Claims Status Agent

Explains claim status, EOB detail and denial reasons to members in channel. The agent authenticates the member, retrieves claim and EOB detail from the claims platform, and explains the outcome in plain language grounded in the member's own plan documents. Where a denial is explainable, it explains it and states the next step. Where an appeal is warranted, it assembles the case and routes it to a licensed specialist. Answers cite the plan provision they came from, so the explanation survives a compliance review.

It works across Claims platform, Member portal, Plan documents, CRM. The named integration surface is Claims adjudication platform; Member portal and eligibility service; Plan document repository; CCaaS and CRM.

We deliver it on the platforms you already own — Genesys Cloud, Kore.ai, Azure OpenAI. Pronix.ai is a systems integrator, not a software vendor, so the code, prompts and evaluation sets belong to you.

Autonomous autonomy. No benefit determination, coverage decision or appeal outcome is made by the agent. Answers are grounded in the member's own plan documents with the provision cited. Every action outside policy stops at a reviewer queue with the agent's reasoning, evidence and proposed change attached. Appeals, grievances and eligibility disputes escalate to a licensed specialist immediately.

Read access to claim, EOB and eligibility data. A current, versioned plan-document repository. An agreed member authentication standard.

HIPAA-aligned handling with a signed BAA and PHI confined to your tenancy and region. Customer and employee data stays inside your tenancy and region; no training on your data by default. PII is redacted before it reaches a model, and prompts, responses and tool calls are retained under your retention policy. Every tool call, input, decision and system write is logged and replayable for audit and model-risk review.

Delivery runs in 4 phases. Weeks 1–2 · Scope: Intent and plan-line selection, document repository review, compliance sign-off on answer style. Quarter 2+ · Scale & run: Expanded across plan lines and channels with quality and citation reporting.

35–55% of claims-status demand resolved in channel. Expected ranges from comparable production engagements: Claims demand resolved in channel 35–55%; Cost per escalated contact 20–30% lower; Answers with a cited plan provision 99%+; Appeal packages arriving complete 2x more. Your baseline is agreed before build starts and reported on the same measures after go-live.

Production pilot: One plan line live across voice and digital with compliance-reviewed transcripts and a measured containment result. Scale and run: All plan lines, multilingual coverage, and appeals-package assembly run under a service SLA. Fixed-price pilot with milestone billing, then a retained pod with quarterly outcome reviews.

Price on request. Every agent is scoped to your integration surface, data readiness and compliance posture, so we send a written estimate after a 30-minute scoping call rather than publish a band that would not apply to you.