96% of provider calls never reached CareFactor’s staff.
EHVAhealth reads CareFactor’s plan summaries, SPDs, claims, and EOBs to answer provider calls on its own, and connects calls that belong elsewhere to the right vendor. Only 3.7% of in-scope calls were passed to CareFactor’s team.
Measured on every live call, Sep 28 – Oct 24, 2026 · Updated October 26, 2026
Measured on 5,300 live provider calls.
Never reached CareFactor staff
Answered or sent to the right vendor
Calls a month
Hours of calls
Overview
CareFactor is a third-party administrator with 30,000 covered lives. EHVAhealth answers its inbound provider calls on eligibility, benefits, and claims: about 5,900 calls a month, roughly 265 every weekday. Across every live inbound call from September 28 to October 24, 2026, 96% of in-scope calls never reached CareFactor’s staff: EHVAhealth answered 67% on its own, connected another 10% straight to the right PBM or prior authorization vendor, and passed just 3.7% to CareFactor’s team.
The challenge
Provider calls are repetitive, but they are not simple. Answering a benefits question correctly means knowing the specific plan the member is on. Answering a claims question means reading the claim’s status, the EOB, and the details behind them. CareFactor’s groups also use many different PBMs and prior authorization vendors, and which one handles a call differs by group, so callers regularly need to reach the right outside party. All of that landed on the same call center that serves CareFactor’s members.
How EHVAhealth handles it
- Eligibility: confirmed on 2,068 calls, with plan type and network given on 411.
- Benefits: EHVAhealth reads each plan summary and summary plan description (SPD) to answer for the member’s actual plan. It gave benefits from the member’s plan on 1,227 calls, and precertification rules along with them on 1,009.
- Claims: EHVAhealth reads the claim status, the EOB, and more. It found and explained a claim on 1,707 calls: paid (759), denied (360), patient responsibility (328), processed with no payment (311), reversed (162), still in process (146), and duplicate (116).
- PBMs and prior authorization: when a call belongs with an outsourced party, EHVAhealth transfers it to the right PBM or prior authorization vendor for that caller’s group. That covered 436 in-scope calls, 10.1%.
- Around the clock: the line is always answered. 463 calls, 9% of the total, came in before 8 am, after 5 pm, or on a weekend.
Results
Of 5,300 live inbound calls, 4,324 (82%) were in scope. Here is where every in-scope call ended up. Everything except the last row stayed off CareFactor’s phones, which is the 96%:
| Outcome | Calls | Share of in-scope |
|---|---|---|
| Handled with no staff | 2,911 | 67.3% |
| Connected to the right PBM or precert vendor | 436 | 10.1% |
| Member or claim record not found | 515 | 11.9% |
| Not handled | 277 | 6.4% |
| Passed to CareFactor staff | 158 | 3.7% |
Counting every inbound call, in scope or not, 55% were handled with no staff and 63% were handled or connected to a vendor. EHVAhealth answered 349 hours of provider calls in those four weeks. The median call lasted 2 minutes 35 seconds, and the median time to reply to a caller was 1.3 seconds.
CareFactor reports a dramatic decrease in the load and stress on its call center, which can now better focus on serving members.
How we measured
These figures cover every live inbound call on the current system from September 28 to October 24, 2026, with test calls left out. Outcomes come from the system’s own call tags: “never reached CareFactor staff” counts every in-scope call that was not transferred to CareFactor’s team, including calls where the record was not found or the call was not handled. “Answered with no staff” means the call was tagged processed and was not transferred. Neither is a separate accuracy audit.
Listen to 11 CareFactor provider calls
Real calls. Patient names are bleeped out, and member IDs, dates of birth, dates of service, and claim numbers are partly bleeped.
Claim applied to the deductible, with a billed-amount correction
2:16Catches a mismatch, confirms the details, corrects the billed amount, and explains why no payment was issued.
Read the transcript
Thanks for calling CareFactor on a recorded line. This is Paulina. Are you calling on behalf of a provider?
Yes.
What are you calling about today?
Claims.
Could I get a member ID or a claim number first?
E-B-M [redacted]
Got it. And date of service?
I need to repeat the ID number.
Of course, go ahead.
E-B-M [redacted]
Okay. And date of service?
July [redacted], 20[redacted]
Thanks. And billed amount?
One thousand.
I am having difficulty finding that claim. I have the member ID as E as in echo, B as in bravo, M as in Mike, [redacted], the date of service as July [redacted], 20[redacted], and the billed amount as $1,000. Is that all correct?
No.
What would you like to correct?
The billed amount.
Got it. And the billed amount?
$1,089.
Okay. The claim was processed on August 21st, 2026, and no payment was issued because the allowed amount was applied to the patient’s responsibility. There is a deductible amount of $553.75.
Where can I get the EOB?
If you need the formal EOB, you can log into the portal at mycarefactor.com.
Do you have the claim number?
The claim number is 0-8 [redacted].
Can you hear me? Okay, thank you.
Yes. Is there anything else I can help you with?
No, thank you.
Thank you for your call. Have a great day.
