46% member-services deflection for a Medicare Advantage payer — CMS-safe agentic AI
A regional Medicare Advantage payer was buckling under AEP call volume for benefits, PCP changes, ID cards and prior-auth status. pronix.ai deployed Salesforce Agentforce on Health Cloud with Amazon Connect voice and CMS-safe guardrails — 46% deflection and CSAT flat through AEP.
- Client
- Regional Medicare Advantage payer, 1.2M members
- Industry
- Health Payers
- Platform
- Salesforce Agentforce · Salesforce Health Cloud · Amazon Connect
*Representative outcome; results vary by client, scope and platform configuration.
The challenge
AEP week-one call volume was 4.2x steady state and abandon rates were pushing 18%. Any assistant had to respect CMS marketing rules, never quote plan pricing outside the sanctioned language, and route anything clinical to a licensed agent.
Our approach
CMS-safe intent boundary
Locked the assistant to five non-marketing intents — benefits summary, PCP change, ID card, prior-auth status, claim status. Anything else routed to a licensed agent within one turn.
Health Cloud grounded answers
Agentforce topics grounded on member record, plan document library and prior-auth queue — no free-text drift, every answer traceable to a sanctioned source.
Voice + web from day one
Same Agentforce topics served the Amazon Connect voice bot and the member portal chat; one authoring surface, two channels live together.
AEP surge playbook
Pre-loaded 12 seasonal FAQs, added an overflow callback offer at 60-second wait, and staged a war room for the first ten AEP days.
“AEP week one used to be the worst week of our year. This year the queue held — and members got answers at 10pm.”
Illustrative case study. Scenarios, metrics, quotes and client details are representative composites based on Pronix engagements and industry benchmarks unless a named client is shown with written consent. Outcomes vary by client, scope, data quality and platform configuration. Nothing on this page is a guarantee, warranty or professional advice. See our Terms of Use for the full disclaimer.
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