claim and the accumulator

  3. 03 · Drafting

    2 modes

    • MS-04

      Cost share misquoted

      Quoted against a deductible that has since moved.

    • MS-05

      Answered as a denial

      A coverage decision is settled at the desk, no appeal rights.

    Stage drafts

    The answer, its citation and the confidence beside it

  4. 04 · Routing / intake

    1 mode

    • MS-06

      Grievance never logged

      It goes down as an enquiry and the clock never starts.

    Stage routes

    Determinations, grievances and appeals to their queue

  5. 05 · Change / Version

    1 mode

    • MS-07

      Silent benefit drift

      A mid-year benefit change moves answers unnoticed.

    Stage tracks

    Model, prompt, benefit-rule and directory changes

  • Sev-1 · determination made off the path
  • Sev-2 · wrong benefit detail reaches the member
  • Sev-3 · the answer thins, the member calls back
See the complete Healthcare failure-mode catalogue

Affected slices

Accuracy is not spread evenly across the queue

Aggregate answer accuracy can look acceptable while a few kinds of contact carry most of the corrections, most of the call-backs and most of the misrouted determinations. Nestack reports performance by slice, not only in total.

Slice performance — reported separately, not only in aggregate

Illustrative example
SliceFailure rateLiftLift vs. thresholdStatus
Interpreter-assisted calls5.1%3.2×Review
Similarly named plan variants4.2%2.6×Review
Riders and group carve-outs3.0%1.9×Watch
Routine benefit look-ups1.0%0.6×Normal

Bar: lift vs. routine look-up baseline · scale 0–4.0× · tick marks the 2.0× review threshold

2 of 4 slices over threshold

Evidence-linked improvement

Most fixes land in the source, not the prompt

When an answer is wrong the cause is usually upstream — a rider that never reached the document store, or two systems naming one plan differently.

Improvement cycle · five stages

Switchback — the path turns at Improve and returns at Learn

  1. 01

    Detect

    Answer accuracy, citation checks or call-backs move in one contact cohort.

  2. 02

    Diagnose

    Traced to enrolment resolution, the document store, the accumulator feed, the directory or the routing rule.

  3. 03

    Improve

    The source is corrected, or the rule re-approved by benefits and compliance, then version-linked.

  4. 04

    Verify

    Re-run against held-out contacts from the affected cohort, including the ones that failed.

  5. 05

    Learn

    The contact becomes a regression case and the correction enters the member-services runbook.

  6. Learn → Detect

    The return edge. A document or directory correction belongs to the team that owns it — the agent only stops repeating the error.

Typical build scope

Twelve workstreams across six weeks

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

Workstream

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

  1. 01Workflow discovery and automation-boundary definition.Week 1
  2. 02Core-system, CRM and telephony assessment.Week 1, Week 2
  3. 03Plan-variant and effective-date rules.Week 1, Week 2
  4. 04Identity verification and disclosure scope.Week 2
  5. 05Governing-document store and citation model.Week 2, Week 3
  6. 06Claim, accumulator and eligibility read.Week 3
  7. 07Provider-directory and network-status read.Week 3, Week 4
  8. 08Determination, grievance and appeal routing.Week 4
  9. 09Answer-accuracy and citation evaluation suite.Week 4, Week 5
  10. 10Language access and accessibility testing.Week 5
  11. 11Contact-centre desktop integration.Week 5, Week 6
  12. 12Observability, deployment 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 line of businessProductionProduction desktop integrationAdvancedMulti-product / multi-market
Introduced at Pilot
Cited answer drafting✓✓✓
Plan-variant and effective-date resolution✓✓✓
Identity verification and audit logging✓✓✓
Determination routing to qualified staff✓✓✓
Baseline evaluation✓✓✓
Introduced at Production
Claim, accumulator and eligibility read—✓✓
Provider-directory network answers—✓✓
Grievance and appeal intake to deadline—✓✓
Observability and evaluation—✓✓
Introduced at Advanced
Language access and accessibility coverage——✓
Multi-product and enterprise controls——✓
Build priceFrom $5,000From $8,000Custom quote
Final build price
Confirmed after discovery based on lines of business, plan-variant count, core-system and directory integrations, contact 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. 01How an enrolment is identified across core, CRM and directory

    Plan-variant and effective-date resolution rules

    Week 1

  2. 02Your plan documents by year, variant, group and rider

    Governing-document store and citation model

    Week 2

  3. 03Access to core claims, CRM, telephony and directory APIs

    HealthEdge, Facets or QNXT, Salesforce and Genesys integration

    Week 2

  4. 04Identity-verification, disclosure and minimum-necessary rules

    Identity gate, disclosure scope and audit logging

    Week 2

  5. 05Your determination, grievance and appeal routing rules and their clocks

    Routing to the queue that owns each, against its deadline

    Week 4

  6. 06Real calls that went wrong, including the ones that were nearly denials

    Evaluation suite, regression cases and failure-mode testing

    Week 4

  7. 07Named representatives, and the languages and formats your members use

    Language and accessibility testing, then pilot calls and validation

    Weeks 5–6

Nothing else is required

Deployment, documentation and Agent Care handover are ours.

Delivery timeline

Four phases across six weeks

Phases are drawn over the weeks they actually occupy. Week 5 carries both the language and accessibility slices and the first supervised calls.

Phase

W1

W2

W3

W4

W5

W6

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

Week focus

W1Enrolment routing, the identity gate and the determination line

W2Enrolment resolution, identity gate and the document store

W3Claim, accumulator and directory reads behind the cited draft

W4Evaluation suite, citation checks and determination-routing tests

W5Desktop integration, supervised calls and the language slices

W6Representatives speak from the copilot on the floor, then handover

Reading the band
A bar stops at the last week its work is named in. The language slices sit in week 5 because they come from supervised calls, not a sample.
At the end of W6
The copilot has run beside live calls and been read by the representatives who speak from it, then 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 a member-services copilot around your plan documents.

Show us your plan documents, how an enrolment is identified across your systems, and where a question becomes a determination. We'll answer one real call from those documents and agree where the copilot stops.

Typical delivery
4–6 weeks
Deployment
Your core and contact-centre stack
Who speaks
Your representative, always
After launch
Agent Care available

Nestack Agents · Member services

AGT-HC-04 · Agent Care available after launch

Build a member-services copilot

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

About you
Your systems

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