Claim Filing Orchestrator
Automates claim submission, routes exceptions, and ensures SLA compliance
Description
Challenge:
Final claim submission is often slowed by manual dependencies—missing sign-offs, routing errors, SLA breaches, or communication delays between stakeholders. These inefficiencies create compliance risks, extended cycle times, and poor claimant experiences. Without automation, insurers struggle to maintain consistency across different claim types and lines of business, leading to increased rework, missed deadlines, and escalations.
How It Works:
The Claim Filing Orchestrator takes over once validation is complete. It compiles verified claim data into a structured packet, applies business rules to check approval requirements, and automatically files claims via the correct submission portals. For high-value or exception cases, it routes tasks to designated human handlers while maintaining SLA tracking. Real-time notifications keep stakeholders updated, while a full audit trail ensures compliance and dispute-readiness. By orchestrating automated and manual workflows seamlessly, it ensures smooth, timely, and accurate claim filing.
Benefits:
Cuts filing time from days to under 1 hour with automation
Ensures 100% SLA compliance tracking through timestamped logs
Reduces manual routing tasks by 60–70%
Achieves 98% accuracy in submission rules across products and LOBs
Strengthens compliance with full audit-ready records
Improves claimant and stakeholder experience with real-time updates
Resources
Features
The Claim Filing Orchestrator streamlines the last mile of claim submission, combining automation with rule-based decisioning. It validates prerequisites, manages dependencies, routes exceptions, and ensures SLA-driven outcomes—all while keeping communication flowing between systems and stakeholders.
Features & Capabilities:
Auto-Packet Generation: Builds complete claim submission packets from validated data.
Approval Requirement Checks: Confirms if high-value or special-category claims need sign-offs.
Conditional Routing: Sends exception cases to underwriters or handlers based on thresholds.
Multi-Channel Submission: Files claims across insurer, TPA, or exchange portals.
SLA Tracker: Monitors filing deadlines and benchmarks in real time.
Escalation Alerts: Notifies supervisors if tasks remain unassigned or overdue.
Audit Logging: Records every action, timestamp, and submission detail.
Stakeholder Updates: Sends proactive notifications via email, portals, or apps.
Dynamic Adaptation: Adjusts process flow based on claim type, value, and complexity.
Exception Management: Flags and routes conditionally approved claims for follow-up.
Operating Blueprint
Knowledge Sources:
Applicant & Agent Uploads: Medical records, lab reports, and supporting documents ingested via portals or field uploads.
OCR & Document Parsing: Converts scanned PDFs and handwritten inputs into machine-readable text for downstream processing.
Medical Knowledge Base: Provides reference taxonomies (ICD-10, SNOMED) for condition classification.
Underwriting Rules Library: Ensures documents are mapped to correct policy requirements and risk categories.
Audit Metadata Logs: Captures ownership, timestamps, and processing trail for compliance and traceability.
Business Rules:
Claim Submission Prerequisite: All validations must be complete before filing.
Approval Requirement: High-value/special claims require designated sign-off.
Routing Threshold: Route to manual review if value/complexity exceeds limits.
Escalation Rule: Escalate to supervisor if unassigned for >4 hours.
SLA Breach Alert: Trigger alert if filing exceeds defined SLA.
Exception Notification: Inform stakeholders when conditionally approved claims are filed.
Tool Workflow:
Receive validation-complete case signal.
Auto-generate draft claim form/packet.
Verify approval/sign-off requirements.
Assign exceptions to human handlers if needed.
Submit claim via designated portals.
Track SLA compliance with logs and timestamps.
Send notifications to stakeholders in real time.
Record submission and move case to adjudication.
Badges
Classification
Capabilities
