What can AI agents take over in Healthcare — payer operations?

tacitrun ships 10 Healthcare — payer process blueprints — Prior authorization intake & criteria match, Pended & exception claims adjudication, Member appeals & grievances and Coordination of benefits & overpayment recovery and more — each stating its inputs, outputs, KPIs and the points where a person stays in the loop. They are the starting point: the domain agents themselves are built by reading your own procedure, and every write they make waits for your approval.

High-value, high-volume payer operations processes.

Utilization Management & Claims

Prior authorization intake & criteria match

Intake an authorization request, extract clinical facts, and match against medical-necessity criteria. Auto-approve clean criteria; route the rest to a clinician. Never auto-denies.

Inputs
Auth request (X12 278 / fax / portal) · Clinical documentation · Member eligibility
Outputs
Touchless approval · Request for information (pend) · Clinician review packet
KPIs it moves
Touchless approval rate · Determination cycle time · Turnaround-time compliance · Auto-approval accuracy
Systems it usually runs on
Availity / clearinghouse · Core admin (Facets/QNXT/HealthEdge/Tapestry) · MCG / InterQual
Where a person stays in the loop
All adverse (medical-necessity) determinations — licensed clinician · Out-of-network exception

Pended & exception claims adjudication

Triage claims that fail auto-adjudication: classify the pend reason, gather data across systems, auto-resolve deterministic pends, and route judgment calls to an examiner.

Inputs
Pended 837 claim · Member eligibility + accumulators · Provider contract + fee schedule
Outputs
Adjudicated claim · Examiner review packet · SIU referral
KPIs it moves
Auto-adjudication rate · Pend resolution cycle time · Cost per claim · Prompt-pay compliance
Systems it usually runs on
Core admin platform · Clearinghouse (837/835) · Code-edit engine
Where a person stays in the loop
Pricing/contract exception · Medical-record-required review · FWA referral

Member appeals & grievances

Classify appeal vs grievance, determine the regulatory track and clock, assemble the case file, and route to the right reviewer with the acknowledgment drafted.

Inputs
Appeal/grievance submission · Original determination · Claim/auth + records
Outputs
Classified + clocked case · Assembled case file · Acknowledgment + resolution letters
KPIs it moves
Timeliness compliance · Overturn rate · Cycle time · Misclassification rate
Systems it usually runs on
Core admin + A&G case system · Document management · Correspondence
Where a person stays in the loop
Determination by independent reviewer (clinical overturn requires clinician)

Coordination of benefits & overpayment recovery

Detect other-coverage and overpayments, establish primary/secondary order, and pursue recovery or adjustment.

Inputs
Claim + other-coverage indicators · Payment history · COB rules
Outputs
COB order · Recovery / adjustment case
KPIs it moves
Recovery rate · COB accuracy · Days-to-recover
Systems it usually runs on
Core admin platform · COB vendor · Recovery workflow
Where a person stays in the loop
Recovery pursuit / write-off decision

Provider & Member Operations

Provider credentialing & re-credentialing

Run primary-source verification and exclusion screening, flag adverse findings, and assemble a committee-ready file.

Inputs
CAQH application · License / DEA / board data · Exclusion lists
Outputs
Committee-ready file · Clean-file consent agenda · Flagged exceptions
KPIs it moves
Credentialing cycle time · PSV accuracy · Clean-file rate · On-time re-cred %
Systems it usually runs on
CAQH ProView · NPPES / state boards · OIG-LEIE / SAM / NPDB · Credentialing system
Where a person stays in the loop
Credentialing Committee / Medical Director approval · Adverse-finding review

Provider data / roster load & directory accuracy

Validate, dedupe, and load provider roster updates against the provider master and keep the public directory accurate within mandated windows.

Inputs
Group roster / change request · Provider master · NPPES
Outputs
Loaded provider record · Updated directory · Rejected rows with reasons
KPIs it moves
Directory accuracy · Auto-load rate · Roster turnaround · Mandated-window compliance
Systems it usually runs on
Provider master / network mgmt · NPPES / CAQH · Public directory
Where a person stays in the loop
Conflict resolution · Contract-linkage exception

Member enrollment & eligibility (834)

Process inbound 834 enrollment files: validate, apply adds/changes/terms, and reconcile discrepancies so downstream eligibility is correct.

Inputs
834 enrollment file · Plan/benefit config · Premium/payment file
Outputs
Applied enrollment · ID card trigger · Reconciliation exception
KPIs it moves
Auto-apply rate · 834 cycle time · Reconciliation accuracy · Eligibility error rate
Systems it usually runs on
Core admin (enrollment) · EDI 834 / CMS-MARx · ID card + fulfillment
Where a person stays in the loop
Exception resolution · Retro-enrollment beyond window

Member services inquiry triage

Classify inbound member contacts, pull eligibility/benefit/claim context, draft the resolution, and route true exceptions to a representative.

Inputs
Member contact (call/chat/portal) · Eligibility + benefits · Claim/auth status
Outputs
Drafted resolution · Case + routing · Knowledge-grounded answer
KPIs it moves
First-contact resolution · Average handle time · CSAT · Containment rate
Systems it usually runs on
Core admin platform · CRM / service platform · Knowledge base
Where a person stays in the loop
Coverage/benefit exception · Escalation / complaint

Digital member & provider self-service

Member self-service (claim status, ID card, benefits)

Resolve common member requests digitally — claim status, digital ID card, benefit/accumulator lookups — with deflection and guided answers.

