eGain AI Knowledge Suite for Healthcare – Health Plans
Deliver trusted AI for your members, built on governed knowledge.
Fragmented, ungoverned knowledge undermines member service, compliance, and every AI initiative built on top of it
Agents give members the wrong answer because updates to benefits or CMS rules need to work through multiple disconnected systems.
Without a governed, auditable knowledge layer, AI spreads inconsistencies faster, across every channel, without a full compliance trail.
High turnover means someone is always working from information that’s a rule change behind.
A comprehensive suite delivering trusted knowledge for every member interaction, every agent, and every compliance audit.
One Governed Source of Truth
One versioned, audited knowledge layer that every agent, AI system, and quality team draws from.
Real-Time Agent Guidance
Pre-built health plan workflows walk agents through prior authorization, formulary questions, and eligibility lookups step by step, in real time.
AI That Passes Compliance Review
eGain sits underneath your existing AI stack with real-time API connectivity. Every answer is versioned, approved, and auditable down to the source.
Autonomous Call Handling
Prior auth status lookups, benefit summaries, and eligibility confirmations are handled autonomously, reducing call types by 60 to 80 percent.
Proactive Compliance Monitoring
eGain monitors knowledge accuracy and compliance exposure, flagging gaps before they reach a member, trigger a CMS violation, or endanger Stars ratings.
Built for Compliance from Day One
Built-in HIPAA compliance, BAA support, and SOC 2 Type II certification.
What customers say
G.T. Sweeney, Chief Information Officer, Healthfirst
Jorik van der Hoek, Manager, Knowledge Management and AI, Achmea
Frequently Asked Questions
Member services agents handle some of the most regulatory-sensitive conversations in any industry, including benefits inquiries, prior authorization questions, formulary exceptions, and enrollment calls. eGain gives every agent a single, governed source of verified knowledge so answers are consistent across every channel and every agent, regardless of tenure or call volume.
When CMS issues a new prior authorization rule or updates Medicare Advantage requirements, health plans have a hard deadline to get every agent working from the correct information, and a compliance gap on even one call can create audit exposure. eGain lets compliance and operations teams update content in one place and know immediately that every agent and every AI channel reflect the current requirement, with a full audit trail showing when the update was made and that it was accessed.
Yes. Health plans that use BPO partners for member services still own the compliance liability, regardless of who answers the call. eGain governs the knowledge content centrally so the health plan controls what BPO agents know and say, without requiring changes to the BPO’s own technology environment. eGain enforces health plan standards across every agent, whether they’re in-house or outsourced.
Star Ratings are sensitive to member experience quality, which depends heavily on the accuracy and consistency of information agents provide. When agents work from governed, current knowledge, first-contact resolution improves, escalations decrease, and the member experience becomes more consistent, all of which factor into the measures that drive Star Rating performance.
Yes. eGain integrates with Salesforce Health Cloud and other CRM platforms your member services team already uses. It adds a governed knowledge layer on top of existing systems rather than replacing them, so agents get accurate, verified answers surfaced inside the tools they already work in.
