Agent Workflow Library

Runs the full NCQA CR1–CR10 credentialing workflow—NPI validation, CAQH sync, primary source verification, OIG/SAM/NPDB exclusion screening, and committee-ready packet assembly.

Drives credentialed providers through payer enrollment—requirement mapping, application pre-fill, multi-channel submission, contract clause parsing, rate analysis, and No Surprises Act roster confirmation.

Validates provider directory accuracy, runs CMS Medicare Advantage network adequacy calculations, targets recruitment to coverage gaps, and produces No Surprises Act–compliant directory updates.

Translates SPD/SBC documents into CAPS-ready benefit rules, validates MHPAEA parity across six classifications, runs adjudication regression tests, and routes go-live and amendments through mandatory human gates.

Configures BH-specific claims edit rules, manages code mappings and telehealth adjudication logic, runs test claim batches, and surfaces denial-pattern optimizations—every rule change goes through approval.

Captures the insurance card, resolves payer ID, runs 270/271 eligibility, cascades through BH carve-outs, extracts plan-specific benefits, and generates a patient cost estimate before the visit.

Drives 834 enrollments and exchange members from intake through HRA scoring, PCP assignment, and first-90-day engagement—with mandatory human gates for clinician HRA review and crisis outreach.

Handles the full BH prior auth lifecycle—requirement determination, clinical packet assembly, FHIR R4 (CMS-0057) submission, concurrent review, and SB 1120-compliant denial review with peer-to-peer coordination.

Monitors Federal Register, eCFR, Regulations.gov, and LegiScan in real time; runs MHPAEA NQTL comparative analyses and 42 CFR Part 2 SUD confidentiality audits; produces legal-review-ready remediation packages.

Designs behavioral-health VBC contracts end to end—quality metric selection with feasibility flags, baseline measurement, provider scorecards, shared-savings scenario modeling, and renewal evidence packages.