Member services
The call center and the digital service channels.
- Benefits, claim status and ID card questions
- Cases opened from calls, chat and portal messages
- Callbacks and follow-ups that do not get lost
Healthcare / Payer Operations
Payer operations software development
Member and provider service, appeals and grievances, prior authorization and utilization management each run on their own tools, and the member's case falls between them. Agnotic Technologies builds payer operations software that gives service, clinical and appeals teams one case record, routed work and reporting that matches the rules you are measured against.
One case record
Per member or provider issue, across every team
Clocks
Regulatory timeframes tracked on each case type
X12 278 · FHIR
Prior authorization intake from fax, portal and API
Trusted by global innovators
Industry Overview
What is payer operations software?
Payer operations software is the set of tools a health plan's service, clinical and appeals teams use to handle member and provider contacts, prior authorization and utilization management, appeals and grievances, and the reporting those workflows require. Agnotic Technologies builds payer operations software for health plans and TPAs around one case record, connected to the core administration system.
Operations teams
Which payer operations teams do we build for?
Four teams, four sets of rules, one member. The tools should share the record even when the teams do not share a floor.
Provider services
The teams that support the network.
- Eligibility, claim status and payment questions
- Credentialing and contract inquiries
- Provider disputes tracked to resolution
Utilization management
Clinical teams that decide prior authorization and concurrent review.
- Requests from fax, portal and FHIR APIs in one queue
- Clinical criteria and reviewer routing
- Decision timeframes and notices
Appeals and grievances
Teams that handle complaints and reconsiderations.
- Intake by phone, letter, portal and fax
- Case types, deadlines and extensions
- Decision letters and reporting
Industry Challenges
Why do payer operations workflows break?
The same failure points show up in plans of every size.
No single case: a member calls three times and speaks to three people with three records.
Deadlines tracked by hand: appeal and authorization timeframes live in spreadsheets, and misses are found at audit.
Fax in, retype out: requests arrive as images and someone types them into the system of record.
Reporting after the fact: measures assembled monthly from exports instead of from the workflow itself.
Our Approach
How do we design the case record?
One case record is the design decision the rest of payer operations software depends on.
Case types with clocks
Each case type carries its regulatory timeframe, extension rules and required notices.
Linked to the core
Cases reference the member, provider, claim or authorization in the core, never a copy of it.
Every touch recorded
Calls, documents, decisions and letters attach to the case with who, what and when.
Minimum necessary access
Service staff see what their role needs; clinical detail is limited to reviewers.
Capabilities
What do we build for payer operations?
Tools for each operations team, all working on the same case record.
Service desk
Member and provider views with coverage, claims, authorizations and case history, plus scripts for common contacts.
Case management
Case types, routing, service levels, tasks and escalations for every operations team.
Prior authorization intake
Fax and portal capture into structured requests, plus FHIR intake through Da Vinci PAS.
Utilization management workbench
Clinical criteria, reviewer assignment, decisions and notices with a full audit trail.
Appeals and grievances
Intake, classification, deadline tracking, decision letters and reporting.
Operations reporting
Queues, timeliness and outcomes from workflow events, by team and case type.
Engineering Stack
Which standards and technologies do operations tools use?
The standards, channels and platforms behind the payer operations tools we build.
Standards
X12 278FHIR R4Da Vinci CRD, DTR and PASHL7 v2 where clinical data arrives
Channels
Telephony and IVRSecure messagingFax and document capture
Backend
Node.jsJavaPythonPostgreSQL
Infra
AWSAzure
Failure-point list
Where do operations workflows fail, and what do we build instead?
Failure points we design against in payer operations work, the workflow each belongs to and the design that removes it.
| Workflow | Failure point | What we build instead |
|---|---|---|
| Member service | The agent cannot see claims, authorizations and prior contacts on one screen | A service desk that reads the core, the authorization system and the case history into one member view |
| Provider service | Claim status questions answered by looking each claim up by hand | Provider self-service for eligibility and claim status, with a case opened only when self-service cannot answer |
| Prior authorization | Fax requests retyped, then lost between intake and clinical review | Document capture into a structured request, FHIR intake where providers support it, and one queue for reviewers |
| Utilization management | Reviewer routing by email, with no record of who held the request when | Rules-based routing by service type and licensure, with every handoff timestamped |
| Appeals and grievances | Deadlines and extensions tracked in spreadsheets | Case types with regulatory clocks, reminders before deadlines and extension records |
| Correspondence | Decision letters written by hand with inconsistent reasons | Letter templates filled from the case record, with the reviewer's reason captured as data |
| Reporting | Monthly measures built from exports | Reporting from the workflow events themselves, including the prior authorization measures payers must report |
Measured Impact
Which measures do operations leaders need?
Measures we build reporting around, agreed with your operations leads before launch.
Timeliness
Cases decided within their timeframe
By case type: standard and expedited authorizations, appeals and grievances.
First contact
Contacts resolved without a callback
Member and provider contacts closed on the first interaction.
Electronic share
Requests that arrive structured
Prior authorization requests received through the portal or API instead of fax.
Overturn
Appeals that reverse the original decision
A signal for the rules and criteria upstream.
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Use Cases
Which payer organizations do we build operations tools for?
Payer types with their own rules, timeframes and notices.
01
Medicare Advantage organizations
Grievances, organization determinations and appeals with their own timeframes and notices.
02
Medicaid managed care plans
State-specific service levels, fair hearing coordination and reporting.
03
Commercial and marketplace plans
Internal appeals and external review under federal rules.
04
TPAs and insurtech startups
Payer operations for startups: service and case tools built before the call center grows.
05
Delegated utilization management vendors
Authorization operations run on behalf of several plans with separate rules.
