Live Agent Demo

Network Adequacy Monitoring

Watch an agent continuously monitor provider network coverage against CMS access standards, detect adequacy gaps by specialty and geography, and auto-generate corrective action plans — well before regulatory deadlines.

Agentic AI Classical + GenAI Simulated

Domain: Network Operations · Compliance

Steps: 6 Runtime: <90 sec AI Type: Agentic + GenAI

Step 1 of 6

Network Scan Initiation

Agent initiates a full provider network scan across all specialty categories, benchmarking current ratios against CMS MA time and distance standards.

SCANNING

Network Overview — SilverCare MA (HMO)

18,400Total Members

2,847Contracted Providers

2,614Active & Credentialed

43Pending Termination

⚠ 3 specialties below CMS time/distance standards — immediate action required

Specialty	Status	CMS Standard
Primary Care	✅ Compliant	1:200
Cardiology	✅ Compliant	1:800
Mental Health	🔴 Critical	1:300
Nephrology	🔴 Deficient	1:1,500
OB/GYN	🟡 Marginal	1:800
Oncology	🟡 Marginal	1:1,200
Orthopedics	✅ Compliant	1:1,000

Service Area: Harris County, TX · CMS Deadline: April 17, 2025 · Last scan: 47 days ago — OVERDUE

Step 2 of 6

Gap Analysis by Specialty

Agent breaks down each specialty gap by member impact, CMS ratio standards, and geographic time/distance breaches — identifying which require mandatory corrective action plans.

ANALYZING

Specialty Gap Analysis — Harris County, TX

Specialty	Members Affected	CMS Standard	Current Ratio	Status
Mental Health	3,240	1:300	1:487	🔴 Critical
Nephrology	1,820	1:1,500	1:2,600	🔴 Deficient
OB/GYN	4,100	1:800	1:1,050	🟡 Marginal
Oncology	2,800	1:1,200	1:1,380	🟡 Marginal
Primary Care	—	1:200	1:187	✅ Compliant

Time/distance breaches: Mental Health — 8 ZIP codes exceed 30-min urban standard. Nephrology — 4 ZIP codes exceed 45-min standard.

Total members without adequate access: ~5,800 (31.5% of plan) · Mandatory CAP required under 42 CFR 422.112

Step 3 of 6

Provider Recruitment Targeting

Agent identifies the highest-leverage recruitment targets by specialty, geographic fit, MA acceptance status, and estimated coverage restoration potential.

TARGETING

Mental Health Recruitment Targets

Provider	Clinicians	Gap ZIPs	Status
Houston Behavioral Health Group	4	77084, 77095	Ready
Westside Counseling Associates	2	77449	Ready
Memorial Mental Health Center	Community HC	77084	Ready
TeleHealth Mind (virtual)	Unlimited	All 8 gap ZIPs	Immediate

Nephrology Recruitment Targets

Provider	Physicians	Gap ZIPs	Status
Gulf Coast Kidney Center	3 nephrologists	77545, 77578	Ready
Houston Kidney Specialists	5 nephrologists	All gap ZIPs	Fee gap $12/visit

Estimated coverage restoration: Mental Health 97% with all 4 recruited · Nephrology 100% with Gulf Coast alone

Step 4 of 6

Corrective Action Plan Generation

Agent auto-drafts a CMS-compliant Corrective Action Plan with timed milestones, responsible parties, and attestation language — ready for CMO signature.

GENERATING

Corrective Action Plan — SilverCare MA · Harris County, TX

Regulatory basis: 42 CFR 422.112 · Submission deadline: April 17, 2025

Action	Specialty	Target	Completion Date	Owner
Execute contract — TeleHealth Mind (interim)	Mental Health	All 8 gap ZIPs	March 25, 2025	Contracting
Execute contract — Houston Behavioral + Westside	Mental Health	77084, 77095, 77449	April 10, 2025	Contracting
Execute contract — Gulf Coast Kidney Center	Nephrology	77545, 77578, 77583	April 3, 2025	Contracting
Member notification — all affected members	All gaps	5,800 members	April 14, 2025	Member Services

Attestation: "This CAP was prepared in compliance with 42 CFR 422.112 and CMS MA Network Adequacy Requirements." — DRAFT: Pending CMO and VP Network signature

Auto-generated by NestedLoop Network Agent · March 14, 2025 · 3 days buffer before CMS deadline

Step 5 of 6

Member Impact & Notification

Agent identifies all affected members, personalizes notification letters by language and access type, and queues multi-channel outreach — compliant with CMS member rights requirements.

PROCESSING

Member Notification Status

Specialty Gap	Members Affected	ZIP Codes	Language Versions
Mental Health	3,240	77084, 77095, 77449, 77474 (+4)	EN · ES · VI
Nephrology	1,820	77545, 77578, 77583, 77584	EN · ES

"Dear SilverCare MA Member, We want to inform you that your plan is actively working to expand access to [Specialty] providers in your area. While we recruit additional in-network providers, you have the right to request a single case agreement for out-of-network services at in-network cost sharing..."

5,800Letters queued

847Phone outreach (high-risk)

Mar 21Mail date (7 days early)

Step 6 of 6

Compliance Dashboard & Monitoring

Agent activates continuous network monitoring — weekly breach alerts, monthly adequacy scans, quarterly CMS comparisons — and publishes the compliance restoration timeline.

COMPLETE ✓

7Specialties scanned

2Critical gaps

5,800Members notified

Compliance Restoration Timeline

Specialty	Interim Fix	Full Resolution	Status
Mental Health	March 25 (TeleHealth)	April 10	On Track
Nephrology	—	April 3	On Track
OB/GYN	—	Monitoring	Watching

Risk reduction: Proactive correction avoids estimated $185,000–$340,000 in CMS penalty exposure · Manual network review estimated: 3.5 days. Agent completed in under 4 minutes.

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