AI Agent FraudGuard AI - Healthcare Claims Fraud Detection System Active

Eligibility Verification Agent

Uses Claude 3.5 Haiku for rapid eligibility lookup against member databases and real-time 270/271 EDI transactions.

View Core Logic Back to Worker

Parent Worker FraudGuard AI - Healthcare Claims Fraud Detection System

Agent ID

eligibility_verification_agent

Portal Nexgile-PulseIQ Hub

Sector Health Insurance & InsurTech

Status

Operational

Problem Statement

The challenge addressed

Processing claims for ineligible members or non-covered services wastes resources and leads to payment errors. Manual eligibility checks are slow and may use stale data. Coordination of benefits (COB)...

Core Logic

How the agent solves it

Uses Claude 3.5 Haiku for rapid eligibility lookup against member databases and real-time 270/271 EDI transactions. Verifies coverage dates, benefit limits, and service-specific authorization requirem... Uses Claude 3.5 Haiku for rapid eligibility lookup against member databases and real-time 270/271 EDI transactions. Verifies coverage dates, benefit limits, and service-specific authorization requirements. Detects COB situations and determines payment order. Validates provider network status and calculates member cost-sharing. Achieves 99.7% accuracy with 89ms average latency.

System Navigation

Explore related components

Portal

Nexgile-PulseIQ Hub

Digital Worker

FraudGuard AI - Healthcare Claims Fraud Detection System

Current Agent

Eligibility Verification Agent

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