AI Dependent Eligibility Verification Agent
Automating Dependent Eligibility Audits with AI
Intelligent document recognition and validation
AI automation classifies uploaded documents—birth certificates, marriage licenses, student letters, court orders—extracts key fields, and validates them against your plan's documentation matrix and eligibility rules.
Fraud detection with human oversight
Automated forensic analysis flags tampered documents, metadata anomalies, and suspicious patterns, routing flagged cases to reviewers with clear confidence scores and explainable findings.
Automated adjudication and downstream file generation
The system applies plan rules to approve, pend, or reject dependents, then generates purge files for HRIS and carriers, COBRA qualifying events, and surcharge updates—with full audit trails for compliance.
How Cassidy automates this using AI
Step 1: Ingest plan rules and documentation matrix
Cassidy's Knowledge Base syncs your SPD, plan documents, CBAs, and documentation requirements—so every verification decision reflects your specific eligibility rules, relationship types, and acceptable proofs.
Step 2: Trigger on document submission
The Workflow activates when an employee uploads verification documents through your white-labeled portal, capturing marriage certificates, birth certificates, student letters, court orders, and affidavits.
Step 3: Classify and extract document data
Cassidy uses OCR and document classification to identify document types, extract names, dates, and issuing authorities, and cross-reference extracted data against the dependent's enrollment record.
Step 4: Validate against plan rules
The Agent checks extracted data against your documentation matrix—confirming marriage dates precede coverage start, student letters are current, divorce decrees align with termination policies, and QMCSO exceptions are honored.
Step 5: Flag fraud and route for review
Forensic analysis detects tampered documents, font inconsistencies, and metadata anomalies. Flagged cases route to human reviewers with confidence scores and clear explanations, keeping your team in the driver's seat on high-risk decisions.
Step 6: Generate determinations and communications
Cassidy produces approval, conditional approval, or rejection decisions with reason codes, then drafts personalized notices, missing-document requests, and appeal instructions—all branded to your TPA or employer client.
Step 7: Create downstream system files
Approved and rejected cases flow into purge/termination files for HRIS and carriers, COBRA qualifying event files, and surcharge updates for payroll—with immutable audit logs for ERISA and HIPAA compliance.
Implement it inside your company
- Hands-on onboarding and support
- Self-paced training for your team
- Dedicated implementation experts
- Ongoing use case discovery
- ROI tracking & analytics dashboards
- Proven playbooks to get started fast
