Insurance eligibility verification

Agents (Early Access) · Use case

An agent that checks insurance eligibility for your upcoming appointments each morning, then handles each patient one of three ways — it files a note when coverage is good, emails the patient when something's off, or flags a teammate when it isn't sure.

The scenario

Before every visit, someone on your team runs the same check by hand:

• Pull the chart.
• Read the insurance on file.
• Open the payer's portal.
• Type in the member ID.
• Read the result back.
• Note it, or pick up the phone and call the patient.

Take Maria Delgado — on the books three days out, with Aetna PPO on file. If her plan has lapsed and nobody catches it in time, the visit goes ahead anyway, and it comes back weeks later as a denied claim and a surprise bill she wasn't expecting.

How it works

The agent runs once a day and sorts each upcoming appointment into one of three outcomes. It only ever does one thing per patient — it never both notes and emails the same person.

The adaptable agent

This is an example insurance-eligibility agent — a ready-to-use starting point. Use it as-is to see how it works, then change the highlighted fields so it matches how your practice runs day to day.

It's made of two kinds of pieces:

• Fixed pieces hold the agent's judgement and the safety rules that keep it reliable. Leave these as they are.
• Fillable pieces (shown in [BRACKETS]) are the details you swap for your own apps, inboxes, and timing.

Trigger

What starts the agent.

Instructions

Paste this into your agent. Change the highlighted [BRACKETED] fields to match your practice; leave the rest as it is.

TRIGGER CONTEXT
You run once a day. There's no single patient to look at — each run, you
build your own list: work out today's date, look [LEAD_DAYS] days ahead
(3 by default), and pull that day's appointments.

STEPS
1. Get the appointment list from [EHR_APP] for the target date.
2. Keep only the appointments that still need a check: ones that are still
   booked (not cancelled) and that bill insurance. If there are none, see
   "When something's unclear" below.
3. For each appointment, one at a time:
   a. Find the patient in [EHR_APP] by their patient id (or by last name
      and date of birth if all you have is a name).
   b. Read the insurance on file: payer, member id, name on the plan, plan type.
   c. Check eligibility with [ELIGIBILITY_APP] using the patient's name,
      date of birth, payer, and member id.
   d. Decide which one of the three outcomes fits, and do just that one:
      • Coverage is active and the name matches - save a short note to the
        chart (payer, plan, dates, and copay if it's returned). Don't email
        the patient. (A child correctly listed under a parent's plan still
        counts as a match — save it.)
      • Coverage is inactive, expired, or terminated, or the name or date of
        birth clearly doesn't match - send one secure email through
        [SECURE_EMAIL_APP] asking the patient to confirm or update their
        insurance before the visit. Don't save a note.
      • Anything you're unsure about - hand it to a person; don't guess.
        This includes confusing plan types, the plan on file disagreeing
        with what the check found, no insurance on file, a payer you can't
        find, or a result you can't read. Email [STAFF_INBOX] with the
        patient, the appointment, and what's unclear.
4. After the last appointment, send one short summary (how many were noted,
   emailed, and flagged) to [STAFF_INBOX].

WHEN SOMETHING'S UNCLEAR
- No appointments that day - you're done. Note "nothing to check today" and stop.
- More than one patient matches - don't pick one and don't run a check. Add
  them to the flag email and move on.
- No insurance on file - flag a teammate.
- A check fails for one patient - try it up to 3 times; if it still fails,
  flag that patient and keep going.
- Never both save a note and email the patient for the same appointment.

WHEN YOU'RE DONE
- Every appointment ended up in exactly one outcome (noted, emailed, or flagged).
- Each note is saved, each email is sent, and the summary has gone out.

GUARDRAILS
- Try a failed step up to 3 times before stopping.
- Handle one appointment at a time.
- When the run is finished, stop.

Tools to select

Tools are the actions you let your agent take inside your apps.

Swap any of these for the equivalent tool your practice already uses.

What to fill in

These are the only things you change so the agent fits your practice. Everything else stays the same.

What it produces

Every time it runs, the agent sorts each patient into one of three outcomes, based on what the eligibility check finds:

Try a variation

• "Check 7 days ahead instead of 3, so patients have a week to fix their coverage." (change [LEAD_DAYS])
• "When coverage has ended, also let billing know, not just the patient." (add [STAFF_INBOX] to the email step)
• "Send the daily summary to two inboxes — front desk and billing." (list both in [STAFF_INBOX])

Make it yours

• Change the highlighted fields, not the rest. The three outcomes and the "ask a person when unsure" rule are what keep the agent safe — leave those as they are.
• Match your own apps. Swap Athena Health, pVerify, and Paubox for the EHR, eligibility tool, and secure email your practice already uses.
• Set the timing to your prep window. Three days ahead is the default; pick whatever gives your front desk enough time to chase a lapsed plan before the visit.
• Let it ask for help. When the agent can't tell who a patient is, it hands the appointment to a person on purpose. Keep it that way — it checks and routes, it never diagnoses or guesses identity.

Helpful articles

• Create your first agent — the build flow from trigger to tools.
• Set up your agent's trigger — schedule vs event, and when to use each.
• Test your agent before publishing — how to read a run and confirm each step.
• Troubleshooting agents — what to do when a run stalls or a step fails.
• Patient intake → triage & routing — the sibling use case: read a new intake and send it to the right person.