AI Payer Contract Compliance Agent

How Cassidy automates this using AI

Step 1: Trigger on HPMS engagement or scheduled audit prep

The Workflow activates when CMS issues an engagement letter through HPMS or on a recurring schedule—pulling scope details, universe request tables, and record layout requirements into Cassidy's Knowledge Base.

Step 2: Normalize and validate universe data

Cassidy ingests data from A&G platforms, UM systems, pharmacy, and claims repositories, then transforms records into CMS-compliant formats—validating date/time fields (CCYY/MM/DD, HH:MM:SS), enforcing time zone consistency, and applying exclusion rules for reopenings and withdrawals.

Step 3: Monitor timeliness and flag at-risk cases

The agent applies encoded ODAG/CDAG timeliness rules—14-day standard determinations, 72-hour expedited windows, Part B drug special timeframes—and surfaces cases approaching deadlines to compliance teams with auto-generated escalation alerts.

Step 4: Assemble evidence and generate audit artifacts

Cassidy compiles case-level evidence packets including screenshots, determination timestamps, clinical review documentation, and notification delivery proofs, then packages them for webinar presentations and integrity testing.

Step 5: Generate RCA and Impact Analysis templates

When noncompliance is identified, the Workflow auto-populates Root Cause Analysis templates within the 2-business-day window and drafts Impact Analyses with case counts, affected populations, and Star Ratings exposure within 10 business days.

Step 6: Sync CLM obligations and propagate protocol changes

Cassidy extracts regulatory obligations from provider and FDR contracts, maps them to operational controls, and when HPMS memos update protocols, triggers CLM amendment workflows and notifies impacted teams to adjust system configurations.