AI Admin Agents for Providers and Plans
AI for
CarelonAutomate Workflows with AI
By leveraging AI, Carelon can streamline revenue cycle management processes, automating billing actions and ensuring timely follow-ups for claims, thus enhancing overall efficiency and reducing manual errors.
Processing
Intake & Data Entry for Carelon
Connect to fax or upload documents from Carelon to automatically extract all fields and automate entry into your internal EMR and Billing systems.
Intake/case IX-8842
SOURCE FAX·EMR EPIC·03:14:22
intake.genhealth.ai /case-8842 / scan / sleep-rx.pdfcase-8842 / record
Live01 · Scan→02 · Record
Page 1 / 2
FAX · IN03/04/2026
Sleep Rx · CPAP
PatientAbe Lincoln
DOB02 / 12 / 1947
OrderCPAP, full setup
DxG47.33 — OSA
PlanBCBS TX · 847-21
ProviderL. Patel, MD
Scanning · 34 fields detected
Order · auto-filedSource · sleep-rx.pdf
CPAP Therapy
Member 847-21 · BCBS TX · MRN 789012
PatientAbe Lincolnp.1 · ln 1
DOB1947-02-12p.1 · ln 2
CPTE0601p.1 · ln 3
ICD-10G47.33p.1 · ln 4
PayerBCBS TX · eligible ✓p.1 · ln 5
Citation · sleep-rx.pdf, p.1, ln 4“Dx: G47.33 — OSA, recommend CPAP, full setup.”
✓
Claim filed837P · BCBS TX · ack 200
Utilization Management
Prior Authorization for Carelon
Submit or adjudicate prior auths with AI that understands the full picture between plan policies and patient histories. Works seamlessly with Carelon.
Prior auth/PA-2261
METFORMIN·T2D-04·03:14:22
priorauth.com/case/PA-2261
LiveMatch policy/Decision/Submit
EMR · Chart
847-21chart · 12 mo34
APPROVED
Prior
Authorization
Request
Authorization
Request
Payer Policy
BCBSIs the patient diagnosed with type 2 diabetes mellitus?
Does the patient have an A1C of 7.5% or greater?
Has the patient experienced a contraindication to metformin?
3 / 3 criteria metApproved
Verification
Eligibility for Carelon
Run eligibility checks without having to run eligibility checks. GenHealth will login to Carelon, verify patient eligibility, and close the loop in your internal applications.
Eligibility/case EL-4719
PAYER BCBS TX·MEMBER 847-21·03:14:22
healthplan.com/
Livelogineligibility/checkeligibility/result
Login/Patient info/Result
01 · Sign in
HealthPlan Portal
Provider workspace · BCBS TX
Email
genhealth@example.com
Password
●●●●●●●●●●
Sign in →
02 · Patient lookup
Eligibility Check
Verify member coverage with payer · real-time
Patient information
First name
Abe
Last name
Lincoln
MRN
MRN123456
Check eligibility →Checking…
03 · Result
Eligibility Result
Returned by BCBS TX · 270/271 in 1.2s
Abe Lincoln
MRN MRN123456
Active coverage
Member has coverage
Effective Jan 1, 2025 — Dec 31, 2025
Done ↵
Orders
DME Resupplies for Carelon
Automate everything from patient outreach, data entry to provider faxes fulfillment. Integrates directly with Carelon workflows.
Resupply/RX-7714
METFORMIN·90-DAY·03:14:22
resupplies.com/orders/RX-7714
LivePlan/Schedule/Ship
Patient Prescription
847-21Rx · active
Metformin 500mg
NDC 0093-1048-01 · oral
Sig
1 tab BID
Days supply
90 days
Quantity
180 tabs
Refills
3 of 3
Ship to
Abe Lincoln
1600 Pennsylvania Ave NW
Washington, DC 20500
Washington, DC 20500
last fill Dec 128 days remaining
Resupply Schedule
2026January ship · Jan 1
90X
February ship · Feb 1
90X
March ship · Mar 1
90X
April ship · Apr 1
90X
Start date
Jan 1, 2026
Cadence
Every 30 days
Window
8–11am
shipments scheduled0 / 41 / 42 / 43 / 44 / 4 ✓
Order →
Ordered