Claim Filing & Workflow Orchestration Agent
Files validated claims, routes exceptions, and tracks SLAs until adjudication begins
Description
Challenge:
Delays in claim finalization often stem from missed sign-offs, incomplete routing, or overlooked exceptions. Manual follow-ups, unclear handler assignments, and lack of SLA tracking cause downstream bottlenecks—impacting turnaround times, customer satisfaction, and audit readiness. The Claim Filing & Workflow Orchestration Agent addresses this by automating final filing, ensuring all prerequisites are met, routing exceptions precisely, and monitoring end-to-end SLA timelines until the claim enters adjudication.
How It Works:
Once a claim clears prior validations, the agent generates a filing-ready packet by assembling structured data, required documents, and metadata tags. It checks for sign-off dependencies (e.g., medical authority, financial thresholds) and verifies task completion statuses. If filing criteria are met, it submits the claim to the core adjudication system. For exceptions—such as missing authorizations or out-of-policy treatments—it routes the case to predefined handlers with deadlines and escalations. SLA clocks are monitored in real-time, and stakeholder alerts are sent if response times near thresholds. Every transition is logged and auditable.
Benefits:
Reduces claim filing time by over 60% through automation
Prevents SLA breaches via proactive monitoring and escalation logic
Ensures all prerequisites (sign-offs, approvals, docs) are met before submission
Eliminates routing errors by assigning handlers based on claim context
Builds a complete filing log to support downstream adjudication and audits
Enables seamless AI-human handoffs across last-mile workflows"
Features
The Claim Filing & Workflow Orchestration Agent automates the last step of claims processing—filing. It checks dependencies, finalizes routing, flags exceptions, and initiates downstream workflows. The agent ensures compliant, complete, and traceable submissions across all claim types.
Features & Capabilities:
Final Filing Packet Generation: Builds a structured claim file with validated inputs and supporting docs
Sign-Off Dependency Check: Verifies mandatory approvals before filing (e.g., physician sign-off for surgery)
Exception Routing: Assigns special cases to designated roles based on condition or cost
SLA Monitoring Engine: Tracks pending actions with escalation rules tied to time limits
Handler Assignment Engine: Selects the next reviewer or processor based on policy, role, or task type
Claim Filing API Trigger: Submits valid claims directly to adjudication queue
Filing Confirmation & Logging: Records filing status and timestamps in audit logs
Stakeholder Notification: Sends real-time alerts for pending, filed, or escalated claims
Filing Delay Predictor: Flags claims at risk of missing SLA based on past patterns
Integrated Handoff Management: Ensures all upstream checks are honored before downstream processing begins.
Eligibility Logic
Decision Logic Flow:
This agent activates only after all upstream validation agents clear the claim. It then initiates a final check for filing readiness—ensuring no signature, task, or threshold condition is pending. Based on this, it either files the claim, routes it to a handler, or escalates to ensure SLA compliance.
Key Logic Pathways Followed:
Validation Completion Check: Agent activates only after prior validations succeed
Sign-Off Dependency Validation: Checks if required medical or financial approvals are complete
Filing Readiness Verification: Ensures all data, docs, and meta tags are complete and consistent
Threshold-Based Routing:
If claim exceeds pre-set limits (e.g., surgery cost), route to special handler
SLA Tracker Initiation: Starts SLA countdown and assigns internal deadline for handler action
Escalation Logic: If task remains open beyond threshold, escalate to next-in-line authority
Auto-Filing Trigger: If no blockers exist, files claim directly into adjudication engine
Notification Dispatch: Alerts stakeholders based on current status: pending, routed, filed, or escalated
Filing Status Logging: Creates timestamped audit log of filing action
Adjudication Queue Handoff: Pushes filed claim into downstream processing queue for decision-making.
