OPS-SOP-014 — Employer Prospect Intake & Cost-Controlled Quoting
1. Purpose
This SOP defines the end-to-end process for receiving, qualifying, and quoting employer group prospects for the Unity Care Member Plan Master Trust. Version 2.0 introduces a tiered quoting model to control actuarial costs without sacrificing rate accuracy — ensuring Davies actuarial resources are reserved for groups that genuinely require external expertise, while smaller, lower-risk groups are quoted efficiently using internal tools.
📌 Core Principle — Cost-Controlled Quoting
Gradient AI pre-screening is
mandatory for every group at every tier before any rate is developed. Davies engagement is triggered by risk profile and group size, not by default. Unnecessary Davies engagement is a controllable cost — this SOP controls it.
2. Scope
Applies to all inbound and outbound employer group prospects (2+ employees) being evaluated for participation in the Unity Care Member Plan. Covers initial contact through signed Letter of Intent (LOI) or quote decline. Group onboarding after LOI is covered in OPS-SOP-015.
3. Roles & Responsibilities
| Role | Responsibilities in This SOP |
|---|
| Sales | Lead capture, discovery call, data collection, proposal delivery, LOI execution, CRM maintenance |
| Operations | Tier routing decisions, Gradient AI pre-screen submission, Davies engagement management, variance flag review, quote coordination, compliance flag escalation |
| Finance / Actuarial | Internal rate table maintenance (Tier 1); Davies relationship management; 15% variance review |
| Compliance — Tessa | Review of all proposal materials and ad creatives; complex-state flag review |
| Legal Counsel — Eric Gregory | Sign-off required before quoting any group in NY, CA, or ME; stop-loss situs and mandate review |
| Jason Strain / HLRA (Brown & Brown) | Facultative underwriting for Tier 3 groups (>500 lives or One Health JV scale); must be notified in parallel when Tier 3 is triggered |
| Leadership | Approval required for non-standard pricing or any group with projected ARR >$500K |
4. Quoting Tier Definitions
Every prospect is assigned a quoting tier by Operations after Gradient AI pre-screen results are received. The tier determines who develops the rate and what external resources are engaged.
▮ TIER 1 — Internal Quote (No Davies Required)
Criteria — ALL of the following must be true:
- Group size < 50 enrolled lives
- Gradient AI SAIL Score < 1.2
- No high-cost drug flags from Gradient AI output
- No complex states (NY, CA, ME) in the employee population
- No captive, SRS, or HLRA structure required
Rate development: Sales uses Gradient AI output + Unity standard internal rate table. Operations reviews before proposal is sent. No Davies engagement.
⚠ TBD: Internal rate table for Tier 1 quoting — Finance / Actuarial to develop and approve before Tier 1 quoting goes live.
▮ TIER 2 — Davies Required
Criteria — ANY ONE of the following triggers Tier 2:
- Group size ≥ 50 enrolled lives
- Gradient AI SAIL Score ≥ 1.2
- High-cost drug flag in Gradient AI output
- Any employees in complex states (NY, CA, ME)
- Captive, SRS, or HLRA structure required
- Strategic account designation (One Health-scale or Leadership-flagged)
Rate development: Operations engages Davies actuarial. Davies receives census + Gradient AI output only — raw claims data is NOT provided to Davies unless explicitly authorized by Operations (reduces billable hours). Davies hourly engagement capped per engagement.
⚠ TBD: Davies hourly rate cap per engagement — Finance to set and document. Cap must be confirmed with Davies in writing before each engagement.
▮ TIER 3 — Facultative / HLRA (Jason Strain)
Criteria — ANY ONE of the following triggers Tier 3:
- Group size > 500 enrolled lives
- One Health JV or equivalent strategic partnership scale
- Leadership directive to engage facultative underwriting
Rate development: Operations and Leadership jointly scope. Jason Strain / HLRA is notified and engaged in parallel — not sequentially — with Davies. HLRA facultative underwriting runs simultaneously with any Davies work. Leadership approval required before quote delivery.
