Orvera AI

Member services, answered and resolved, on your existing stack.

For health plans. Orvera runs the member services line and the provider line across voice, chat and digital, resolves the conversation on the core administrative platform you already run, and audits every one.

SOC 2 Type II, HIPAA Compliant, GDPR
Hear the calls
Why coverage decides it

CMS tests the phone number. A sample cannot tell you which site failed.

CMS runs its Timeliness Study at the phone number level and its Accuracy and Accessibility Study at the call center level, so every legal entity behind a shared number or a shared vendor site carries that site's result.

A quality program on a sample

1-3%of conversations reviewed
  • Cannot tell you which site, which behavior or which team
  • Results arrive a quarter after the fact
  • The delegated sites you are accountable for are invisible
  • An assertion about your floor, not a record of it

Orvera

100%of conversations audited
  • Audited against the behaviors CMS actually fails plans on
  • Hold time and disconnect rate reported per regulated number
  • In quarter, not a quarter after the fact
  • Every interpreter and TTY event logged at interaction level
For health plans

Member services and the provider line.

Benefits, claims and grievance intake on the member line. Eligibility verification and the chart chase on the provider line. The compliance evidence produced as a byproduct of all of it.

  1. CMS call-center behaviorsPer site
    Hold time standard
    2 min
    Disconnect standard
    5%
    Current enrollee, Part CMonitored
    Current enrollee, Part DMonitored
    Pharmacy help deskMonitored
    Reported per team, site and delegated vendor
    01

    Every CMS call-center behavior, audited

    CMS publishes the behaviors it fails plans on, from a callback offer instead of a live person to a CSR demanding identifiers before confirming they can help. Orvera audits 100% of calls against those behaviors and reports the failure rate per team, site and vendor.

    • Moves Part C and Part D call-center compliance
    • Covers the delegated sites you are accountable for
    • Reported per team, site and vendor
    • Compliance measures, not Star Ratings measures
  2. Claim status and EOBExplained
    Adjudication
    Translated
    Next step
    Stated
    EOB openedLive
    Reasoning in plain languageYes
    Grievance boundaryHeld
    Read from the core administrative platform
    02

    Claim status and the EOB, explained

    A member opens an EOB or a provider bill and calls to ask why it was denied. Orvera reads the claim in the core administrative platform, translates the adjudication and denial reasoning into plain language, and states the correct next step.

    • Moves member satisfaction on claim resolution
    • Read from the core administrative platform
    • The grievance boundary is handled, not crossed
    • The correct next step is stated, not implied
  3. Benefit inquiryMember's own plan
    Plan variant
    PPO 750
    Accumulator
    Live
    Copay$45
    Deductible$750 of $750
    Answer sourceShown
    Coverage determinations handed to a person
    03

    Benefits answered from the member's own plan

    A member asks whether a service is covered, what the copay is, or how much deductible is left. Orvera reads the member's own plan benefit package and live accumulator, answers with the specific dollar figure, and hands off any coverage determination.

    • Moves repeat contact on the same benefit question
    • Scoped to that member's own plan variant
    • Answers with the specific dollar figure
    • Coverage determinations handed to a person
  4. Agent AssistLive on the call
    Approved answer

    Specialist copay is $45 once the deductible is met. This member has met it.

    Evidence of Coverage, PPO 750, benefit grid
    Tabs the rep skippedFour
    SummaryDrafting
    Approved answer surfaced inside the rep's own flow
    04

    The right benefit in front of the rep

    A human rep on a benefit call tabs between the core platform, the benefit grid, the accumulator and a PDF of the Evidence of Coverage. Orvera surfaces the approved answer for that member's specific plan variant inside the rep's flow, with the source shown.

    • Moves average handle time, down 8 to 15% in the first 90 days
    • The approved answer, with its source shown
    • Inside the rep's own flow, not another tab
    • The summary drafts while the call is live
  5. Provider services lineAuthenticated
    Cost per verification
    $6.78manual
    $0.34electronic
    Office authenticatedPass
    Eligibility and cost shareReturned
    Electronic route offered for next time
    05

    Eligibility verification on the provider line

    A provider office calls the plan to verify a patient's eligibility, benefit and cost share before service. Orvera authenticates the office, returns eligibility, benefit, cost share and accumulator from the core administrative platform, and offers the electronic route for next time.

