Claim Pathway Agent
Ensure every claim follows the correct submission route
Description
Challenge:
Claimants often face confusion when deciding between cashless and reimbursement claim routes. Misaligned submissions—such as attempting cashless at a non-network hospital or failing to secure pre-authorization—lead to delays, rejections, and frustration. Insurers deal with high volumes of incorrectly routed claims, manual rerouting requests, and increased turnaround times, eroding both efficiency and customer trust. Without clear, automated guidance, operational overhead and claimant dissatisfaction remain high.
How It Works:
The Claim Pathway Agent evaluates treatment details, hospital eligibility, and policy rules to recommend the correct claim route—cashless or reimbursement. It cross-checks the provider against the insurer’s network, verifies pre-authorization requirements, and dynamically adapts recommendations based on emergency vs planned admissions. The agent then generates a tailored checklist of required documents and timelines for the chosen path, ensuring clarity and compliance from the outset. By aligning claimant actions with backend processing logic, it minimizes rerouting, reduces rejections, and accelerates claim approvals.
Benefits:
Ensures 85–90% accurate routing to correct modality
Cuts manual rerouting tasks by up to 70%
Reduces incorrect claim rejections by 45–55%
Speeds claim approvals by 30% via aligned pathways
Delivers 100% customized document checklists to claimants
Improves claimant experience with proactive, dynamic guidance
Resources
Features
The Claim Pathway Agent removes guesswork by intelligently guiding claimants through the appropriate submission method. By integrating hospital network data, policy rules, and pre-auth trackers, it provides end-to-end clarity while preventing mismatched claims.
Features & Capabilities:
Network Eligibility Check: Verifies if hospital is in-network for cashless claims
Pre-Authorization Validation: Confirms pre-auth requirement status and next steps
Dynamic Pathway Logic: Distinguishes emergency vs planned admissions for correct routing
Policy Alignment: Detects if plan supports cashless or reimbursement-only claims
Duplicate Submission Prevention: Flags attempts to file via multiple modalities
Tailored Document Checklist: Generates required docs & timelines per selected route
Real-Time Hospital/TPA Integration: Links claimant to provider portals and contact details
Adaptive Guidance: Updates advice if pre-auth or hospital status changes mid-journey
Operating Blueprint
Knowledge Sources:
Network Hospital Registry: Validates hospital eligibility and department tie-ups
Policy Documents: Defines coverage clauses, cashless eligibility, exclusions, and co-pays
Treatment Details: Admission type, diagnosis, and treatment context
Pre-Auth Tracker: Tracks approval, pending, or initiation status
Claims History: Reviews prior modality outcomes for claimant/provider
Regulatory Guidelines: Defines compliance on timelines and modality requirements
Business Rules:
In-Network Rule: Default to cashless if hospital is eligible
Pre-Auth Rule: Enforce pre-auth for planned procedures; advise reimbursement if missing
Emergency Rule: Allow expedited reimbursement or partial cashless for urgent cases
Policy Coverage Rule: Flag if policy supports reimbursement-only models
Duplicate Check Rule: Prevent duplicate claims across reimbursement and cashless routes
Checklist Rule: Generate tailored documentation per chosen pathway
Tool Workflow:
Capture hospital and treatment details from claimant
Verify network eligibility with provider registry
Confirm pre-auth requirement and approval status
Recommend cashless or reimbursement based on rules
Generate next-step guidance with document checklist
Connect to hospital/TPA portals or reimbursement forms
Track claim submission status and update claimant in real-time
Badges
Classification
Capabilities
