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See how AI helps health insurance members
Member needs to find an in-network dermatologist near their home.
"AI searches the network: "I'd be happy to help you find an in-network dermatologist! Let me search based on your plan and location. I found 12 dermatologists within 10 miles of your ZIP code 60601 who are in-network with your PPO plan. Top 3 recommendations based on availability and ratings: 1. Dr. Sarah Chen at Midwest Dermatology - 2.3 miles away, accepting new patients, next available: January 18, 4.8/5 stars. 2. Dr. Michael Roberts at Chicago Skin Care - 4.1 miles away, accepting new patients, next available: January 22, 4.7/5 stars. 3. Dr. Lisa Park at Downtown Dermatology - 1.8 miles away, accepting new patients, next available: February 1, 4.9/5 stars. Your coverage details: Specialist visits have a $40 copay with your plan. No referral needed since you have a PPO. If the dermatologist orders tests or procedures, those may have separate costs - I can look up specific procedures if you know what you need. Would you like me to help you schedule with any of these providers, or would you like to see more options?""
Member received a bill they don't understand and thinks they were overcharged.
"AI explains the charges: "I can help you understand this bill. Let me look up the claim details for your visit to ABC Medical on January 5th. Here's the breakdown: Total charged by provider: $450 (office visit + blood work). Insurance negotiated rate: $285 (we have contracted rates with this provider). What insurance paid: $227 (your plan covers 80% after deductible). Your responsibility: $58. Bill breakdown: Your remaining 2024 deductible was $42, so that was applied first. Then your 20% coinsurance on the remaining $80 = $16. Total you owe: $58. Why you might have expected less: If you looked at the original $450 charge, $58 seems much lower. But our negotiated rate and your coverage work together to reduce your cost. Is this bill accurate? Yes, this matches your benefits. Your plan paid correctly. If the provider is billing you more than $58, that would be an error - let me know and I can contact them on your behalf. Would you like me to explain any specific line item, or help with setting up a payment plan?""
Member wants to know if their new medication is covered and what it will cost.
"AI checks drug coverage: "Let me look up coverage for Ozempic on your plan. Good news and some details to share: Coverage status: Yes, Ozempic is covered on your plan's formulary, but it's on Tier 3 (Preferred Brand). Cost breakdown: With your plan, Tier 3 drugs have a $75 copay for a 30-day supply. If you use our mail-order pharmacy, you can get a 90-day supply for $150 (saves $75 every 3 months). Prior authorization: Ozempic requires prior authorization for coverage. Your doctor will need to submit documentation that you've tried metformin first and have a diabetes diagnosis. I can send the PA form to your doctor. Alternatives to consider: If cost is a concern, there are Tier 1 alternatives: Metformin (generic): $10 copay, Glipizide (generic): $10 copay. However, these work differently than Ozempic - your doctor should advise on what's best for your condition. Next steps: Should I send the prior authorization form to Dr. Johnson's office, or would you like to discuss alternatives with your doctor first?""