Benefits investigation and verification that shows where every value came from
Coverage checked across sources and summarised within a day.
See one case, screen by screen ↓It is the patient access work of finding out what a patient's plan covers for a specific therapy before it starts: tier, cost share, deductible and out-of-pocket position, prior authorization, step therapy, quantity or site-of-care rules, the specialty pharmacy, and whether copay help counts. Benefits Investigation & Verification has six agents gather and read every source and write one cited summary, for a benefits specialist to settle and release.
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A specialty therapy cannot start until the hub knows what the patient's plan covers: the tier, the cost share, the deductible and out-of-pocket position, prior authorization, step therapy, the quantity limit or site of care, the mandated specialty pharmacy, and whether copay help counts toward the deductible. The electronic benefit check answers in seconds, but from the payer's benefit file as of a date — and that file can lag a mid-year formulary change.
So the benefits specialist phones the payer, sits through the phone menu and the hold, reads the formulary and the portal criteria, and reconciles four or five sources by hand. A wrong “PA not required” becomes a rejected first fill. A missed accumulator becomes a surprise at the pharmacy counter halfway through the year. Either can end with a patient giving up on therapy before it starts.
Estimated split of the elapsed hours for one specialty pharmacy-benefit case, by hand and with the solution. The working solution's dashboard shows weekly median turnaround moving from about 41 hours to about 18 over 90 days.
Six agents gather and read every payer source and write one cited summary; where the eBV and the payer call disagree, both are quoted and a benefits specialist decides.
Jordan Ellis is prescribed Veltrimab 150 mg/mL pen by Dr. Rafael Moreno at Lakeside Dermatology Associates. The plan is Brightwater Health PPO, with Aldenway Rx as the PBM. The office enrolls Jordan through its portal on Oct 6 at 16:20 — case BV-2417. Here is what happens next, screen by screen, in the working solution.
By the next morning the case holds the hub record from enrollment, the pharmacy eBV from the clearinghouse, a 14-minute payer call transcript from Oct 7 09:12, the formulary's Jul 1 update and a capture of the portal's PA criteria page. The eBV reads cleanly: tier 4, $50 copay per fill, prior authorization not required, step therapy not indicated. Its benefit data is as of Jun 15, 2026. The case is 17 hours into a 48-hour promise.
“Ready to build. Every value will cite the eBV line, the call moment, the portal page or the plan page it came from.”
The agents read every value from every source and write it into the summary with the lines it came from. Six values agree, four disagree, one needs confirming. On prior authorization the row turns amber and quotes both sides: the eBV's “Prior authorization: Not required” beside the payer rep at 05:05 — “Prior authorization is required: moderate-to-severe plaque psoriasis, at least 10 percent body surface or hands, feet, face or genitals, and 12 weeks of a conventional systemic.”
Why: “Brightwater added prior authorization when Veltrimab moved to tier 5 on Jul 1 … The eBV answers from Jun 15 data.”
Tier 5 since Jul 1, not tier 4. 30% after the deductible, up to $250 per fill, not the old $50 copay. Prior authorization required. Step therapy applies — one preferred biologic first. Each choice is recorded with what it overrode. She also confirms the signal the eBV never reported: a copay accumulator. Help from the Northwind copay program will not count toward Jordan's $2,500 deductible or $6,800 out-of-pocket maximum.
Source triangulator’s limit: “A person settles every disagreement.”
The plan rules reader turns the portal criteria into a checklist and looks for each one in the case record. Plaque psoriasis — L40.0 on the enrollment form. Body surface 14%, recorded Sep 29. Methotrexate for 16 weeks, stopped for raised liver enzymes. The fourth, one preferred biologic first, is not met: Jordan has had no prior biologic, so the office should request a step therapy exception with the reason.
The plan rules reader never states that a PA will be approved.