5. Cost Control Rules
| Rule | Detail | Owner |
|---|
| Gradient AI pre-screen — mandatory, all tiers |
No rate development begins for any group until Gradient AI pre-screen is complete and output is reviewed. No exceptions. |
Operations |
| Davies data restriction |
Davies receives census + Gradient AI output only. Raw claims data is withheld unless Operations explicitly authorizes in writing. This limits billable review hours. |
Operations |
| Davies hourly rate cap |
Each Davies engagement is capped at the approved hourly rate limit. Confirm cap with Davies before each engagement. If Davies projects the scope will exceed cap, escalate to Finance before proceeding. |
Finance / Operations |
| Tier 1 internal rate table |
Tier 1 groups are quoted using the Finance/Actuarial-approved internal rate table. Sales does not build custom rates outside this table without Operations approval. |
Finance / Actuarial |
| 15% variance rule |
If the Davies-developed quote deviates more than 15% (higher or lower) from the Gradient AI predicted rate, Operations must review and approve before the proposal is sent to the employer. A >15% deviation triggers a documented variance memo. |
Operations |
| Leadership approval threshold |
Any non-standard pricing structure or any group with projected annual recurring revenue (ARR) > $500K requires Leadership approval before proposal delivery. |
Leadership |
⚠ 15% Variance Rule — Detail
When Davies returns a final rate: Operations calculates the percentage deviation from Gradient AI's predicted PMPM. If deviation exceeds ±15%: (1) Operations documents the variance in writing with explanation, (2) Finance/Actuarial reviews, (3) Operations approves or escalates to Leadership, (4) proposal is held until clearance is granted. The proposal is not sent until clearance is documented in the CRM.
6. Prospect Qualification Criteria
| Criteria | Threshold | Notes |
|---|
| Group size | 2+ enrolled employees | Actuarial credibility improves at 10+. Tier 1 cap is <50 lives. |
| Geography | PHCS network coverage in employer's state(s) | Verify network adequacy before quoting. Multi-state: confirm all states covered. |
| Industry | No blanket exclusions; flag high-risk industries | Construction, healthcare, staffing — flag for closer Gradient review. |
| Current coverage | Employer currently offering or evaluating group health | Fully uninsured groups may require longer sales cycle. |
| Union employees | Flag for Compliance review | CBA agreements may limit or block plan changes. |
| Complex states | NY, CA, ME — auto-Tier 2; flag for Legal | Eric Gregory sign-off required before quoting proceeds. Stop-loss situs and state mandates must be reviewed. |
7. Intake & Quoting Process
1. Lead Capture — All inbound leads (website form, broker referral, direct outreach, event) are entered into the CRM within 1 business day of contact. Required fields: company name, contact name / email / phone, employee count (estimate), current carrier, state(s) of operation, lead source.
Owner: Sales.
⚠ TBD: CRM platform — confirm Go High Level as primary sales CRM and configure pipeline stages to match this SOP.
2. Initial Qualification Call — Sales conducts a 20–30 minute discovery call within [TBD] business days of lead entry. Goal: confirm employee count, plan renewal date, decision timeline, budget sensitivity, current premium spend, and prior claims data availability. Outcomes: Qualified → proceed. Not a fit → log reason in CRM and close. Owner: Sales.
3. Data Collection — Sales requests the following from the employer:
- Census (employee names, DOB, zip codes, enrollment tier)
- 12–24 months prior claims data (if available and willing to share)
- Current plan design and premium rates
- Renewal date
- List of states with enrolled employees
All received data is logged in CRM with date received. PHI in claims data is handled per HIPAA — stored in PHI-secure location [TBD] and shared only with Davies/Gradient AI under executed BAAs.
Owner: Sales.
⚠ TBD: Confirm PHI-secure storage location and access controls before handling any prospect claims data.
4. Gradient AI Pre-Screen (Mandatory — All Tiers) — Operations submits census (and claims data if available and authorized) to Gradient AI. Output reviewed: SAIL Score, morbidity index, predicted annual claims (PMPM), high-cost drug flags, top individual claimant projection. Pre-screen must be complete and output documented in CRM before tier routing or rate development begins.
Owner: Operations.
⚠ TBD: Confirm Gradient AI BAA is fully executed before any prospect PHI is submitted. Legal Counsel to verify.
