Patient assistance program eligibility, every rule checked and cited to the page that proved it
Every application checked against every rule, most decided within a day.
See one case, screen by screen ↓Software that takes a free-medicine application from the packet that arrives by fax, portal or mail to a signed decision: residency, prescription, coverage path, household, income against the poverty guideline and signatures checked against the programme's rules. Patient Assistance Program Eligibility adds six agents that read the packet, walk it down the rules and cite each finding to its page, for a reviewer to decide and sign.
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A patient assistance programme gives medicine free to uninsured and under-insured patients below an income limit. Every application arrives as a packet — the form signed by the patient and prescriber, the prescription, pay stubs or a tax return, benefit and pension letters, and the insurer's appeal decision or Medicare Part D plan letter — by fax, portal or mail. A reviewer keys the figures, annualises each pay stub by hand, looks up the poverty guideline for the household size and compares, packet by packet.
The hard cases sit between documents. The application lists four people and the tax return three, because a baby was born after the tax year. A prior-authorisation denial arrives where an appeal decision is needed, or a Medicaid card is in the packet. Two reviewers can decide the same facts differently, and when an auditor or the patient asks why, the reasoning sits in a reviewer's notes, not against the page that proved it. Rules applied unevenly are a compliance risk under HHS-OIG guidance on assistance programmes.
Estimated split for a typical new free-goods application, by hand and with the solution.
Agents read the packet and walk the programme's rules, each branch cited to its page; a reviewer signs, then the letter goes out.
Northwind Cares runs a patient assistance programme for three medicines — Veltrimab, Corventa and Talmirex. Sam Patel, an eligibility reviewer, starts the day with 20 open applications. Here is what happens next, screen by screen, in the working solution.
The rail on the left holds 20 open applications and 4 decided: 3 need Sam, 7 are clear to approve, 4 are recommended for denial and 5 wait on documents. Maria Santos's fax has just arrived at 08:42. Ana Ruiz's Veltrimab application is open on the decision path — the programme's rules drawn as a tree, with her route lit and each gate citing its page.
“Every lit branch cites the page that proved it · click a gate or a document to see the proof.”
Maria Santos's packet is 8 pages and 4 documents, faxed by Dr. Tomás Rivera's office for Talmirex. The Packet Reader labels every page, the Signature & Identity Checker confirms a Houston address and the Coverage Checker works out the coverage path, while the tree lights gate by gate as each agent works.
Each step is shown as it runs: “Coverage Checker · finding the coverage path.”
Her pay stub from Ship Channel Terminals, dated Oct 2, shows $1,472.00 weekly. Annualised at × 52 that is $76,544, against $27,320 for a household of 3 — 280% of the poverty guideline, under the 400% limit. All 13 rules are met and the branch to eligible lights, with the pay stub open on the right at page 6.
“Eligible — recommend approve · all 13 rules met · 280% of the guideline.”
Ana's insurer, Crestline Health, upheld its denial on appeal; her doctor's office faxed 11 pages. Her income is $3,780 bi-weekly × 26 = $98,280 plus Marco's Schedule C net profit of $20,120 — $118,400. Her application lists 4 people; the 2025 tax return shows 3, because Leo was born in March 2026. With 4 she is at 359% of the guideline; with 3, 433% — over the limit.
“Needs you — the household size decides the outcome.”
Programme rule 4.2 counts the people living in the home today, as attested and signed on the application; the tax return proves income, not the household. Sam counts 4. The household gate records “4 people · counted by Sam Patel”, the income gate passes at 359% and the outcome turns to eligible.
Rule 4.2: “Where the two differ, the reviewer records which count was used and why.”
The approval shows Veltrimab free for 12 months, Oct 7, 2026 to Oct 6, 2027, shipped from Clearwater Free Goods Pharmacy with the referral sent on signing. The basis is 4 people, 359% of the guideline, 13 of 13 rules met — no second signer needed. The approval letter is drafted from the approved template, with every figure taken from the decision.
Ana's application is approved and enrolled the morning after her fax arrived — 0.9 business days on the clock, against the 4.5-day standard. The decision record lists six findings, from residency to signatures, each with the document and page that proved it, the agents that checked it and the rules version, 2026.4. One click exports it for audit.
“Approved and enrolled · Sam Patel · Oct 7 · 09:13.”
Bradley Hughes applied for Corventa after Front Range Mutual upheld its denial. His 2025 return shows $167,200 for a household of 3 — 612% of the guideline, over the 400% limit. The path leaves the spine at the income gate, red. The recommendation is a denial, and Omar Haddad second-signs every denial before the letter is sent.
Every denial letter lists independent charitable foundations and explains how to ask for a review within 30 days.
Walter Brooks, 71, is on Medicare Part D. His Social Security letter and pension statement add to $31,800 — 147% of the guideline for 2. He has spent 6.2% of his income on prescriptions this year, above the programme's 3%. Free medicine is given outside the Part D benefit and the plan is told. Every Part D approval needs a second signer, so Omar Haddad signs after Sam.
“Eligible — two people sign · Medicare Part D: Omar Haddad signs after you.”
Enrolments last 12 months. Each night the solution finds enrolments ending in 45 days, pre-fills the renewal from last year and drafts the reminders. This morning 17 enrolments end in the next 60 days, 6 reminders are ready to send and 2 patients are at risk of a gap, with a call task for each.
“Reminders go out 45 days ahead, pre-filled from last year, so therapy never stops.”
The same applications, seen by the four people who carry the programme — what their day looked like, and what it looks like now.
Agents read the packet and walk the programme's rules, each branch cited to its page; a reviewer signs, then the letter goes out.
