AI Coordination of Benefits Verification Agent

How Cassidy automates this using AI

Step 1: Trigger on new claim or eligibility change

The Workflow activates when an 837 claim arrives or an 834 eligibility update signals a potential COB situation—such as a new dependent, employment status change, or Medicare enrollment.

Step 2: Query coverage sources

Cassidy sends real-time 270 eligibility requests, checks CAQH COB Smart data, and pulls from CMS BCRC feeds to build a complete picture of the member's active coverages.

Step 3: Determine primacy with rules engine

The Agent applies NAIC order-of-benefit rules and CMS MSP logic—evaluating employer size, active vs. retiree status, ESRD windows, and birthday rule scenarios—to determine which plan pays first.

Step 4: Score confidence and route accordingly

Cassidy assigns a confidence score to each determination. High-confidence cases auto-resolve and update the COB file; low-confidence cases route to analysts with an evidence bundle of 271 responses, employer attestations, and decision traces.

Step 5: Control the claim pre-payment

For claims requiring verification, Cassidy places a hold with standard CARC/RARC codes, sets an SLA for resolution, and releases the claim for secondary processing or denial once primacy is confirmed.

Step 6: Maintain Section 111 compliance

Cassidy tracks MSP occurrences, effective dates, and employer details to support quarterly RRE submissions to CMS—reducing CRC recovery exposure and keeping your GHP reporting on schedule.