An AI phone agent that answers member eligibility and claim-status calls instantly — and hands the rest to a care guide with full context, no repeating, no waiting.
Built on the proven provider foundation
Members calling for routine answers — am I eligible, what's the status of my claim — waited in the same queue as everyone else, tying up care guides on questions a system could answer. Pisteyo delivered a Member Phone Agent that handles those routine calls instantly, authenticates the member once, and routes everything else straight to a care guide with context already in hand.
The organization is a healthcare provider whose care-guide teams — in-house and outsourced — field a high volume of inbound member calls every day. A large share are routine: members checking eligibility or the status of a claim. Answering them well, and fast, matters to member experience — but it doesn't always need a person.
Every member call landed in the same queue, so routine eligibility and claim-status questions competed for care-guide time with the calls that genuinely need empathy and judgment. The organization asked Pisteyo to contain the routine calls with an AI phone agent — without adding friction: no authenticating twice, no menu traps, and anything beyond eligibility or claim status straight to a care guide.
A staged delivery designed for quality, compliance, and trust — moving from scope to a production-ready capability without disrupting the business.
Reused the provider phone foundation so the member agent inherited a tested eligibility and claim-status flow.
Designed call routing so only eligibility and claim-status inquiries reach the AI; everything else goes to the member queue and care guides.
Streamlined authentication to remove double authentication — improving the member experience and reducing cost.
Reviewed the menu design for efficient handling and a clean path to a person when needed.
Coupled member authentication with the care-guide handoff so an agent picks up with the member already verified and context ready.
Validated readiness with sanity tests and status reviews before going live.
The honest view: every deployment meets real-world constraints. Here is what was hard, and the deliberate choices that kept quality high and risk low.
Members with eligibility or claim-status needs must reach AI, everyone else a person — without double authentication. The team validated the routing logic before launch.
An early flow risked authenticating members twice. Pisteyo redesigned it to a single pass, improving experience and cutting cost.
The menu had to contain routine calls without frustrating members; it was reviewed specifically for clean escalation to a care guide.
Bypassing AI for non-routine inquiries keeps spend aligned to where AI actually adds value.
Pisteyo delivered a Member Phone Agent that answers routine eligibility and claim-status calls instantly and routes everything else to a person with context already in hand. Routine member calls are now contained by AI.
“This simple Member Phone Agent has been a net positive for my members and the team of care guides serving them.”
With the member channel contained for routine inquiries, the agent's scope can widen over time and pair with proactive outreach — turning the phone line from a cost center into a responsive, always-on service layer. Combined with the provider phone agent and plan chat, the organization is building a consistent AI front door across audiences.
Routine eligibility and claim-status calls; everything else routes straight to a care guide with the member already authenticated and context in hand.
No — a single authentication flow is shared with the care-guide handoff, which also lowers cost.
Yes — members get instant self-service answers on eligibility and claim status any time of day.
It reused the proven provider phone foundation, inheriting a tested eligibility and claim-status flow.
Routine member calls are contained, handle time is shorter, wait times drop, and care guides focus on the conversations that need a person.
The same operator-led approach — strategy, build, and measured adoption — applied to your workflows.