The office copy lists plan status, tier, cost share, deductible and out-of-pocket met, prior authorization, step therapy, the quantity limit of 2 pens per 28 days, Crestline Specialty Pharmacy only, and copay support — eleven values, each cited. It carries the payer call reference ALW-1007-55813 and the standard statement that a benefits investigation does not guarantee coverage or payment.
The patient letter comes from the approved template PL-04 v3, in English or Spanish. The compliance checker passes it before anyone can release it: reading grade 5.8 against a limit of 6, template approved Sep 2 by Lena Ortiz, the no-promise sentence present, no diagnosis named, and the copay rule allowed for a commercial plan.
“It is not a promise that your plan will pay. Your plan makes the final decision.”
Release sends the summary to Lakeside Dermatology Associates by portal and fax, the letter to Jordan in English, and five tasks to Sam Patel. Dana signs with the meaning of her signature, her name and the date.
Meaning of signature: “I reviewed the benefits values and their sources and approve this release.”
Help the office submit prior authorization through the Aldenway Rx portal, due Oct 9. A step therapy exception with Dr. Moreno, attaching the methotrexate history. A referral to Crestline Specialty Pharmacy. Enrollment in the Northwind copay program, planning the year around the accumulator. A call to Jordan to explain the benefits. A reverification reminder is set for Dec 1, 2026 — the plan renews on Jan 1.
BV-2419 is Corventa 300 mg IV infusion at Northgate GI Infusion Center, under Cobalt Ridge HMO's medical benefit. The medical eBV says “Pre-determination not required”; policy MP-418 requires prior authorization for J3590, and the rep confirmed it. The agents explain the difference and flag a site-of-care rule after two infusions for her to confirm.
“The medical eBV answers whether a pre-determination is needed, not a prior authorization.”
The same case, seen by the five people who touch it — what their week looked like, and what it looks like now.
Six agents gather and read every payer source and write one cited summary; where the eBV and the payer call disagree, both are quoted and a benefits specialist decides.
Brings every piece of payer evidence into the case — eBV responses, call transcripts, plan documents, portal captures and the hub record — and says what is still missing: arrived, waiting, on hold or failed.
Reads about 27 benefit values from each source — status, tier, cost share, deductible and out-of-pocket with amounts met, PA, step therapy, quantity limit or site of care, specialty pharmacy, accumulator wording — each with its source line and the eBV's data-as-of date.
Turns formulary footnotes, coverage policies and portal criteria into a prior authorization and step therapy checklist, then marks each criterion met, not met or unknown against what the hub record documents.
Compares the eBV, the payer call and the plan document value by value, explains each disagreement — stale eBV data, a mid-year update, a different benefit — and recommends the newest dated source. Flags accumulator, maximizer, government-plan and site-of-care signals.
Drafts the office benefits summary and the plain-language patient letter, in English or Spanish, from the approved templates and the settled values only, with the payer call reference.
Checks every letter and summary before a person can release it: template version, reading level, the no-promise sentence word for word, minimum necessary health information and the government-plan rule.
Settles and confirms. The agents propose; a named person decides.
Ask about a case, a payer or a rule — or say what to change. Every answer shows the line it came from.
What does Jordan's plan need before the first fill?
Four things on Brightwater Health. Prior authorization is required, although the eBV says not required from Jun 15 data; the hub record already meets 3 of 4 criteria. Step therapy: one preferred biologic first, so the office needs an exception. Crestline Specialty Pharmacy only. Cost: tier 5 since Jul 1, 30% after the deductible, up to $250 a fill — and copay help won't count toward the deductible.
How are Medicare and Medicaid cases handled?
The copay program is never offered to Medicare or Medicaid patients. For BV-2421 on Larkspur Medicare Advantage the route is the Medicare Prescription Payment Plan and the $2,100 Part D cap, plus a foundation referral. BV-2422 on Pinecrest Medicaid pays the $4 state copay. Omar Haddad gives a second check before release, and the compliance checker blocks any copay mention in those letters.
