AGI.do

Processes

What will AGI do for Determine covered service?

AI-deliverabilitydigital

Since there are no seeded child occupations, the scalar is derived from the process name and industry lens ('Direct Health and Medical Insurance Carriers'). Determining covered services consists entirely of evaluating policy rules against claims or medical records, which is pure information transformation and knowledge work.

A medical claim or prior authorization request specifying a procedure or diagnosis code is submitted by a provider or member.

Trigger
A medical claim or prior authorization request specifying a procedure or diagnosis code is submitted by a provider or member.
Outcome
The requested service is formally classified as covered, denied, or pending further medical review based on the member's active policy.

The work itself

Grounded Work Profile

Measured by

  • Coverage Determination AccuracyprocessProfile
  • Auto-Adjudication RateprocessProfile
  • Determination Cycle TimeprocessProfile
  • Denial Appeal RateprocessProfile

Key steps

  • Extract service and diagnosis codes from the incoming requestprocessProfile
  • Retrieve the member's active benefit plan and policy detailsprocessProfile
  • Cross-reference service codes against plan inclusions, limitations, and exclusionsprocessProfile
  • Evaluate medical necessity criteria and prior authorization rulesprocessProfile
  • Check against benefit maximums and accumulated limitsprocessProfile
  • Assign a definitive coverage status to the requested serviceprocessProfile

How AGI delivers it

Four ways AGI delivers for Determine covered service

  • Autonomous Agents as digital employees

    Hire a digital employee that does the job under earned, supervised autonomy.

    Agents.do

  • Services-as-Software

    Get the professional outcome delivered as software, priced on results, not headcount.

    Services.do

  • Business-as-Code

    Encode how your work runs, once, as software that executes itself.

    Platform.do

Go deeper

Explore Determine covered service

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