AI Medicare Coordination Benefits Agent

How Cassidy automates this using AI

Step 1: Trigger on patient encounter or scheduled verification

The Workflow activates when a new patient encounter is registered, an MSP questionnaire is completed, or on a defined cadence (such as every 90 days) to ensure coverage data stays current.

Step 2: Normalize identifiers and construct 270 inquiry

Cassidy validates and normalizes patient demographics MBI, DOB, and payer member IDs then constructs a compliant HETS 270 request per ASC X12 005010X279A1 and CMS Companion Guide specifications.

Step 3: Submit real-time eligibility verification

The Workflow submits the 270 inquiry to HETS, handles TA1/999 acknowledgments, and parses the 271 response to extract Part A/B eligibility, MA/Part D enrollment, MSP records (payer name, policy number, effective dates, MSP type), and QMB status.

Step 4: Reconcile MSP data and flag discrepancies

Cassidy compares HETS 271 results against patient-attested coverage and payer EOBs, generating a discrepancy report when conflicts exist and queuing BCRC/MAC outreach tasks with auto-generated evidence packages.

Step 5: Determine payer order and prepare claim data

Using statutory MSP rules, Cassidy determines the correct payer sequence for each date of service, then populates 837P/I other payer loops (2320/2330), CAS segments, and UB-04 MSP value codes validated against MAC-specific edits before submission.

Step 6: Monitor adjudication and trigger corrective actions

Cassidy watches incoming 835 remits for CO-22 denials, MA enrollment rejections, or MSP coding errors automatically triggering new 270 verifications, claim corrections, or secondary submissions when COBA crossover gaps are detected.