Re-call the payer whenever the eBV and the call disagree on cost
Done. New rule: when the eBV and the payer call disagree on tier or cost share, the AI caller calls the payer back and asks for the effective date, before the case reaches you. Over the last 30 days this would have caught 41 cases early — most of them mid-year tier moves like Brightwater's Jul 1 update. The rule is live in Settings and recorded in the audit trail.
What do the patient letters promise?
Nothing about payment. Every letter uses approved template PL-04 v3, in English or Spanish, stays at or below grade 6, names no diagnosis, and ends with the approved sentence: “It is not a promise that your plan will pay. Your plan makes the final decision.” The compliance checker blocks release if any check fails.
13 screens from the working solution, on its sample data. Pick one to see it large.
Turnaround, checks and letter rules are settings — changes are versioned and audited.
| Setting | Default | Choose from |
|---|---|---|
| Turnaround promise to offices | 48 hours | Step up or down; clocks turn amber at three quarters of it and red past it |
| Recommend the newest dated source | On | On · Off — when the eBV, the payer call and the plan document disagree |
| Second check for Medicare and Medicaid cases | On · Omar Haddad | Omar Haddad · Lena Ortiz |
| Medicare and Medicaid | Never offer the copay program; suggest the foundation or free-drug route | On · Off |
| No promise of coverage | Every letter carries the approved no-promise sentence | On · Off |
| Call reference on every summary | An office summary needs the payer call reference number | On · Off |
| Highest reading level | Grade 6 | Step up or down, one grade at a time |
| Letter template | PL-04 v3 · approved Sep 2 | PL-04 v3 · approved Sep 2 · PL-04 v2 · retired Sep 2 |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample case data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (24–48 hour turnaround norms for patient support programmes; CMS Part D out-of-pocket cap for 2026, $2,100). People, offices, payers, products and patients named on this page are fictional — characters and sample data in the working solution.
It is the patient access work of finding out what a patient's plan covers for a specific therapy before it starts: tier, cost share, deductible and out-of-pocket position, prior authorization, step therapy, quantity or site-of-care rules, the specialty pharmacy, and whether copay help counts. Benefits Investigation & Verification has six agents gather and read every source and write one cited summary, for a benefits specialist to settle and release.
The eBV answers from the payer's benefit file as of a date. In the sample case that date is Jun 15, two weeks before a Jul 1 tier move that added prior authorization and step therapy. The solution reads the eBV, the payer call, the formulary and the portal criteria, and quotes both sides wherever they disagree.
The source triangulator compares every value across sources, explains why they differ — stale data, a mid-year update, a different benefit — and recommends the newest dated source. A benefits specialist chooses for each value, or asks for the payer to be called back. Each choice is recorded.
Yes. Accumulator and maximizer wording on the call or in the plan document is flagged as a signal for the specialist to confirm, even when the eBV does not report it. The summary and the case manager's tasks then say what it means for the patient's deductible and copay enrollment.
Yes. For an infused product under the medical benefit it reads the medical eBV and the coverage policy, and separates a pre-determination from a prior authorization. For Medicare and Medicaid the copay program is never offered; the foundation, Medicare Prescription Payment Plan or free-drug route is suggested and a second person checks it.
Yes. The agents gather, read, compare and draft. A benefits specialist settles every disagreement, confirms every signal and releases with an electronic signature, and the compliance checker blocks release on any failed letter check.
Yes. The turnaround promise, newest-source recommendation, second check for government plans, the no-promise and call-reference rules, the highest reading level, the letter template, Spanish letters and name hiding are all settings, versioned and audited.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your programme rules, approved templates and a sample of past benefits cases — and it goes live once every quality gate has passed. We will walk you through it on your own cases first.
Every enrollment form becomes a complete hub case in minutes, gaps faxed back same hour.
1-min demoPrior Authorization SupportEach payer criterion proven from the chart, so therapy starts in days.
1-min demoPatient Assistance Program EligibilityEvery application checked against every rule, most decided within a day.
1-min demoWe'll run Benefits Investigation & Verification on a sample of your own past benefits cases.