90% of provider calls answered without a person on the line.
EHVAhealth reads CareFactor's plan summaries, SPDs, and EOBs to answer benefits and claims questions on its own, around the clock, so the call center can give members its full attention.
Last updated October 9, 2026
Our most sophisticated build yet.
Autonomy
Covered lives
Daily volume
Call handling
Overview
CareFactor is a third-party administrator with 30,000 covered lives. EHVAhealth answers its inbound provider calls on eligibility, benefits, and claims, about 200 calls a day, and resolves 90% of them without a person on the line. It is the most sophisticated build we have delivered so far: nearly every provider who calls gets the information they need, quickly, on the first call.
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
- Benefits: EHVAhealth reads through each plan summary and summary plan description (SPD) to answer benefits questions for the member's actual plan, handling 90% of them on its own.
- Claims: EHVAhealth reads the claim status, the EOB, and more to answer claims questions, handling 90% of them on its own.
- 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, even though those vendors differ from group to group.
- 24/7: the line never closes. Urgent care centers calling on a weekend get eligibility and benefits answers right then, not on Monday morning.
Results
EHVAhealth resolves 90% of CareFactor's provider calls autonomously. CareFactor reports a dramatic decrease in the load and stress on its call center, which can now better focus on serving members.
Listen to 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.
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, 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.
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 answers 90% of those calls on its own, any hour of the day, and gives CareFactor a complete record of every one. Its 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.