Processes

What will AGI do for Enforce medical policy?

A medical claim or prior authorization request is submitted by a healthcare provider for review.

Trigger: A medical claim or prior authorization request is submitted by a healthcare provider for review.
Outcome: The service is formally approved, denied, or adjusted in alignment with documented medical necessity criteria and plan benefits.

The work itself

Grounded Work Profile

Ingest prior authorization request or flagged medical claimprocessProfile
Retrieve corresponding member benefit plan and clinical policiesprocessProfile
Evaluate submitted clinical documentation against medical necessity criteriaprocessProfile
Route complex or ambiguous cases to a medical directorprocessProfile
Formulate the final coverage determinationprocessProfile
Generate and transmit the decision notice to the provider and memberprocessProfile

How AGI delivers it

Services-as-Software
Get the professional outcome delivered as software, priced on results, not headcount.
Services.do
Autonomous Agents as digital employees
Hire a digital employee that does the job under earned, supervised autonomy.
Agents.do
Business-as-Code
Encode how your work runs, once, as software that executes itself.
Platform.do

Value flow

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