Claim Validation Agent
Validate claims for accuracy, compliance, and consistency before adjudication or payout
Description
Challenge:
Claims often enter insurers’ systems with incomplete, inconsistent, or inaccurate data. Manual validation is slow, error-prone, and may miss duplicate submissions, policy misalignment, or fraud indicators. Without automated validation, invalid claims consume resources, delay processing, and increase operational and regulatory risk.
How It Works:
The Claim Validation Agent automatically verifies every submitted claim against policy coverage, internal records, and regulatory rules. It extracts structured data from forms and supporting documents using OCR/NLP, cross-checks details against PAS, CRM, and Claims databases, and applies rule-based checks for duplicates, inconsistencies, and potential fraud. Discrepancies are flagged for review, while validated claims proceed to adjudication or payout. Detailed audit logs ensure compliance and dispute resolution readiness.
Benefits:
Achieves 97–99% accuracy in claim-data validation
Reduces manual review effort by 80–90%
Detects 95%+ duplicate claims before adjudication
Cuts claim validation time from hours to <1 minute
Reduces downstream claim rejections by 50–60%
Improves claimant trust through transparent, consistent validation
Features
The agent ensures all submitted claims meet defined accuracy, completeness, and compliance standards before entering adjudication or payment workflows.
Features & Capabilities:
Data Extraction: OCR/NLP converts claim forms, invoices, and supporting documents into structured fields
Cross-Validation: Match submitted details with PAS, CRM, and Claims history
Policy Rule Enforcement: Apply coverage limits, exclusions, waiting periods, and sum-insured checks
Document Consistency Check: Align claim forms with medical bills, treatment records, and receipts
Duplicate Detection: Identify duplicate submissions across claimants, providers, and policies
Fraud/Anomaly Screening: Detect mismatched diagnosis-treatment pairs, inflated bills, and suspicious claims
Outcome Classification: Validated, Conditionally Validated (requires additional documents), or Invalid
Audit Logging: Maintain detailed logs for compliance, governance, and dispute resolution
Regulatory Compliance: Apply country and line-of-business specific rules
Provider Network Validation: Confirm claims originate from registered providers unless reimbursement exceptions apply
Operating Blueprint
Knowledge Sources:
Policy Administration System: coverage terms, limits, exclusions, active status
CRM/Member Database: claimant demographics and identity verification
Claims History Database: prior claims, duplicates, settlement history
Regulatory & Compliance Rules: local insurance mandates
Provider/Treatment Network Repository: hospital/doctor eligibility, treatment consistency
Business Rules:
Policy Active Check: Reject claims tied to inactive or lapsed policies
Coverage Match: Claim type must fall within policy terms
Document Consistency: Align claim form, bills, and medical records
Duplicate Detection: Prevent repeat submissions
Sum Insured Validation: Ensure claimed amount ≤ coverage
Exclusion Rule Check: Reject excluded treatments/events
Provider Network Validation: Accept only registered hospitals/providers unless exceptions apply
Regulatory Check: Apply region-specific compliance rules
Fraud Rule Application: Flag claims matching predefined fraud patterns
Tool Workflow:
Claim Intake: Receive FNOL, forms, and supporting docs
Data Extraction: OCR/NLP for structured field capture
Cross-Validation: Match against PAS, CRM, and Claims history
Policy Rule Application & Fraud Screening: Verify coverage, limits, exclusions, and anomalies
Outcome Classification: Validated, Conditionally Validated, or Invalid
Routing: Forward validated claims, request additional info, or reject invalid submissions
Badges
Classification