    • Moves cost per verification, $6.78 manual against $0.34 electronic
    • A separately budgeted seat pool most vendors ignore
    • The calling office is authenticated first
    • The electronic route is offered for next time
  6. Chart chase, provider lineRetrieval only
    In scope
    The chase
    Coding and submission
    Not in scope
    Practice reachedLive
    Release requirementsCaptured
    Receipt recordedMember, measure
    Orvera retrieves the chart. It never reads, codes or submits it.
    06

    The chart chase, on the provider line

    A risk adjustment or quality reporting cycle opens and the charts sit in provider offices that each have their own release process. Orvera reaches the office, establishes what that practice actually requires, chases every outstanding request, and records receipt against the member and the measure.

    • The chase runs against every open request, not a coordinator's capacity
    • Each practice's own release requirements captured, not assumed
    • Receipt recorded against the member and the measure
    • Orvera retrieves the chart. It never reads, codes or submits it
  7. Voice of CustomerIn year
    Source
    Every call
    Survey sample
    Not needed
    Customer serviceWeight 2
    Getting care quicklyWeight 2
    Care coordinationWeight 2
    Themes under the rated measures, while the year is open
    07

    CAHPS drivers, in year, from real calls

    Plans learn what members think from a survey fielded on a sample and reported after the measurement year closes. Orvera mines every conversation for the themes underneath the rated experience measures and reports them by plan, region and driver while the year is open.

    • Moves the weight-2 CAHPS measures in the 2027 Star Ratings set
    • Read from conversations the plan already owns
    • Reported by plan, region and driver
    • Orvera does not administer the survey
Proof

Hear the calls

Real conversations from the member line and from the provider line behind it.

Eligibility and benefits check

Listen for the coverage and cost share read back from the plan's own record.

Open enrollment question

Listen for how a plan-year question is handled inside the enrollment window.

Claim status check, inbound from a provider office

Listen for how the calling office is authenticated before any claim detail is given.

Deployment lifecycle

AI agents are deployed through a structured lifecycle aligned to real contact center environments, not a switch you flip and hope.

01

Workflow creation

Your benefit rules, member scripts, call-center standards and past interactions are turned into structured workflows the agent follows.

02

Testing and validation

Workflows are tested across real scenarios for accuracy, escalation handling and compliance before a single live call.

03

Controlled deployment

Agents go live through a defined process, monitored and connected to your core administrative platform, telephony and ticketing.

04

Continuous improvement

Live performance feeds back into the workflows, sharpening resolution and compliance week over week.

Speed to value

From your benefit rules to full production deployment.

3-6weeks

to full production deployment.

  • Your own benefit rules and member scripts mapped into executable logic
  • Tested and validated across scenarios before go-live
  • Deployed within your existing core administrative platform and CCaaS

Timelines depend on workflow complexity and enterprise requirements.

Enterprise-ready

Approved-knowledge grounding, granular controls and full audit logs, across every channel. Every interaction comes with a complete report, transcript and summary.

Approved-knowledge grounding

Agents answer only from the sources you approve, no open-web guessing.

Verification on every disclosure

Identity, authority and minimum necessary, scored on 100% of conversations.

Full audit logs

A complete report, transcript and summary for every interaction.

Granular controls

Permissions, guardrails and policy, configured per channel and use case.

SOC 2 Type II
SOC 2 Type II
HIPAA Compliant
HIPAA Compliant
GDPR Compliant
GDPR Compliant
Also a provider?

Patient access runs on the same deployment.

Integrated systems that own hospitals and medical groups alongside the plan get scheduling, registration and patient billing from the same program, written back to the EHR.

See patient access for providers
Orvera AI
Get started

Start with one queue.

Bring your member services line, and Orvera builds it, deploys it and runs it inside 3 to 6 weeks, absorbing the deployment and implementation cost as a strategic partnership.

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