Group-Benefits & Disability-Claims AI Agent (ERISA Procedure)
Take the enrolment and eligibility position, intake the disability claim, open the correct regulatory clock, assemble the medical and vocational evidence, and draft the determination and its notice for a qualified reviewer to decide.
An employee enrols, and the agent records the eligibility position from the plan and the enrolment system.
02
A claim is filed, and the agent opens the clock from the date the plan received it, not the date it was assigned.
Reason
03
Medical and vocational evidence is assembled into the file, each item tied to its source.
04
The plan's own claims-and-appeals procedure is applied to the claim, not a generic timeline.
05
New evidence or a new rationale is surfaced to the claimant to answer before any final determination is drafted.
Decide
06
Missing evidence, an unaddressed treating-physician or SSA finding, and a clock at risk are flagged.
07
The drafted determination and notice are routed to the independent reviewer named for the claim.
Out
08
The claim, its clock, the evidence and the reviewer's decision stay on the file.
09
Execute write actions only inside the approval boundaries agreed during implementation.
→Product statement
The agent drafts the determination and its notice; a qualified reviewer decides, and a licensed clinician decides anything turning on medical judgement.
Example workflow
One claim, intake to determination
AgentHuman
1Claim receivedClaim form, plan documents, enrolment record or employer notice
2Clock openedFiling date, plan type, extension eligibility and the applicable claims procedure
3Evidence assembledMedical and vocational findings, treating-physician and SSA positions, and confidence
4Controls appliedClock-compliance checks, independence checks, disclosure-timing checks and confidence threshold
No human action required
Stages 1 to 4 run unaided, and no determination issues at any of them — the agent is assembling, and the reviewer's lane opens at the confidence gate.
5DecisionBranches at the confidence threshold
High confidence
Goes to the reviewer's queue as a completed file.
Low confidence
Routes for additional evidence before the file reaches the reviewer.
Independent review
The file is held with its evidence, its flagged gaps and the confidence.
Determine · Request more evidence · Escalate
Determined — released for notice▼
6Claims and plan systems updatedOnly where write access and approval policy allow it
7Outcome evaluatedEvidence completeness, disclosure timing, clock compliance and post-determination appeals
Evidence returns
Every evidence return is counted in the evaluation.
What should not run autonomously
Human approval stays in control
Outside the boundary — human approval required8 items
Denying, reducing or terminating a benefit.
Deciding medical necessity or disability status.
Setting an offset or the benefit amount.
Closing a claim.
Automation boundaryAgent acts unaided
✓Intake the claim and open the clock the regulation requires.
✓Assemble the medical and vocational evidence, tied to its source.
✓Surface new evidence or rationale to the claimant before a final determination.
✓Flag what the file still needs, and hold the draft.
Any write happens inside the boundaries agreed at implementation, never ahead of the reviewer.
Rescinding coverage outside the appeal procedure.
Resolving a return-to-work or accommodation request.
Marking a procedural miss de minimis on its own say-so.
Changes to claims-procedure rules or state configuration.
Example output
One claim on the clock, annotated
Everything the agent assembles is attached to the source it came from.
Claim-file output · single claimIllustrative example
Claim
Drafted finding
Clock status
Evidence type
Confidence
Attribution
Own-occupation LTD claim
States the evidence as insufficient, without addressing the treating physician's finding
Day 22 of 45
Treating physician letter
87%
Reviewer of record and licence ID
As receivedTaken from the assembled evidence and the clock as filed — nothing on this side is decided by the agent.
Why this is flaggedThe treating physician's finding is on the record and unaddressed.
ActionDetermineRequest more evidenceEscalate
What the score decidesBelow the configured threshold before it reaches the approver.
Value
Where AI adds value
The same four claims, placed at the point in the workflow where each one applies.
Where the value landsValue 01 – 04
Every claimFrom the claim intake
03Intake & assembly
Assemble against the clock
Draw on the assembled evidence and the plan's configured claims procedure.
01Approved path
The procedure is the substance
A clock that opens on the wrong date can send the claim to court before the plan ever gets an appeal.
02Human review
Point the reviewer at what the file
Missing evidence, an unaddressed treating-physician finding and a clock nearing its deadline are flagged, so review starts where the deadline is closest.
04Build an evidence trail
The claim, the clock it was filed against and the reviewer who decided stay on the file.
Integrations
Typical integrations
Five system groups connect to the same agent. Which of them are in scope is decided in discovery.
A blended turnaround rate across short-term and long-term claims can look compliant while a handful of claim cohorts absorb most of the procedural risk. Nestack reports the procedure-defect rate by slice, not only in total.
