Claim Handler Notification & Collaboration Agent
Delivers complete claim summaries to handlers and enables contextual collaboration across teams
Description
Challenge:
In many health claim processes, claim handlers face fragmented case data, unclear task assignments, and time-consuming back-and-forth to resolve questions. Without timely alerts and contextual collaboration, complex claims often suffer from missed SLAs, incomplete reviews, and stalled approvals. This results in higher turnaround times, increased escalations, and poor claimant experience.
How It Works:
The agent gets triggered on claim submission or updates. It auto-generates a structured case summary—pulling from claim data, policy details, medical records, pre-auths, and approval statuses. This summary is routed to the appropriate claim handler or queue via integrated collaboration platforms like Microsoft Teams, Slack, or internal dashboards. A threaded collaboration space is initiated for real-time clarifications, document discussions, or escalation needs. SLA clocks are monitored, and handler responses are tracked. If no action is taken within set thresholds, the agent auto-reminds or escalates to supervisors. All interactions are archived for audit.
Benefits:
Reduces handler wait time with instant case delivery
Cuts claim resolution delays with built-in collaborative threads
Prevents SLA breaches through automated reminders and escalations
Enables informed decision-making with complete data views
Anchors all discussions and decisions to the claim ID
Creates a structured, auditable collaboration trail across teams
Features
This agent enables seamless collaboration across claim teams by generating and routing structured case summaries with rich metadata. It integrates with internal and external platforms to streamline communication, ensure timely actions, and drive resolution without unnecessary back-and-forth.
Features & Capabilities:
Automated Case Summary Generation: Collects and formats key claim details, pre-auths, costs, and documentation status
Handler Assignment Logic: Pushes cases to handlers or backup queues based on load and priority
Collaboration Thread Creation: Launches discussion threads on Teams/Slack tied to each claim
SLA Monitoring & Reminders: Tracks response time, sends nudges, and escalates if needed
Multi-User Access Management: Enables joint discussion with medical reviewers or provider reps
Chat Archival & Audit Logging: Logs all conversation history under the claim ID for future reference
Priority-Based Escalation: Detects delay in response and auto-routes to escalation owners
Claimant Update Sync: Feeds resolution progress to CRM or claimant-facing systems
Eligibility Logic
Decision Logic Flow:
Once a claim is filed or updated, the agent initiates case evaluation, formats the claim summary, and routes it to the right handler. It checks SLA conditions and engages relevant stakeholders if collaboration is required. It continuously monitors message acknowledgment and triggers follow-ups or escalations based on real-time responsiveness.
Key Logic Pathways Followed:
Notification Routing Rule: Route case summary to assigned handler or backup based on workload balance
Content Assembly Rule: Auto-populate summary with claim status, policy checks, documents, pre-auth notes, and costs
SLA Acknowledgment Rule: If message not seen/responded within X minutes, send reminder
Escalation Rule: If no response in Y hours, forward to escalation owner or supervisor
Multi-Stakeholder Access Rule: Provide thread access to medical experts or hospital reps as needed
Chat Logging Rule: Auto-log all collaboration messages and associate with the claim ID
