AI Vision Benefits Claim Processing Agent
Automating Vision Benefits Claim Processing with AI
Payer-Specific Submission Intelligence
The agent navigates the distinct requirements of each vision payer—portal-based workflows for VSP Eyefinity, EyeMed Online, and Versant Health, plus standard EDI 837P for Spectera—applying the correct authorization, provider IDs, and materials catalog logic automatically.
Real-Time Eligibility and Benefits Application
Automated workflows verify member eligibility, pull plan-specific benefits data (frame allowances, lens option coverage, exam frequency), and calculate patient responsibility at the point of service before claims are even created.
End-to-End Remittance and Exception Handling
The system ingests EOPs from payer portals and 835 ERAs where available, auto-posts payments with CARC/RARC mapping, flags underpayments or denials, and routes correctable exceptions for resubmission without manual intervention.
How Cassidy automates this using AI
Step 1: Trigger on appointment or check-in
The Workflow activates when a patient appointment is scheduled or check-in occurs, pulling member information from your PM or EHR system to initiate the claim lifecycle.
Step 2: Verify eligibility and retrieve authorization
Cassidy connects to the appropriate payer channel—Eyefinity for VSP, EyeMed Online, Versant Health ECP Portal, or EDI 270/271 for Spectera—to verify coverage, pull benefit details (frame allowance, lens tiers, copays, frequency), and retrieve or create the required authorization.
Step 3: Capture encounter and apply coding logic
As exam and materials data flows from your EHR, Cassidy maps services to the correct CPT codes (92002–92014, 92015, contact lens fitting) and captures materials selections using each payer's catalog logic—SKUs and lens options for portal-based plans, HCPCS V-codes where EDI applies.
Step 4: Scrub and submit claims
Cassidy validates each claim against payer-specific rules—auth presence, NPI/Tax ID/Office ID combinations, benefit allowances, and duplicate checks—then submits via the correct channel: portal automation for VSP/EyeMed/Davis or 837P to Spectera (payer ID 00773).
Step 5: Monitor status and handle exceptions
The Workflow tracks claim status through portal dashboards and EDI acknowledgments (999, 277CA), automatically correcting and resubmitting deterministic errors while routing complex exceptions—benefit exhaustion, auth mismatches, non-covered materials—to a human worklist.
Step 6: Post remittance and reconcile payments
Cassidy ingests EOPs from payer portals and 835 ERAs, auto-posts line-level payments and adjustments to your ledger, reconciles EFT deposits, and generates patient statements for any uncovered balances or overages.
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