Splits each faxed, uploaded or mailed packet into pages and labels every document and the person it belongs to — application, pay stub, tax return, benefit letter, insurance letter, Medicare letter, prescription — keeping page numbers so every later figure can cite its page.
Extracts every income figure, annualises pay stubs and benefit letters — weekly × 52, bi-weekly × 26, semi-monthly × 24, monthly × 12 — adds every household source and works out the share of the poverty guideline, with the arithmetic shown.
Decides the coverage path — uninsured, denied after appeal or Medicare Part D — and checks the letter that proves it; for Part D, the plan letter and the pharmacy out-of-pocket statement against the programme's share of income.
Confirms the patient and prescriber signed and dated, the privacy authorisation is signed, the prescriber NPI is valid and the address is in the U.S.
Applies the 13 programme rules to every application the same way, exactly as written in the current version, and proposes approve, request more or deny — each finding with its citation.
Writes approval, denial, missing-document and re-enrolment letters from approved templates in plain language, and refers approved patients to the free-goods pharmacy.
Decides and signs every application. The agents propose; a named person decides.
Ask about any application, rule or letter — or say what to change. Every answer points to its source.
Why does Ana Ruiz's application need me?
PAP-10418 meets 11 of 13 rules. The two open ones — household size and the income limit — turn on one question: the application lists 4 people, the 2025 tax return shows 3, because her son Leo was born in March 2026. With 4 people she is at 359% of the guideline; with 3, 433%. The household rule counts people living in the home today, so the recommendation is to count 4 — that makes her eligible.
How do you handle Medicare Part D patients?
They follow their own path: free medicine is given outside the Part D benefit, the plan is told so it never counts toward out-of-pocket costs, and they must have spent at least 3% of household income on prescriptions this year. A second person always signs. Walter Brooks spent $1,960 on an income of $31,800 — 6.2%, so he qualifies; George Lambert spent $480 (1.7%), so the recommendation is a denial with a note on when to re-apply.
How do you annualise pay stubs?
The same way every time: weekly × 52, bi-weekly × 26, semi-monthly × 24, monthly × 12. The most recent proof wins, and it must be dated within 90 days. Ana Ruiz's $3,780 bi-weekly is $98,280 a year; Maria Santos's $1,472 weekly is $76,544. Out-of-date proof is requested again — it is never a reason to deny.
Can we prove decisions are consistent?
Yes. Every night the consistency check compares decisions with the same facts: in the last 30 days, 1,186 decisions in 5 fact patterns, 0 that differ. Nine reviewer overrides each carry a written reason. The prescriber, office and prescription volume are never inputs.
13 screens from the working solution, on its sample data. Pick one to see it large.
Programme rules apply to every application the same way. Changes are versioned and audited.
| Setting | Default | Choose from |
|---|---|---|
| Household income limit | 400% of the HHS poverty guideline | 300% · 400% · 500% · 600% |
| Medicare Part D out-of-pocket spend | 3% of household income | 2% · 3% · 5% |
| Income proof must be dated within | 90 days | 60 days · 90 days · 120 days |
| Enrolment length | 12 months | 6 months · 12 months |
| Poverty guideline table | 2026 HHS guidelines · 48 contiguous states and DC | View table: the guideline and the limit for households of 1 to 8 |
| Denials need a second signer | On | On · Off |
| Medicare Part D approvals need a second signer | On | On · Off |
| Missing-document requests go to | Whoever can fix it — the patient for income, the office for signatures | Whoever can fix it · Always the office |
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 programme data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (URAC industry standard for a new free-goods decision — 4.5 business days). Poverty guideline figures are the 2026 HHS guideline table as used in the working solution; HHS-OIG guidance on patient assistance programmes is cited for rules applied consistently. People, the programme, its medicines, insurers, offices and pharmacies named on this page are fictional — characters and sample data in the working solution.
Software that takes a free-medicine application from the packet that arrives by fax, portal or mail to a signed decision: residency, prescription, coverage path, household, income against the poverty guideline and signatures checked against the programme's rules. Patient Assistance Program Eligibility adds six agents that read the packet, walk it down the rules and cite each finding to its page, for a reviewer to decide and sign.
The Income Calculator extracts every income figure, annualises it — weekly × 52, bi-weekly × 26, semi-monthly × 24, monthly × 12 — adds Schedule C net profit and every household source, and divides by the HHS guideline for the household size. The arithmetic is shown and recomputed, never rounded before the comparison, and the limit is a setting.
The application is flagged for a person. Both counts are shown side by side with their pages and the share of the guideline each one gives. The programme rule counts the people living in the home today, as attested on the application; the reviewer records the count used and why.
Yes. The Coverage Checker decides the coverage path. Medicare Part D patients must have spent the programme's share of income on prescriptions this year, receive free medicine outside the Part D benefit and need two signers. A Medicaid card in the packet means the programme does not apply, and a prior-authorisation denial alone prompts a request for the appeal decision.
No. The prescriber, the office and the volume of prescriptions are never inputs. The 13 rules are applied the same way to every applicant, and a nightly check compares decisions with the same facts.
Yes. The agents recommend and never decide; a reviewer signs every approval and denial, and denials and Medicare Part D approvals need a second signer. A missing signature or out-of-date proof becomes a request, never a denial.
Yes. The income limit, Medicare Part D spend, income proof window, enrolment length, poverty guideline table, second signers and who receives missing-document requests are settings. Rule changes need compliance approval and are versioned.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your programme rules, application forms, letter templates and a sample of past packets — and it goes live once every quality gate has passed. We will walk you through it on your own applications 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 demoBenefits Investigation & VerificationCoverage checked across sources and summarised within a day.
1-min demoWe'll run Patient Assistance Program Eligibility on a sample of your own past application packets.