Claim Drafting & Reconciliation Agent
Compiles and reconciles multiple claim submissions for the same medical event into a single, organized draft record
Description
Challenge:
Medical claims are often submitted in fragments—spanning multiple documents, hospitals, or follow-up treatments—which leads to duplication, mismatches, and delays in adjudication. Manual collation is time-consuming and error-prone, often missing critical links between documents and claim items. The Claim Drafting & Reconciliation Agent addresses this by consolidating fragmented inputs into a single, structured, and audit-ready claim draft that aligns with policy guidelines and medical event timelines.
How It Works:
Once a new claim is initiated, the agent scans for existing submissions tied to the same medical event—based on claimant ID, diagnosis code, date of admission/discharge, and hospital metadata. It auto-compiles these entries into a unified draft, linking each document to its correct claim section, and flags inconsistencies like duplicate costs or mismatched diagnosis codes. Any newly submitted document updates the draft dynamically. All entries are versioned, traceable, and ready for adjudication—minimizing back-and-forth and accelerating payout decisions.
Benefits:
Reduces claim drafting time by 85–95% through automation.
Ensures 100% alignment between documents and claim sections.
Resolves 90%+ document mismatch issues before adjudication.
Minimizes delays caused by missing or inconsistent inputs.
Builds version-controlled drafts with a full audit trail.
Streamlines hand-off to adjudication and payment teams.
Features
The agent brings structure and consistency to complex, multi-entry claims by consolidating related submissions into a unified draft format. It intelligently links documents, eliminates duplications, and maintains traceability for every data point—ensuring compliance and faster resolution.
Features & Capabilities:
Medical Event Linking: Detects multiple claims tied to the same event based on diagnosis and treatment timelines
Document Alignment Engine: Matches documents like bills or prescriptions to their respective claim items
Duplicate Detection: Identifies and flags repeat entries or overlapping costs
Dynamic Draft Generation: Updates claim drafts in real time as new data is submitted
Versioning & Change Logs: Tracks manual edits, flags overrides, and maintains draft history
Base vs. Rider Separation: Clearly separates charges under core coverage and add-on riders
Mismatch Alerting: Auto-alerts when submitted documents don’t match policy terms or claim details
Audit Readiness: Prepares structured drafts with traceable links and minimal need for human rework
Eligibility Logic
Decision Logic Flow:
Check for multiple claim entries linked to a single medical event
Build a structured draft and tag all incoming documents
Validate document-to-section match
Highlight discrepancies (missing info, conflicting costs)
Sync with adjudication workflow for review and payout
Key Logic Pathways Followed:
Detect overlapping claims via ICD/CPT codes and date match.
Group and align treatment documentation to correct sections.
Flag duplicate cost entries and request clarification if needed.
Maintain original claim references within the draft.
Separate base policy vs. add-on benefit charges.
Trigger versioning if any draft is manually edited or corrected.