Thanks, you too. Bye.
Mental health copay, explained until it’s clear
1:28Answers a copay question from the member’s plan, then rephrases when the caller needs it spelled out.
Read the transcript
Thanks for calling CareFactor on a recorded line. This is Ethan. Are you calling on behalf of a provider?
Yes.
What can I help you with today?
I’m figuring out copays.
Are you calling about medical, dental, or vision?
Medical.
Got it. And member ID?
E-B-0 [redacted]
Okay, then the patient’s first and last name and date of birth.
[redacted], 12-[redacted]-20[redacted]
The patient has active coverage starting February 1st, 2020. What benefits would you like to check?
Mental health assessment.
For an in-network office visit, there is a $15 copay, then 100%.
Is 100%... the insurance will cover 100%, or they have to pay 100% of the standard visit?
The insurance covers 100% after the copay.
So will they pay us $15 every time he comes in for therapy?
Yes, the patient pays $15 for each in-network office visit.
Okay. All right, thank you.
Is there anything else I can help you with?
That’s all.
Thank you for your call. Have a great day.
Eligibility, then a precertification requirement
1:06Confirms coverage, flags that outpatient surgery needs precertification, and gives the number to call.
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Thanks for calling CareFactor on a recorded line. This is Michelle. Are you calling on behalf of a provider?
Yes.
What can I help you with today?
Eligibility and benefits, and authorization.
Are you calling about medical, dental, or vision?
Medical.
Got it. And member ID?
E-B-M [redacted]
Okay, then the patient’s first and last name and date of birth.
[redacted], August [redacted], 19[redacted]
Okay. The patient has active coverage starting January 1st, 2026. What benefits would you like to check?
Authorization, please.
Which service are you looking to get authorization for?
Outpatient medical.
Outpatient surgery needs precertification. You can call 614-766-5800.
(Asks for a reference number.)
The call reference number is EHVA0926.
Emergency room benefits and the provider network
1:14Answers an ER coinsurance question, then identifies the carrier network and plan type.
Read the transcript
Thanks for calling CareFactor on a recorded line. This is Michelle. Are you calling on behalf of a provider?
Yes.
What can I help you with today?
Eligibility.
Okay. And are you calling for medical, dental, or vision?
(Unclear.)
Got it. And member ID?
E-B-M [redacted]
Let me look that up. Then the patient’s first and last name and date of birth?
[redacted], November [redacted], 19[redacted]
Okay. The patient has active coverage starting January 1st, 2026. What benefits would you like to check?
Emergency services.
For in-network emergency room visits, the plan pays 80% after the deductible. Is there anything else you need?
Provider network?
The carrier is Cigna, and the plan type is HDHP.
Call reference number?
Okay. Your call reference number is EHVA0926.
Diagnostic testing benefits and deductible met to date
1:13Reads the plan’s diagnostic testing tiers, then gives the deductible and how much has been met.
Read the transcript
Thanks for calling CareFactor on a recorded line. This is Abby. Are you calling on behalf of a provider?
Yes.
What can I help you with today?
Eligibility.
Are you calling about medical, dental, or vision?
Medical.
Got it. And member ID?
E-B-M [redacted]
Okay, then the patient’s first and last name and date of birth?
[redacted], October [redacted], 19[redacted]
The member has active coverage starting September 1st, 2024. What benefits would you like to check?
Diagnostic testing.
For in-network diagnostic tests like X-rays or blood work, the plan pays 100% after the deductible, up to $500 per calendar year, then 80%.
Is the deductible met?
The individual deductible is $287, and $43.16 has been met so far.
Okay, thank you.
Dental eligibility in under a minute
0:55Verifies active dental coverage and its start date, start to finish.
Read the transcript
Thanks for calling CareFactor on a recorded line. This is Abby. Are you calling on behalf of a provider?
Yes.
What can I help you with today?
(Unclear.)
Okay. And are you calling about medical, dental, or vision?
Dental.
Got it. And member ID?
E-B-M [redacted]
Okay, then the patient’s first and last name and date of birth.
[redacted], June [redacted], 20[redacted]
Just a moment while I check. The patient has active dental coverage that started September 9th, 2023. Was there specific coverage information you needed?
No.
Is there anything else I can help you with?
No.
Thank you for your call. Have a great day.
Claim paid, with payment details
1:31Gives the paid date, amount, and claim number, then points the office to the right place for check and payee details.
Read the transcript
Thanks for calling CareFactor on a recorded line. This is Ashley. Are you calling on behalf of a provider?
Yes.
What can I help you with today?
Checking claim status.
Can I have the member ID or a claim number?
Yes. The member ID is E-B-M [redacted].
What was the date of service?
5-[redacted]-20[redacted].
And the billed amount?
$478.
That claim was paid on May 26, 2026, for $117. The claim number is 0-8 [redacted].
What date was the claim paid?
May 26, 2026.
Was it paid by a single check?
That was paid on May 26, 2026, and payments are handled by VPay. You can reach them at 855-808-8420 to confirm the check details.
Was the check made out to SJC Medical Group?
