How a Leading Health Plan Accelerated Access to Care Through Real-Time Benefit Verification

Overview

A leading health plan sought to improve the speed and consistency of benefit eligibility and coverage verification. Its existing process required clinical and administrative teams to navigate multiple systems, interpret responses in different formats, and reconcile incomplete or conflicting information before confirming a member’s eligibility, coverage limits, and benefit requirements.

The organization needed a scalable approach that could reduce administrative effort, accelerate authorization decisions, and provide members and providers with clearer, more timely coverage information.

Challenge

Benefit verification was a fragmented, labor-intensive process. For each case, staff often had to:

• Query multiple eligibility, benefit, and claims systems
• Interpret responses presented in different formats
• Manually validate coverage limits, exclusions, and constraints
• Reconcile incomplete or inconsistent information
• Conduct additional follow-up when coverage details were unclear

As request volumes increased, the manual workflow led to delays and inconsistent turnaround times. Clinical and operational teams spent valuable time gathering and validating information instead of advancing case decisions and supporting members.

The impact extended across the healthcare experience. Members faced uncertainty about their coverage, prolonged authorization decisions, and potentially delayed treatment, and providers encountered additional follow-up and rework, creating friction at the point of care.

The organization needed to make benefit verification faster, more consistent, and more scalable without compromising accuracy, compliance, or oversight.

Solution

Autonomize AI implemented an AI-powered benefit verification capability that automates and orchestrates eligibility and coverage checks across multiple data sources in real time. The solution:

• Connects to multiple eligibility and coverage systems simultaneously
• Normalizes and reconciles responses into a unified structure
• Applies organization-specific rules to validate eligibility, coverage limits, and constraints
• Delivers a structured, reviewer-ready determination in less than 45 seconds

Embedded directly into existing utilization management and authorization workflows, the solution gives reviewers a comprehensive view of a member’s benefits without requiring them to navigate multiple systems or manually gather, compare, and interpret coverage information.

Autonomize transformed benefit verification from a routine source of delay into a real-time intelligence capability. By closing the administrative gap between a request and a coverage determination, the solution enables faster, more consistent decisions while giving providers timely answers and members greater clarity about their benefits.

Results

The solution delivered reliable performance across both peak and steady-state volumes:

• Processed an average of 77,000 requests per week 
• Achieved a successful processing rate of more than 99.5%
• Consistently maintained response times of less than 45 seconds, including during periods of elevated demand

Clinical and Operational Impact

By automating one of the most time-consuming administrative steps in the authorization process, Autonomize helped the organization improve efficiency, accelerate decisions, and scale without compromising performance. The solution:

• Reduced the manual effort required to verify eligibility and coverage
• Enabled near-real-time benefit determinations
• Improved the consistency of benefit interpretation across reviewers
• Minimized rework caused by incomplete or conflicting information
• Reduced workflow interruptions and the need to navigate multiple systems
• Allowed clinical teams to spend more time evaluating care needs
• Supported growing request volumes without performance degradation

With structured, comprehensive benefit information available in seconds, reviewers could make decisions with greater speed and confidence while spending less time gathering and reconciling administrative data.

Provider and Member Impact

Providers received faster answers and clearer information about coverage requirements, limitations, and constraints. This reduced follow-up inquiries, accelerated authorization workflows, and improved coordination among payers, providers, and care teams.

Members benefited from faster case decisions, greater clarity about their coverage, and less uncertainty while awaiting a determination. By removing an administrative bottleneck at the beginning of the authorization process, the solution helped reduce delays between a request for care and access to approved services.

Together, these improvements created a faster, more scalable, and more member-centered authorization process, strengthening operational performance while improving the experience for clinical teams, providers, and members.

Conclusion

By automating benefit eligibility and coverage verification across fragmented systems, Autonomize transformed a historically manual bottleneck into a fast, structured, and scalable workflow. The result is quicker decisions, lower administrative burden, and a more efficient path from request to resolution without compromising accuracy, compliance, or oversight.