This SOP governs the use of Gradient AI for pre-screening all new employer groups before quoting and onboarding into the Unity Care Member Plan Master Trust. Gradient AI provides predictive risk analytics including SAIL scores, morbidity indices, predicted annual claims, high-cost drug flags, and individual claimant projections. This SOP also covers annual re-screening for existing groups at renewal.
This SOP applies to: Operations, Underwriting, and any staff who submit data to or retrieve outputs from the Gradient AI platform. This SOP does not authorize the submission of PHI to Gradient AI until a Business Associate Agreement (BAA) is fully executed.
| Term | Definition |
|---|---|
| SAIL Score | Gradient AI's composite risk score. A score above 1.5 indicates elevated actuarial risk and requires Davies actuarial review before quoting. |
| Morbidity Index | A measure of the group's disease burden relative to a standard population. Higher index = higher predicted claims cost. |
| Predicted Annual Claims | Gradient AI's projected total claims spend for the group over the next 12 months, expressed as aggregate and PMPM. |
| High-Cost Drug Flag | Indicator that one or more members are actively using a high-cost specialty medication (e.g., biologics, oncology drugs). Triggers stop-loss facultative review. |
| Individual Claimant Projection | Gradient AI's prediction of claims spend for individual high-risk members. Any member projected above $250K triggers HLRA notification. |
| Census (Non-PHI) | Demographic data without individually identifiable health information: employee count, age bands, gender split, zip code, industry code. This data may be submitted before BAA execution. |
| PHI | Protected Health Information — any individually identifiable health information. Requires executed BAA before submission to Gradient AI. |
| HLRA | High-Level Reinsurance Agreement — Unity Care's reinsurance carrier arrangement via Jason Strain (Brown & Brown). $350K per-person attachment point. |
| Trigger Condition | Required Action | Owner |
|---|---|---|
| SAIL Score > 1.5 | Davies actuarial review required before quoting. Do not issue quote until Davies confirms risk acceptability and recommended rate adjustment. | Operations → Davies Actuarial |
| High-cost specialty drug active (any member) | Stop-loss facultative review required. Operations contacts Jason Strain (Brown & Brown / HLRA) to request facultative reinsurance coverage assessment for the specific drug/member. | Operations → Jason Strain (Brown & Brown) |
| Individual claimant projected > $250,000 | HLRA notification required. Operations notifies Jason Strain of the projected high-cost claimant prior to enrollment. Attach point and specific reinsurance terms must be confirmed before the member is enrolled. | Operations → Jason Strain (HLRA) |
| Morbidity index > 1.3 (elevated but below SAIL threshold) | Flag for Operations Director review. Enhanced monitoring recommended for first plan year. Document decision rationale in onboarding file. | Operations Director |
| Multiple red flags simultaneously | Escalate to Leadership before proceeding. Document all flags and triage steps. Leadership makes final accept/decline decision. | Operations Director → Leadership |
All existing employer groups are re-screened through Gradient AI at each annual renewal. The re-screening process follows the same steps as new group screening (Section 4), using the current plan year's claims data.
Re-screening must be completed no later than 60 days before the renewal effective date to allow adequate time for rate adjustment, stop-loss negotiations, and actuarial review if triggered.
Regardless of storage location, the following access controls apply to all Gradient AI output files:
| Role | Responsibilities in This SOP |
|---|---|
| Operations Director | Owns this process; approves data submissions; reviews red flag triage decisions; escalates to Leadership when required |
| Legal Counsel (Dickinson Wright) | Negotiates and executes BAA with Gradient AI; advises on HIPAA compliance for data submissions |
| Davies Actuarial | Performs actuarial review when SAIL score exceeds 1.5; provides rate recommendations |
| Jason Strain (Brown & Brown / HLRA) | Performs stop-loss facultative review for high-cost drug flags; receives HLRA notification for projected claimants exceeding $250K |
| Underwriting / Operations Staff | Submits census and screening data; retrieves and files Gradient AI reports; flags red flags for Director review |
| Leadership | Final decision authority on groups with multiple simultaneous red flags or borderline risk profiles |