Slice performance — reported separately, not only in aggregateIllustrative example
Slice
Failure rate
Lift
Lift vs. threshold
Status
Claims where new evidence arrives late
7.7%
4.0×
Review
Own-occupation to any-occupation changes
5.5%
2.9×
Review
Claims with a contested eligibility date
3.4%
1.8×
Watch
Short-term claims with clear evidence
1.9%
0.7×
Normal
Bar: procedure-defect-rate lift vs. the short-term baseline · scale 0–4.0× · tick at 2.0×2 of 4 slices over threshold
Evidence-linked improvement
The cycle isn't done until the procedure holds
A cycle is done when the missed step has become a case the next release must pass. That suite is what the next determination made is measured against.
Improvement cycle · five stagesSwitchback — the path turns at Improve and returns at Learn
01Detect
Procedure-defect rate rises in a claim slice.
02Diagnose
The day the file sat while a form was ordered is traced back through the claim record until the cause narrows to one step.
03Improve
Version-stamp the change and attach the claims that exposed it.
04Verify
The affected cases run again, and a failure stops the release.
05Learn
It becomes a standing test, and the procedure rules change with it.
Learn → DetectThe return edge. Detection next time runs against a suite one claim longer.
Typical build scope
Twelve workstreams across six weeks
The build scope read against the delivery timeline. Week structure follows the six-week plan — discovery, sources, claims workflow, evaluation, integration, then production validation and handover.
WorkstreamWeek 1Week 2Week 3Week 4Week 5Week 6
01Claims-procedure discovery and scope and boundary definition.
02Benefits and claims system assessment.
03Procedure and state-configuration mapping and rule mapping.
04Claim intake and clock normalisation.
05Evidence-assembly logic and source binding.
06Confidence scoring and gap routing.
07Reviewer determination workflow.
08Claims and benefits system integration.
09Deadline and notice cases.
10Guardrails and review controls.
11Claim-trail instrumentation.
12Deployment, documentation and Agent Care handover.
12 workstreams · 6 weeks · bar shows the weeks a workstream is active — several run in parallelFinal scope and sequence confirmed in discovery
Engagement tiers
What each tier includes
Rows are the capabilities named in each tier's scope. Higher tiers include everything below them.
Capability✓ in scope · — not at this tierPilotOne plan, one lineProductionProduction claims systemsAdvancedMultiple plans / states
Introduced at Pilot
Assembly to your procedure and rules✓✓✓
Independent reviewer determination✓✓✓
Procedure-compliance baseline✓✓✓
Introduced at Production
Reporting by benefit type—✓✓
Reviewer workflow in your systems—✓✓
Approved write-back—✓✓
Benefits-system integration—✓✓
Introduced at Advanced
Multi-plan and multi-state rules——✓
Multi-stage reviewer approvals——✓
High claim volume——✓
Multi-plan disability controls——✓
Build priceFrom $5,000From $8,000Custom quote
Final build priceConfirmed after discovery based on integrations, workflow complexity, claim volume, review controls and deployment requirements.
Separate from buildBuild pricing is separate from recurring Agent Care, which covers managed monitoring, evaluations, incidents and verified improvements after launch.
What we need from you
What you bring, and what we build with it
Each input maps to a piece of build scope and a week in the delivery timeline.
You bringWe build with it
01Your claim-file structure and plan documents→Claim-file ingestion and clock mappingWeek 1
02Representative past claims, including denials→Evidence-assembly baseline and clock logicWeek 2
03Your claims-procedure rules and state list→Procedure and state-configuration mappingWeek 1
04Access to relevant APIs, feeds or exports→Claims and benefits system assessment, then integration setupWeek 2
05Determinations you would not want issued→Appeal cases and the evaluation suiteWeek 4
06What no determination may skip→Confidence scoring, gap routing, guardrails and review controlsWeek 3
07Named reviewers to determine claims→Reviewer determination workflow, then pilot and production validationWeeks 5–6
Nothing else is requiredDeployment, documentation and Agent Care handover are ours.
Delivery timeline
Four phases across six weeks
The phases are drawn on the weeks they occupy, so week 5 genuinely doubles rather than padding the plan.
PhaseW1W2W3W4W5W6
DiscoveryW1
BuildW2 – W3
EvaluateW4 – W5
Pilot & LaunchW5 – W6
Week focusW1Claims-workflow discovery, procedure mapping and the automation boundaryW2Benefits-system integration and the assembly baselineW3Assembly workflow, confidence logic and reviewer controlsW4Evaluation suite, deadline checks and failure-mode testingW5Benefits-system integration, pilot claims and targeted correctionsW6One claim cycle worked under the disability lead, then Agent Care handover
Reading the bandA bar covers the weeks its work is named in, and nothing else. The week 5 overlap is real, not padding.
At the end of W6The final checks clear on live claims and monitoring moves to Agent Care.
DurationSix-week plan shown · typical delivery 4–6 weeks depending on scope confirmed in discovery.
Next step · Insurance AI agent
Build a group-benefits and disability-claims agent around ERISA procedure, not a P&C timeline.
Show us your claims procedures and your plan documents. We'll map the intake-to-determination workflow and set the automation boundary; the clock, the evidence and the decision stay with your named reviewer.
