Claim Document Intelligence Agent
Automate claims documents into validated, policy-ready records.
Description
Challenge:
Claims processing often faces inefficiencies due to manual document sorting, missing medical records, incomplete invoices, and altered or duplicate submissions. These issues lead to delays, errors in adjudication, and higher fraud exposure. Without automation, linking documents to the right claim and policy records is error-prone, slowing down approvals and increasing claimant frustration.
How It Works:
The Claims Document Intelligence Agent automates document intake, extraction, classification, and validation using OCR, NLP, and Intelligent Document Processing (IDP). It processes medical and financial documents—such as prescriptions, discharge summaries, invoices, and diagnostic reports—validates ICD codes against policy coverage, checks authenticity, detects duplicates, and ensures timeline consistency. The agent links structured outputs directly to the right claim and policy records, stores documents with full audit metadata, and provides fraud flags when anomalies are detected. This enables faster, more accurate adjudication with reduced manual effort.
Benefits:
90–95% accuracy in document classification and data extraction
75% reduction in manual document sorting and validation
60–80% faster turnaround time for document processing
100% automated mapping of files to claims and policy records
Improved fraud detection with early anomaly and duplicate detection
Resources
Features
The Claims Document Intelligence Agent transforms unstructured document submissions into structured, validated, and policy-ready data. It eliminates manual sorting, enforces compliance, and provides transparent, audit-ready document processing.
Features & Capabilities:
Auto-Classification: Identifies document types (invoices, prescriptions, diagnostic reports, discharge summaries).
OCR & NLP Extraction: Captures structured fields and text from scanned or digital files.
Completeness Checks: Ensures all mandatory documents are submitted for each claim type.
ICD/CPT Validation: Matches medical codes against policy coverage and treatment relevance.
Timeline Consistency: Confirms admission, treatment, and discharge dates follow logical order.
Duplicate Detection: Flags identical or repeated documents using metadata and content checks.
Authenticity Validation: Detects tampered, altered, or forged documents with template and forensic rules.
Identity Cross-Check: Verifies claimant identity across policyholder records and submitted IDs.
Invoice-to-Treatment Match: Validates invoices against supporting medical reports for fraud prevention.
Secure Storage & Audit Logs: Archives all documents with metadata for compliance and traceability.
Operating Blueprint
Knowledge Sources:
Policy & product document checklists
Medical coding standards (ICD, CPT)
Historical claims & treatment datasets
Fraud detection & authenticity pattern libraries
Regulatory compliance mandates for documentation timelines
Document taxonomies & format libraries
Provider registries for verification
Business Rules:
Mandatory Document Rule: Each claim type requires specific documents (e.g., discharge summary, invoices).
File Format & Quality Rule: Only supported file types with legible text/images are accepted.
ICD/CPT Validation Rule: Medical codes must align with covered conditions.
Timeline Consistency Rule: Treatment and claim dates must align with policy terms.
Duplicate Check Rule: Prevents redundant submissions of the same document.
Authenticity Rule: Template, signature, and metadata must pass authenticity thresholds.
Invoice Match Rule: Invoices must correspond to documented medical treatments.
Identity Validation Rule: Claimant identity must align with PAS/CRM records.
Submission SLA Rule: All documents must be submitted within required policy/regulatory timelines.
Tool Workflow:
Claimant/provider uploads documents
Agent auto-classifies and extracts key data
Validates completeness against product checklist
Runs ICD/treatment validation against coverage
Cross-checks identity, timelines, and consistency
Detects duplicates or tampered files
Generates structured, policy-ready data outputs
Stores validated documents with full audit metadata
Flags fraud or discrepancies for review
Routes structured data to claims adjudication system
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Classification
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