Eligibility, Benefits-Verification & Insurance-Discovery AI Agent

What this agent does

Reads the response, not the payment

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

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

Reason

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

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

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

Decide

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

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

Out

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

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

AgentHuman

1Check triggeredScheduling entry, registration intake, self-pay flag or a manual re-check request

2Response gathered270 submitted, 271 returned, MSP questionnaire answers, plan history and discovery results

3Response readPlan status, network, proposed sequence, prior-authorisation flag and confidence

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▼

6Registration and billing systems updatedOnly where write access and approval policy allow it

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 required8 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 boundaryAgent 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 encounterIllustrative example

Encounter

Result line

Plan status

Sequencing basis

Confidence

Attribution

Dual-coverage office visit

271 returns two active plans; sequence proposed with the employer plan primary

Active — dual coverage

MSP questionnaire on file

87%

Payer ID and NPI included

As receivedTaken 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 sequenceThe order comes from the MSP questionnaire and the 271 response on file.

ActionAcceptEditSend for supervisor review

What the score decidesBelow the configured threshold the check picks up a supervisor read before the registrar sees it.

Value

Where AI adds value

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

Where the value landsValue 01 – 04

Every coverage checkFrom 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.

04Build 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 schedulingEpic Prelude · Cerner
MEDITECH · patient access systems

Clearinghouse connectivityAvaility · Change Healthcare
Payer 270/271 gateways

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

Agent

Eligibility, benefits & insurance discovery

Reads the response
Proposes the sequence
Holds for acceptance

Billing systemsPatient billing and collections systems
Prior-authorisation agent

Observability & evaluationOpenTelemetry · 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 defenceInward → 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 – L2Test whether a check may stand

L3Puts the acceptance in a registrar's hands

L4 – L5Keep the response and the payer behind it

L6Holds 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

Depth of coverage ▼

E1Final-output evaluationDid the proposed sequence match the MSP questionnaire and the response on file?

E2Step-level evaluationDid the agent use the right payer, plan and state Medicaid configuration?

E3Tool evaluationDid it read and write the correct encounter, payer and plan field?

E4Confidence calibrationDo low-confidence responses actually draw more registrar edits?

E5Slice evaluationHow does performance change across specific payer mixes?

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 lifecycleDirection of processing →

01 · Retrieval1 mode

EB-03

Stale coverage signal

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

Stage gathers270 request, payer response and plan data

02 · Reasoning2 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 proposesResponse, the proposed sequence and confidence

03 · Tool / write2 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 writesOnly where write access and approval policy allow it

04 · Output1 mode

EB-01

Plan type not distinguished

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

Stage returnsThe status the registrar accepts and billing relies on

05 · Change / Version1 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 tracksModel, 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 aggregateIllustrative example

Slice	Failure rate	Lift	Status
Patients presenting as self-pay	7.3%	3.8×	Review
Members with more than one active plan	5.6%	2.9×	Review
Medicare Advantage read as traditional Medicare	3.5%	1.8×	Watch
Single commercial plan, active coverage	1.9%	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 stagesSwitchback — the path turns at Improve and returns at Learn

01Detect

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

02Diagnose

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

03Improve

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

04Verify

A failing verification case holds the release until it passes.

05Learn

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

Learn → DetectThe 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

01Check workflow and boundary definition and it is logged..

02Clearinghouse and payer-source assessment.

03Payer, plan and Medicaid rule mapping and rule mapping.

04270/271 ingestion and normalisation.

05Response retrieval and sequencing logic.

06Confidence scoring and flag routing.

07Registrar acceptance workflow.

08Clearinghouse and registration integration.

09Response and sequencing cases.

10Guardrails and verification controls.

11Encounter-trail instrumentation.

12Deployment, documentation and Agent Care handover.

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 tier PilotOne payer, one site ProductionProduction clearinghouse integration AdvancedMultiple 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 price From $5,000 From $8,000 Custom quote

Final build priceConfirmed after discovery based on integrations, workflow complexity, transaction volume, approval controls and deployment requirements.

Separate from buildBuild 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.

You bringWe build with it

01Your payer mix, clearinghouse and registration system → Clearinghouse ingestion and payer mappingWeek 1

02Representative recent checks and encounters → Verification baseline and sequencing-rule extractionWeek 2

03Your payer, plan and state Medicaid rules → Payer, plan and Medicaid-rule mappingWeek 1

04Access to relevant APIs, feeds or exports → Clearinghouse and registration assessment, then integration setupWeek 2

05Coverage you would not want billed → Sequencing cases and the evaluation suiteWeek 4

06What no response may be read as → Confidence scoring, flag routing, guardrails and verification controlsWeek 3

07Named registrars to accept checks → Registrar acceptance workflow, then pilot and production validationWeeks 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 W1W2W3W4W5W6

Discovery W1

Build W2 – W3

Evaluate W4 – W5

Pilot & Launch W5 – 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 bandA bar covers the weeks its work is named in, and nothing else. The week 5 overlap is real, not padding.

At the end of W6Validation closes on live encounters, and Agent Care takes over monitoring.

DurationSix-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.

Discuss this agent →

Nestack Agents · Eligibility, benefits & insurance discoveryAGT-HC-15 · Agent Care available after launch