06
Pharmacy and specialty benefit managers
Coverage determinations and appeals for drug benefits.
Integrations
Which systems do operations tools connect to?
The systems a case reads from and writes to between intake and closure.
Core
Core administration system
Channels
Telephony and contact center
Intake
Fax and document capture
Utilization management
Clinical criteria sources
Providers
Provider EHRs (FHIR, X12 278)
Correspondence
Letter generation and mail
Compliance-First Development Services Backed by Global Standards
We build secure, scalable products designed for privacy, interoperability, and regulatory readiness from day one across every sector we serve.
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, and strict access controls.
Fast Healthcare Interoperability Resources
Enabling standardized health data exchange through standards-based API mappings.
Our Edge
Why Global Leaders Choose Us
We combine deep technical expertise with industry-specific knowledge to deliver solutions that aren't just functional, but transformational.
Enterprise-Grade Security
We implement rigorous security protocols and compliance standards (HIPAA, GDPR, SOC2) across all industrial solutions to protect sensitive data.
High-Performance Scaling
Our architectures are built to handle massive data loads and user bases, keeping performance steady whether you're serving ten or ten million.
Accelerated Time-to-Market
Using our suite of internal tools and proven frameworks, we reduce development cycles and get your product to market 40% faster.
Embedded AI Integration
Beyond simple wrappers, we build deep-learning integrations and predictive analytics directly into the core of your industry-specific workflows.
Engagement Model
How do we build payer operations software?
How to build payer operations tools one team at a time. Timing depends on scope and is agreed on the scoping call.
01
Scoping call
We agree which team and which case type come first, and which systems the tools must read.
02
Workflow mapping
We walk each case type from intake to closure with the people who do it, noting every handoff and deadline.
03
Fixed-scope first release
One team's workflow on the case record, connected to the core, with reporting from day one.
04
Next team
Each further team joins the same case record, so member and provider history is shared.
05
Support and change
New case types, regulatory changes and reporting under agreed support terms.
Facts and sources
Which rules shape payer operations software?
Short facts behind operations workflows, each linked to its primary source.
Under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), Medicare Advantage, Medicaid and CHIP payers must decide prior authorization requests within 72 hours for expedited requests and 7 calendar days for standard requests, starting in 2026.
Source: Federal Register, February 8, 2024 (CMS-0057-F)A Medicare Advantage organization must establish meaningful grievance procedures and meet the requirements for organization determinations and appeals set out in 42 CFR Part 422 Subpart M.
Source: 42 CFR Part 422 Subpart M (eCFR)Group health plans and health insurance issuers must provide an internal claims and appeals process and an external review process under 45 CFR 147.136, which generally does not apply to grandfathered plans.
Source: 45 CFR 147.136 (eCFR)The HIPAA Privacy Rule's minimum necessary standard requires covered entities to limit uses and disclosures of protected health information to the minimum needed for the purpose.
Source: 45 CFR 164.502(b) (eCFR)
Voice of success
We don't just build products; we forge lasting partnerships. See how we've helped industry leaders transform their vision into technical reality.
“I can clearly see how Agnotic has a unique way of handling end-to-end development. They are always active on quick chat and provide support quickly.”
Aaron Phelan
Founder, Benchmark
“Agnotic combines deep technical expertise with strong domain knowledge. They understand the business context, anticipate challenges, and make collaboration smooth and effective.”
John Pasmore
Founder, Latimer
“Agnotic is the best technical team we evaluated. Their engineering excellence made our work dramatically easier and allowed us to stay focused on what matters most for maternal care outcomes. They took full ownership of the technical execution, and we are always happy to continue working together.”
Kim Smith
Founder, My Lauren
Related services
Which related services do operations teams use?
Detailed pages for the automation and platforms that operations tools draw on.
Prior authorization automation
AI agents that gather documentation and route requests for review.
Software development for health plans and payers
Our payer page: CMS-0057-F APIs, prior authorization, member and provider portals.
Medical document processing automation
Fax and PDF capture into structured data for intake.
Voice AI agents for healthcare
Call handling for routine member and provider questions.
Healthcare workflow automation
Routing, tasks and escalations across operations teams.
AI claims denial management
The provider side of appeals, useful when designing your dispute workflow.
Healthcare software development company
Our healthcare industry page, with every service and audience we build for.
HIPAA requirements for software teams
The safeguards we build into every system that holds member data.
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More Healthcare Solutions
Explore other production-grade engineering platforms we deliver across healthcare.
Cross-Industry Reach
The Same Engineering Patterns, Across Other Industries
The technical patterns behind this platform translate naturally into adjacent verticals.
Frequently Asked Questions
It depends on how many teams and case types are in scope and which systems the tools must read. We agree a fixed-scope first release, usually one team's workflow, on the scoping call and give you a timeline for it.
Yes. Service and clinical tools handle protected health information, so Agnotic signs a business associate agreement before any member data is shared.
Yes. Cases reference members, providers, claims and authorizations in your core through its APIs or feeds, and the service desk opens from your telephony platform with the caller identified.
Yes. A common first release is the appeals and grievances workflow, or the prior authorization intake queue, for one line of business, with reporting included.
The number of teams and case types, the channels to connect (phone, fax, portal and API), the regulatory variants per line of business, letter generation and the systems the tools must read. We describe these drivers on the scoping call rather than quote a price before it.
No. We build automation that captures, classifies and routes requests and drafts correspondence. Decisions on medical necessity and appeals are made by qualified reviewers, and every decision records who made it and why.
Role-based access limits each screen to what the role needs, following the HIPAA minimum necessary standard, and every view of a member record is logged.
Industries