IIIPayers & Health Plans
AI for the side of healthcare that
actually pays for it.
Payers hold a different kind of complexity than providers. The volume is enormous, the workflows are policy-bound, and the members and providers on the other side of every call have real clinical stakes. Cara's engagements in this space focus on the workflows where AI can move the needle on both member experience and medical cost.
Sub-practices
Where our work tends to sit.
Commercial Plans
Commercial insurers, ASOs, and employer health plans. AI inside member operations, provider engagement, and prior auth.
Medicare Advantage
MA plans navigating CMS stars, risk adjustment, and member retention. AI in HEDIS gap closure, care management, and member acquisition.
Medicaid MCOs
Managed Medicaid plans balancing state contracts with member care. AI inside eligibility, care coordination, and SDoH referrals.
Employer & TPA
Third-party administrators and self-funded employer plans. AI for claims review, member navigation, and network optimization.
Pharmacy Benefit
PBMs and specialty pharmacy operations. AI inside prior auth, formulary management, and adherence programs.
Dental & Vision
Specialty benefit plans. AI for claims adjudication, network management, and member engagement.
Patterns
Where Cara sits in the work.
A representative flow — not a template. Every engagement shapes its own pattern around the partner’s actual constraints.
Example engagements
Patterns we keep seeing.
Agent-driven prior authorization
AI agents that review clinical evidence against policy, draft determinations, and prepare appeals packets. With a clinician in the loop on every non-trivial case.
Member operations & call deflection
Member-facing AI that handles eligibility, benefits, and claim-status conversations end-to-end. With handoff to live agents when the case genuinely requires one.
Utilization review & medical policy
AI that maintains, tests, and applies medical policy. Surfacing where policy language is ambiguous, where precedent has drifted, and where reviewer decisions fall outside established norms.
Care management & HEDIS gap closure
AI agents that review member records for open gaps, draft outreach to members and providers, and coordinate follow-up. Measurable impact on stars and HEDIS scores.
Fraud, waste & abuse
AI that reviews claim patterns, flags anomalies, and prepares case files for the SIU team.
Common questions
What partners ask before
they get on the call.
- Can Cara help with CMS-0057 prior-authorization compliance?
- Yes. Cara builds prior-authorization systems that meet CMS-0057-F interoperability and decision-time requirements: API-based intake, automated decisioning with clinician-in-the-loop on non-trivial cases, structured rationale, and patient-facing transparency. Determinations are auditable end-to-end.
- How does Cara compare to Cohere, Olive, or Availity?
- Those are point products. Cara is an embedded engineering engagement — we build the prior-auth, UR, or member-operations system around your medical policy, your claims platform, and your clinical leadership's review standards. The code is yours afterwards. There is no per-determination platform fee.
- How does Cara handle utilization review and medical policy?
- AI drafts determinations against your specific medical policy with citations to chart evidence and policy sections. A licensed clinician signs off on every non-trivial case. The system surfaces where policy language is ambiguous, where reviewer decisions have drifted, and where precedent should be reviewed.
- Is the AI's reasoning auditable?
- Yes. Every step — input documents, policy match, draft rationale, clinician edits, final determination — is captured with versioning. Member appeals can pull the full record. Internal audits and external regulators can trace every decision.
- What scope of plans do you work with?
- Commercial plans, Medicare Advantage, managed Medicaid, ASOs and TPAs, PBMs, and specialty benefit plans. Cara has worked across utilization management, member operations, HEDIS gap closure, and care management.
“The workflows where AI moves the needle for payers are the same workflows where mistakes matter most. Rigor is not optional.”