5. Tier Routing Decision — Operations reviews Gradient AI output and assigns the prospect a quoting tier (Tier 1, 2, or 3) using the criteria in Section 4. Tier assignment is logged in CRM. If any complex-state, union, or high-cost drug flag exists, Operations routes to Compliance and/or Legal Counsel before proceeding. Owner: Operations.
6. Compliance Flags Review — For any prospect with union employees, complex-state employees (NY/CA/ME), or Gradient AI SAIL > 1.5 or high-cost drug exposure, Operations routes to Compliance (Tessa) and Legal Counsel (Eric Gregory) as applicable. No rate development begins until clearance is received and documented. Owner: Operations.
7. Rate Development — By Tier
| Tier | Rate Development Process | Timing / Notes |
|---|
| Tier 1 Internal |
Sales + Operations use Gradient AI output + Unity internal rate table. No Davies. Operations reviews before proposal is built. |
Target: [TBD] business days. Rate table must be current and Finance/Actuarial-approved. |
| Tier 2 Davies |
Operations engages Davies with census + Gradient AI output only (no raw claims unless authorized). Operations confirms hourly cap before scope begins. Davies returns actuarial rates. |
Davies SLA: [TBD] business days. Operations applies 15% variance check on return. |
| Tier 3 HLRA / Facultative |
Operations + Leadership scope jointly. Jason Strain / HLRA notified and engaged in parallel with Davies. Both tracks run simultaneously. |
Leadership approval required before any rate is sent to employer. HLRA notification must be documented. |
8. 15% Variance Check (Tier 2 & 3) — Upon receiving Davies rate output, Operations calculates deviation from Gradient AI predicted PMPM:
- Deviation ≤ 15%: Proceed to proposal preparation.
- Deviation > 15%: Operations holds the quote. Documents variance in writing with explanation. Routes to Finance/Actuarial for review. Proposal is not sent until Operations (or Leadership for deviations >25%) grants written clearance. Clearance logged in CRM.
Owner: Operations.
9. Proposal Preparation — Sales builds the proposal package:
- Proposed plan design options (1–3 tiers)
- Composite rate comparison vs. current premium
- Cost audit summary (DPC integration savings, Rx optimization — if applicable)
- Network coverage confirmation (PHCS adequacy in their states)
- Unity Care Member Plan overview (trust structure, captive, DPC)
All proposal materials, ad creatives, and digital content used in the proposal must be reviewed by Compliance (Tessa) before use. Turnaround target: 24 hours. Never use unapproved materials. For groups with projected ARR > $500K or non-standard pricing: obtain Leadership approval before sending.
Owner: Sales / Operations.
10. Proposal Delivery — Sales presents the proposal to the employer (in-person, video, or written). CRM updated with: proposal sent date, proposed rates, plan options presented, next follow-up date. Follow-up within [TBD] business days if no response received. Owner: Sales.
11. Decision — LOI or Decline
- Accepted: Employer signs Letter of Intent (LOI). CRM status updated to Won. Handoff to OPS-SOP-015 (Group Onboarding).
- Declined: Log reason in CRM. If timing issue, set future follow-up. If price/design issue, note for product feedback loop to Finance/Actuarial.
- Stalled / No response: Sales follows up per cadence [TBD]. After [TBD] days with no response, move to Nurture status in CRM.
Owner: Sales.
⚠ TBD: LOI template — Legal Counsel (Eric Gregory) to draft and approve before sales use.
8. Tier Routing Quick Reference
Use this table to determine tier. The first trigger that matches routes to the higher tier — evaluate from Tier 3 down.
| Condition | Tier | Action |
|---|
| Group > 500 lives OR One Health JV scale | Tier 3 HLRA | Engage Jason Strain / HLRA in parallel; Leadership scopes |
| Group ≥ 50 lives | Tier 2 Davies | Engage Davies with census + Gradient output only |
| SAIL Score ≥ 1.2 | Tier 2 Davies | Engage Davies with census + Gradient output only |
| High-cost drug flag (Gradient AI) | Tier 2 Davies | Engage Davies; flag for stop-loss review |
| Complex state: NY, CA, or ME | Tier 2 Davies | Eric Gregory sign-off required before quoting |
| Captive / SRS / HLRA structure | Tier 2 Davies | Engage Davies; coordinate with HLRA on structure |
| Strategic account (Leadership-flagged) | Tier 2 Davies | Engage Davies; Leadership notified |
| All conditions: <50 lives, SAIL < 1.2, no drug flags, no complex states, no captive | Tier 1 Internal | Gradient output + Unity rate table; no Davies |
9. Compliance Notes
PHI Handling: Prospect claims data is PHI under HIPAA. Must be stored in a PHI-secure location. Share only with Davies and Gradient AI under executed BAAs. Do not email claims data in unencrypted attachments. Raw claims data is withheld from Davies unless Operations explicitly authorizes in writing (cost control measure).
