Member360
An agentic layer that sits on top of a health plan's claims engine. When a claim is denied, it reads the Explanation of Benefits, decodes the denial, tells you who's responsible for fixing it, and hands you a word-for-word call script and appeal path. It explains the decision — it never makes one.
MRI — Right Knee · DENIED
Billed $1,250 · Member owes $1,250
Almost half of challenged denials are overturned. Almost nobody challenges.
The gap isn't medical — it's informational. The codes, the documents, the phone calls make it hard enough that most people give up before they start. Member360 gives them a foothold.
Five answers for every denied claim.
It reads the EOB, decodes the denial against your plan, and returns the same five things a good claims advocate would — in seconds, not a week of phone calls.
Why it happened
The denial code, in plain English. No CARC jargon, no guessing.
Who's responsible
Provider, plan, or you — so you call the right party first.
What to say
A call script with your claim ID, date, and provider NPI filled in.
What you owe
Real deductible status and what you actually owe — today.
How to appeal
The deadline, the SBC section to cite, and the escalation path.
In healthcare, a confidently wrong answer causes harm.
So the precise parts are deterministic, not guessed. Denial codes are an exact lookup. Plan rules come from one named section of your Summary of Benefits, never an open-ended search. Language models only handle the conversation — where they're genuinely the right tool.
If a code isn't recognized, the system says so and points you to Member Services. It never invents an answer.
Member360 proves we can build AI for complex, high-stakes, data-sensitive problems — not just operations tools. It shows the full range of what we can do.
Member360 is coming soon.
Want to know when Member360 launches — or a system like this built for your domain? Email us.