VPay can confirm the payee for you at 855-808-8420.
Can you repeat that number one more time?
855-808-8420.
Thank you.
Claim denied: accident details needed
0:56Explains why the claim was denied and exactly what the member has to do before the plan can reconsider it.
Read the transcript
Thanks for calling CareFactor on a recorded line. This is Gabriel. Are you calling on behalf of a provider?
Yes.
What can I help you with today?
I need to talk to someone regarding a claim.
I can help you with that. Do you have the member ID or a claim number?
I have the member ID.
Go ahead. What is that ID?
E-C [redacted].
What was the date of service?
July [redacted].
And the billed amount?
$5,016 even.
That claim was denied and no payment was issued because the charges appear to be accident-related, and the plan needs accident details from the member before it can reconsider them. The member needs to return the accident questionnaire to the plan. The claim number is 0 [redacted].
Claim in process, plus the EOB and a reference number
1:34Gives the claim’s status and received date, then handles EOB, reference number, and fax requests.
Read the transcript
Thanks for calling CareFactor on a recorded line. This is Paulina. Are you calling on behalf of a provider?
Yes.
What can I help you with today?
Status.
Could you clarify what you’re looking for the status of?
Claim.
May I have the member ID or claim number?
E-B-M [redacted].
And the date of service?
July [redacted].
And the billed amount?
$331.
That claim is in processing and was received August 7, 2026. The claim number is 0 [redacted].
Can I have an EOB?
If you need the formal EOB, you can log into the portal at mycarefactor.com.
Can I have a reference number?
Your reference number is EHVA0926.
Are you able to fax me an explanation of benefits?
Faxing an EOB isn’t available, but it is on the portal at mycarefactor.com. If you can’t find it there, you can email support at mycarefactor.com to request it.
mycarefactor.com?
That’s correct. Did you need anything else?
No, thank you.
Thank you for your call.
Coverage ended: an eligibility check in about a minute
0:48Finds that the member’s coverage has ended and gives the exact start and end dates.
Read the transcript
Thanks for calling CareFactor on a recorded line. This is Paulina. Are you calling on behalf of a provider?
Yes.
What can I help you with today?
Eligibility.
Are you calling about medical, dental, vision, or prescription?
Medical.
And the member ID?
E-B-M [redacted].
Could you give me the patient’s first and last name and date of birth?
[redacted], January [redacted], 20[redacted].
The member does not have active coverage. The coverage started July 1, 2025, and ended August 31, 2026. What coverage information do you need?
Plan details, claims routing, and payer ID
1:27Confirms coverage and accumulators, then answers where claims go, the electronic payer ID, and the group number.
Read the transcript
Thanks for calling CareFactor on a recorded line. This is Michelle. Are you calling on behalf of a provider?
Yes.
What can I help you with today?
Eligibility and benefits.
Are you calling about medical, dental, vision, or a prescription?
Medical.
What is the member ID?
E-B-M [redacted].
Can I have the patient’s first and last name and date of birth?
First name [redacted], last name [redacted], date of birth December [redacted], 20[redacted].
The member has active coverage starting June 1, 2026. The individual deductible is $5,000 and $0 has been met. The out-of-pocket limit is $7,000 and $0 has been met. What would you like to check?
Claims address.
Claims are only accepted electronically.
Can I have the EDI?
The electronic payer ID is 29076.
Is there a group number?
The group number is 709.
Can I have a reference number?
Your reference number is EHVA0926. Did you need anything else?
No, thank you.
Thank you for your call. Have a great day.
Every call, in one HIPAA-compliant dashboard.
CareFactor sees exactly what EHVAhealth did on every call, and can sort and break calls down however it needs.
Every call logged
Every call EHVAhealth answers is in the dashboard, day or night.
The data retrieved
See exactly which eligibility, benefits, and claims details were looked up and shared.
Call recording
Play back any call to hear exactly what the provider asked and how it was answered.
Read-along transcript
The transcript follows the recording line by line as it plays.
Sort and break down
Sort and break down calls to see where the volume comes from.
HIPAA compliant
Call data, recordings, and transcripts are handled to HIPAA standards.
Conclusion
For a TPA, provider calls are a cost of doing business that does not have to fall on the call center. By reading the same plan documents and claims records CareFactor’s staff rely on, EHVAhealth keeps 96% of in-scope provider calls off CareFactor’s phones: it answers two out of three on its own, sends another one in ten straight to the right outside vendor, and passes fewer than one in twenty-five to CareFactor’s staff, with a complete record of every call. CareFactor’s team gets its time back for the conversations that need a person: its members.
Other TPAs and partners
Acuity Group: 81% automated
Claims, eligibility, and benefits calls answered end to end for a TPA covering 16,471 lives.
Read the case studyWLT Software partnership
WLT endorses EHVAhealth as its preferred voice AI partner for MediClaims customers.
Read the announcementWellNet Healthcare
A TPA running Five9 and Salesforce selects EHVAhealth for its provider calls.
Read the announcementPricing starts at 50¢ per call
One rate, everything included. Volume, scope, and complexity set the number.