Inputs
Member request (web/app) · Eligibility + benefits · Claim history
Outputs
Self-serve resolution · Digital ID card · Escalation when needed
KPIs it moves
Digital containment · Self-serve adoption · CSAT · Call deflection
Systems it usually runs on
Member portal / app · Core admin platform · Eligibility (270/271)
Where a person stays in the loop
Coverage dispute / benefit exception

Provider portal auth & claim status

Answer provider portal/EDI status inquiries (auth status, claim status, eligibility) and surface what is needed to clear a pend.

Inputs
Status inquiry (277/portal) · Auth + claim records · Provider identity
Outputs
Status response · Required-action summary
KPIs it moves
Inquiry deflection · Response time · Portal adoption
Systems it usually runs on
Provider portal / Availity · Core admin platform · EDI (276/277)
Where a person stays in the loop
Disputed status / exception

What a blueprint is, and is not

A blueprint supplies the vocabulary, the typical steps, the KPIs and the approval points for a process. It is a starting point, not a pre-built agent: tacitrun builds the domain agents by reading your own procedure, tests them against cases derived from it, runs them in shadow beside your team, and holds every write for a person. Your IT connects the systems and approves before anything goes live.

Questions people ask

How do I give an agent a reference document (e.g. a sample template) to use at runtime?
Two places, both drag-and-drop: (1) for ONE agent, open it → Knowledge tab → drop the file on “Documents it can look up”; (2) for the WHOLE process (available to every agent in it), the process page has a “Documents for this process” card — drop it there. For example, drop a sample proposal template for a Proposal Generator. Whatever the format — PDF, Word, Excel, CSV, HTML, text, OR a screenshot/image (PNG, JPG, etc.) — we handle it: documents convert to clean markdown (tables and headings preserved, not a flattened blob), and images/screenshots are read by vision (Claude) which transcribes all the text and describes what’s in them (e.g. a screenshot of an invoice becomes a markdown table of its line items). Then we cap it to a sensible size for efficient token use, chunk and embed it so retrieval is sharp. It’s added immediately (no IT approval needed, nothing hardcoded) and shows in the document list. From then on the agent searches it live every run and uses it as a reference — e.g. it drafts new proposals in the shape of your template. To have it ALWAYS apply a rule instead of just look it up, use “Teach it” on the same tab (or the Rules tab for enforceable policies).
What is the Salesforce Data Hygiene blueprint, and how do I use it?
It’s a pre-built end-to-end process (a "crew" of 5 domain agents) that replaces the manual job of cleaning up messy CRM data and re-importing it. In the Catalog it shows as a Blueprint with the problem it solves, the outcomes it delivers, and the process mapped to each domain agent: (1) Data Quality Auditor profiles the object and reports duplicates/blanks/malformed/stale records; (2) Duplicate Finder & Merger proposes human-approved merges; (3) Field Standardizer normalizes phone/state/country/titles/casing; (4) Data Re-import Loader picks up a cleaned file (SFTP/SharePoint/Drive) and UPSERTS each row by external ID — so re-runs update the same record instead of creating duplicates; (5) Import Reconciliation Auditor verifies the load matched the source. Adopt each step from the blueprint; we build a private copy in your workspace that you can adapt, connected to your own Salesforce. Every write goes through human approval until you trust it.
What’s a Skill vs a Blueprint?
A Blueprint is a starter process template. A Skill is a reusable knowledge pack a domain agent loads on demand at runtime.
Do you have blueprints for private equity / deal teams?
Yes. Pick "Private equity" in Blueprints to get the full deal lifecycle (origination → diligence → execution & close with IC + signing gates → value creation → exit), plus the cross-portfolio value-creation playbook as standardized levers (working capital, FP&A, pricing/margin, spend analytics, JML access) that deploy identically across every portfolio company. Human-approval gates are built into the deal-close and IC steps. On Ingest, choosing "Private equity" also offers starter templates — Deal Sourcing & Screening, DD Red-Flag Log, IC Memo & Approval, and 100-Day & Value-Creation Plan.

Why offload this process to tacitrun’s AI operating layer

tacitrun is built for exactly this handoff: a business team describes the process it already runs, and the platform turns it into governed domain agents that work across the systems you have, under your IT’s approval, with every write waiting for a person.

Built from your procedure, not a vendor template
Describe the process in plain English or hand over the SOP. tacitrun compiles it into a process graph and composes one domain agent per step, so the agents carry your rules, your exceptions and your vocabulary.
Tested against the process before it can act
Evaluation cases are derived from the graph itself, so a passing agent is one that does what your process says. Then it runs in shadow beside your team on real work before anyone lets it act.
Every write stops for a person
The approval gate sits on the actual call to Salesforce, Shopify, SendGrid, SAP or any connected system. A person accepts, modifies or rejects; the corrected version is what executes; the trace keeps the record.
Runs across the systems you already have
Built-in connectors, your own REST APIs or MCP servers, and on the Enterprise plan your own cloud project and your own models. The systems of record stay where they are; the layer does the work between them.
IT approves, business leads
Business users build and prove; IT connects the credentials, binds the fields and approves before anything goes live. Neither side inherits the other’s risk.

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