Claim Eligibility Checker
Validate claims in real time with automated eligibility checks
Description
Challenge
Insurers face high volumes of incomplete or ineligible claims entering the pipeline. Manual checks of policy status, coverage, exclusions, and claimant details are slow, inconsistent, and prone to human error. This leads to unnecessary rework, delayed settlements, compliance risks, and frustration for claimants who only learn about ineligibility late in the process.
How It Works
The Claim Eligibility Checker connects to internal and external systems (Policy Admin, CRM, Claims, Underwriting, and provider portals) to validate claim requests against predefined business rules. Upon First Notice of Loss (FNOL), it retrieves claimant and policy data, applies RAG-based eligibility conditions, and classifies outcomes as Eligible, Partially Eligible, or Ineligible. Based on the result, it executes automated actions—such as requesting missing evidence, triggering workflows, sending acknowledgements, or closing ineligible claims. The agent ensures uniform eligibility application across lines of business, while maintaining full audit trails for compliance and dispute handling.
Benefits
Reduces eligibility confirmation time from minutes to seconds.
Prevents ineligible claims from entering the processing pipeline.
Ensures consistent application of policy rules across products and regions.
Improves claimant clarity with real-time status updates and guidance.
Reduces manual rework and operational overhead.
Strengthens compliance with automated audit trails.
Features
The Claim Eligibility Checker automates claim validation by integrating data from multiple systems, applying configurable rule sets, and executing outcome-based actions. It enables faster, more accurate claim initiation while ensuring fairness, transparency, and compliance.
Features and Capabilities:
Real-Time Data Retrieval: Connects to PAS, CRM, Claims, and external portals to gather live policy and claimant data.
Rule-Based Validation: Applies predefined eligibility rules for policy status, coverage, waiting periods, and exclusions.
Outcome Classification: Determines eligibility status as Eligible, Partially Eligible, or Ineligible.
Action Automation: Guides evidence submission, triggers workflows, or terminates ineligible claims.
Network Verification: Confirms provider or hospital affiliation for cashless vs reimbursement processing.
Duplicate Detection: Identifies repeated claims for the same treatment events.
Pre-Authorization Check: Validates if required approvals are in place before processing.
Audit Logging: Records all decisions, timestamps, and actions for dispute resolution.
Configurable Next Steps: Adapts workflows to different products, claim types, and business rules.
Operating Blueprint
Knowledge Sources:
Policy Administration System: Coverage terms, exclusions, sum assured, riders, waiting periods.
CRM & Member Database: Claimant identity, demographics, policy linkage.
Claims History Database: Previous claims, utilization, duplicate detection.
Coverage Rules Repository: Policy-specific conditions, exclusions, sub-limits.
Provider Network Repository: Approved facilities and cashless eligibility.
External Data Feeds: Regulatory updates, fraud/risk alerts.
Business Rules:
Verify Policy Status: Claim valid only if policy is active and premiums up to date.
Check Waiting Periods: Reject or flag claims within mandatory waiting periods.
Validate Illness/Treatment Coverage: Match treatment against covered conditions.
Assess Remaining Sum Insured: Ensure claim amount does not exceed coverage limits.
Verify Hospital Network: Approve cashless only if provider is in-network.
Pre-Authorization Requirement: Block claims missing required pre-approvals.
Evaluate Expense Limits: Enforce policy sub-limits on charges like room rent.
Confirm Location Eligibility: Verify treatment location within permitted geography.
Validate Claimant Identity: Ensure claimant is insured or authorized nominee.
Check Documentation Completeness: Auto-request pending documents if missing.
Tool Workflow:
FNOL Capture: Record claim details from claimant/representative.
Data Fetch: Retrieve info from PAS, CRM, Claims, external systems.
Eligibility Check: Validate policy, coverage, claimant, and financial limits.
Outcome: Mark claim as Eligible, Partial, or Ineligible. Next Steps:
Eligible: Trigger workflow, send ack, request docs.
Partial: Notify limits, ask for more inputs.
Ineligible: Send rejection, log reason, escalate/terminate.
Badges
Classification
Capabilities
