AI Stop-Loss Reporting Agent

How Cassidy automates this using AI

Step 1: Trigger on policy setup or data sync

The Workflow activates when policy terms are loaded or when new claims data arrives from connected sources—TPA claim systems, PBM feeds, eligibility files, and funding statements.

Step 2: Monitor claims against trigger thresholds

Cassidy continuously evaluates incoming claims against configured rules: 50% of specific deductible, catastrophic diagnosis codes, 7+ day inpatient stays, and specialty Rx thresholds—flagging potential large claims in real time.

Step 3: Generate and transmit carrier notices

When triggers are met, Cassidy auto-generates compliant large-claim notices with claimant demographics, diagnosis details, amounts paid, and case management notes—then transmits them to the carrier within policy-required timelines.

Step 4: Assemble proof-of-loss packages

Once claims exceed the specific deductible, Cassidy compiles the complete proof-of-loss: eligibility verification, itemized UB-04/CMS-1500 forms, EOBs, clinical documentation, funding proofs, and COB/subrogation artifacts.

Step 5: Submit and track reimbursements

Cassidy files initial and supplemental specific claims, monitors carrier adjudication, and tracks reimbursement status—while producing monthly aggregate reports with accurate exclusion logic and cumulative loss ratio dashboards.

Step 6: Automate renewal disclosures

At 60-90 days pre-renewal, Cassidy generates standardized disclosure reports with current large claimants, UM/CM cases, and prognosis estimates—orchestrating required signatures from employer, TPA, and broker.