Proposal Material Compliance: All proposal materials, ad creatives, and digital content used in the sales process must be reviewed by Compliance (Tessa) before use. Turnaround target is 24 hours. Never use unapproved materials.
Complex State Compliance (NY / CA / ME): Do not quote employer groups with employees in NY, CA, or ME without sign-off from Legal Counsel (Eric Gregory). Stop-loss situs and state benefit mandates require individual review. This auto-triggers Tier 2 routing.
Union / CBA: Employer groups with union employees must be flagged for Compliance review. CBA agreements may limit or block plan changes regardless of quote quality.
10. Quality Controls & Tracking
| Control Point | Owner | Frequency |
|---|
| CRM pipeline review — all active prospects | Sales + Operations | Weekly |
| Gradient AI pre-screen completed before any tier routing | Operations | Per prospect |
| Tier routing decision logged in CRM with rationale | Operations | Per prospect |
| Compliance flag clearance documented before proposal sent | Operations | Per prospect |
| 15% variance check performed on all Tier 2 / Tier 3 Davies returns | Operations | Per Tier 2/3 quote |
| Davies engagement log (scope, hours authorized, cap confirmed) | Operations | Per Davies engagement |
| Proposal materials reviewed by Compliance (Tessa) | Sales | Per proposal |
| Leadership approval obtained for ARR > $500K or non-standard pricing | Operations / Sales | Per applicable quote |
| Win/loss rate tracking by tier, source, size, industry | Operations | Monthly |
| Tier 1 rate table review and revalidation | Finance / Actuarial | Quarterly |
| Davies cost tracking — actual hours vs. cap per engagement | Finance | Per engagement + monthly summary |
11. Open Items
⚠ TBD: Internal Tier 1 rate table — Finance / Actuarial to develop and approve. Tier 1 quoting cannot go live until this is complete and signed off.
⚠ TBD: Davies hourly rate cap per engagement — Finance to negotiate and document. Must be confirmed in writing with Davies before each engagement begins.
⚠ TBD: Davies SLA (business days for Tier 2 rate return) — Operations to confirm with Davies and document.
⚠ TBD: Gradient AI BAA — Legal Counsel to confirm fully executed before any prospect PHI is submitted to Gradient.
⚠ TBD: PHI-secure storage location for prospect claims data — IT / Compliance to designate and document access controls.
⚠ TBD: CRM platform (Go High Level) — confirm as primary sales CRM and configure pipeline stages to match this SOP workflow.
⚠ TBD: LOI template — Legal Counsel (Eric Gregory) to draft and approve before sales use.
⚠ TBD: Qualification call SLA (days from lead entry to discovery call) — Sales + Operations to set and track.
12. References
- OPS-SOP-015 — Group Onboarding Handoff (Sales → Ops)
- OPS-SOP-009 — Employer Group Onboarding
- OPS-SOP-022 — Regulatory Change Monitoring
- OPS-COMP-006 — Master Compliance Framework
13. Version History
| Version | Date | Author | Summary of Changes |
|---|
| 1.0 | [Original] | Austin Adams | Initial release — Employer Prospect Intake & Quoting |
| 2.0 | [TBD — upon adoption] | Austin Adams | Added tiered quoting model (Tier 1 / 2 / 3), Davies cost controls, 15% variance rule, Gradient AI mandatory pre-screen policy, Davies data restriction rule, hourly cap requirement, HLRA parallel engagement protocol, Leadership ARR approval threshold |
OPS-SOP-014 v2.0 | Employer Prospect Intake & Cost-Controlled Quoting | Unity Care Solutions, LLC — Internal / Confidential