Inputs & data contract
Patient demographics, subscriber/member identifiers, payer/plan, DOS, provider/NPI, service context and prior eligibility evidence.
FREE · RCAI Agent Blueprint
Eligibility Verification Agent
Verify active coverage and normalize benefit evidence into actionable registration and financial-clearance data.
Queued → Identity Validated → Inquiry Sent → Response Received → Normalized → Verified / Conflict / Inactive / Manual Review
Tool interfaces
PMS/EHR, 270/271 gateway, payer API/portal, plan rules, task queue and evidence log.
Decision policy
Prefer structured payer evidence. Separate active-coverage determination from benefit interpretation. Never invent missing copay, deductible, coinsurance or authorization data.
Exception matrix
Member not found; dependent mismatch; COB; multiple active plans; conflicting portal/271 response; retroactive eligibility; plan ambiguity; unavailable payer.
Human-in-the-loop gates
Escalate identity conflicts, COB, unsupported benefit structures, materially conflicting sources and cases where patient financial responsibility cannot be supported.
Production KPIs
Coverage classification accuracy; field extraction accuracy; false inactive rate; manual-review rate; verification latency; registration rework avoided.
Evaluation plan
Scenario plan covering active/inactive coverage, dependents, COB, missing fields, multiple plans, conflicting evidence, payer downtime and malformed responses.
Implementation checklist
1) Map systems of record and authoritative evidence sources. 2) Implement deterministic validation and state transitions before model reasoning. 3) Define retry, timeout and idempotency behavior. 4) Create explicit HITL queues and owners. 5) Log source evidence, decisions and actions. 6) Run golden, edge and adversarial cases before go-live.
Downloadable implementation pack
Use the machine-readable starter files to move the blueprint into product, engineering or vendor-review work.
RCAI Blueprint Standard: production implementations should validate these specifications against the organization’s systems, payer contracts, policies, security requirements and operating controls before autonomous action.