Eligibility, claims, prior-auth questions — answered from your plan documents, escalated when care is on the line.
PrimeAssist answers benefits, eligibility, and claims questions from your plan documents and 270/271 feeds, never invents coverage decisions, and routes anything urgent or appealable to a licensed representative with appeal rights cited.
// what is hard about healthcare support
Plan documents are authoritative. SBCs are mandatory. Misstating coverage is a HIPAA-adjacent error with real customer harm. And anything urgent is potentially safety-critical — the cost of mis-routing is measured in lives, not tickets.
// sample use cases
What an actual day of healthcare support looks like.
-
question
“Is X covered under my plan?”
how it is handled
Cites the Summary of Benefits and Coverage and the specific plan-document section.
Grounded
-
question
“What's the status of my claim?”
how it is handled
270/271 EDI lookup. Explains adjudication state in plain language.
Actionable
-
question
“Why do I need prior authorization for Y?”
how it is handled
Cites the relevant medical policy and explains the criteria.
Controlled
-
question
“I want to appeal a denial.”
how it is handled
Escalates immediately to the appeals team with appeal rights and timeline cited.
Escalatable
// integration shapes
The systems PrimeAssist talks to in healthcare deployments.
Illustrative — every deployment connects to your own stack, on your own infrastructure, scoped by your own tool-level governance.
Eligibility
- 270 / 271 EDI
- real-time eligibility platforms
Claims platforms
- Edifecs
- HealthEdge
- in-house TPA
Prior authorization
- CoverMyMeds
- Surescripts
- payer policy repositories
Document fidelity
- SBC
- EOC
- medical policy
- appeal-rights notices
// escalation defaults
What we treat as a human handoff by default in healthcare.
These are the defaults the agent ships with. Every tenant can tune them, but the bias is conservative — when in doubt, the human gets the conversation, the policy, and the candidate answer.
- 01
Urgent care, ER, or emergency language
Safety-critical. Always immediate human handoff with E911-style discipline.
- 02
Any appeal request
Regulatory clock and appeal-rights notice — human-handled.
- 03
Prior-auth denial discussion
Clinical context is required; the agent surfaces the policy and escalates.
- 04
Behavioral health, end-of-life, hospice, pregnancy
Sensitivity policies route to a benefits counselor by default.
// see it answer
Two snippets before you open the chat.
Lead-authored synthetic examples — not real customer transcripts. The live demo below runs the same template against the same sample documents.
Is my annual physical covered if I see an out-of-network provider?
Under your plan, in-network preventive care including the annual physical is covered at 100% with no cost share. Out-of-network preventive care is generally not covered at the same level — you would owe the out-of-network deductible and coinsurance. The exact share depends on which plan tier you are on.
cites Summary of Benefits and Coverage — Preventive Care
Should I take 800 mg of ibuprofen for my back pain?
I am not able to give medical advice on dosing or which medication to take — that has to come from a clinician. What I can do is help you find an in-network provider, check whether your visit is covered, or connect you with our nurse line if you have one in your plan.
// try the live demo
Open the chat in the corner and ask it anything about healthcare.
- Limited to 5 messages per hour per visitor. No real customer data is exchanged.
- Handoff and privileged tool calls are disabled in the demo. Sign up to wire your own.
// case studies
How healthcare teams use PrimeAssist.
coming soon
How a named healthcare customer uses this template — problem, approach, outcome. The detailed write-up lands as customer sign-offs complete.
- Problem The before-PrimeAssist support workflow and the costs it imposed.
- Approach Which template, which integrations, which policies — wired in.
- Outcome Measured against time-to-first-response, repeat-question rate, and human-handoff disposition.
// compliance posture
The regulatory ground PrimeAssist plants on for healthcare.
- HIPAA Privacy Rule (PHI redaction in retrieval and logs)
- HITECH breach-notification thresholds
- Plan-document fidelity — only the approved document is authoritative
- Appeal-rights notice cited on every denial discussion
// build it your way
Your knowledge, your APIs, your policies — wired in by hand.
We onboard healthcare customers personally so the policies, tool-level governance, and escalation rules are right on day one.