Coverage confirmed while the caller is still on the line.
The highest-volume question in benefits, asked by providers verifying coverage before a visit and by members trying to understand what they will owe. Both get a current, accurate answer from your live data.
The same lookup, said two different ways
A provider wants precision: effective dates, plan codes, accumulator balances. A member wants to know what they will owe. We script both from the same live data.
For providers
Active coverage and effective dates
Whether the member is active on the date of service, and under which plan.
Accumulators and remaining balances
Deductible, out-of-pocket, and visit limits as they stand today.
Prior authorization requirements
Whether a service needs authorization, and where to submit it.
Coordination of benefits
Primary versus secondary, and what we hold on other coverage.
For members
Is this covered?
A direct answer about the service they are asking about, not a benefits booklet.
What will it cost me?
Copay, coinsurance, and what is left on the deductible, in dollars.
ID cards and plan documents
Cards reissued and documents sent by text or mail on the call.
Where to go for care
Handed straight into provider search when they need a name.
Authenticate, look up, explain, log
Authenticate the caller
Verify the provider or member to your disclosure rules before anything is shared.
Query live eligibility
Read current coverage and accumulators from your platform, not a nightly copy.
Explain it at the caller's level
Precision for providers, plain dollars for members, from the same underlying record.
Document and route
Log the call, send anything promised by text or mail, and escalate what needs a person.
Fewer holds, cleaner calls, lower cost
Call resolution
Answer speed
Onboarding
Quality coverage
Eligibility, answered
Where does the coverage data come from?
Live from your admin or eligibility platform through its API, so callers hear the current record. If your platform cannot expose an API, we agree an alternative data path during onboarding.
Can it quote member cost accurately?
It gives copay, coinsurance, and remaining accumulator balances from your data, and is careful to frame estimates as estimates where the final amount depends on adjudication.
How is caller authentication handled?
To your rules. We configure exactly what identifiers are required and what may be disclosed to a provider versus a member versus an authorized representative.
Does it handle coordination of benefits?
It reports what your system holds on other coverage and primacy, and routes the call to your team when the COB record needs updating.
What about self-funded groups with many plan designs?
Plan-specific handling is part of configuration. Sixty designs takes longer to set up than three, and we scope that honestly up front.
Handle the rest of the line too
Take eligibility calls off your team
Hear real handling on your plan designs before you commit to anything.