Claimant Eligibility & Coverage Agent
Confirms coverage, flags exclusions, and guides claimants instantly
Description
Challenge
Claim validation delays, rejections, and claimant confusion often stem from unclear eligibility rules, policy exclusions, and hospital network restrictions. Many claims fail because they bypass critical checks like pre-authorizations, waiting periods, or sub-limits—leading to errors, back-and-forth communication, and increased processing overhead. The Claimant Eligibility & Coverage Agent addresses this gap by acting as the first line of defense, validating claimant eligibility and coverage with precision—right at the moment of FNOL.
How It Works
The agent initiates with real-time prompts to collect policy and incident details from the claimant. It connects to internal systems like the Policy Admin System, Claims Engine, and Coverage Rules Repository to validate policy status, benefit limits, exclusions, sub-limits, and waiting periods. It checks hospital eligibility via external TPA systems, verifies pre-authorization status, and ensures sum insured availability. Based on these checks, it provides a clear outcome: fully eligible, partially eligible, or ineligible—along with actionable next steps like document uploads or cashless vs. reimbursement suggestions. All decisions are audit-logged and applied using a structured business rules engine to maintain consistency, compliance, and speed.
Benefits
Cuts eligibility confirmation time from ~10 minutes to under 30 seconds
Prevents 40–55% of invalid claims through early-stage validation
Achieves 93–98% accuracy using real-time policy and claims data
Delivers instant clarity on treatment coverage and documentation needs
Detects duplicate claims and prevents financial leakage
Builds a full audit trail, supporting dispute resolution and compliance reviews
Features
The Claimant Eligibility & Coverage Agent delivers fast, rule-driven coverage validation through guided interactions. It interprets policy details, flags exclusions, checks hospital networks, and confirms pre-authorizations in real time. By aligning claimant data with policy rules, it ensures accurate eligibility decisions and reduces friction during claim initiation.
Features and Capabilities:
Real-Time Policy Check: Instantly verifies policy status, active coverage, and premium standing.
Coverage & Exclusion Mapping: Cross-checks treatments against covered benefits, exclusions, and sub-limits.
Hospital Network Validation: Confirms if treatment facility is empaneled for cashless claims.
Pre-Authorization Tracker: Flags treatments needing prior approval and checks completion status.
Document Requirement Prompting: Auto-lists necessary documents based on treatment and policy type.
Benefit Limit Assessment: Evaluates sum insured balance and item-specific limits.
Location-Based Rule Checks: Validates treatment city or country against policy allowances.
Claimant Identity Validation: Confirms claimant eligibility based on role or legal status.
Duplicate Claim Detection: Detects repeat claim attempts for the same treatment event.
Outcome-Based Guidance: Clearly indicates eligibility result and next steps for claim processing.
Eligibility Logic
Decision Logic Flow
This agent orchestrates a layered decision process to validate claimant eligibility, applying product rules, coverage constraints, and pre-auth requirements in sequence. Each stage drives a specific decision — enabling real-time classification and guidance.
Key Logic Pathways Followed
Policy Active Check: If active, continue. If inactive or lapsed, halt and alert claimant.
Coverage Lookup: Checks whether illness/treatment is covered. If not, route to manual review or reject.
Waiting Period Validation: If condition falls within waiting period, flag as ineligible.
Sum Insured Validation: Adds current claim amount to past claims. If total exceeds sum insured, trigger partial eligibility or denial.
Hospital Network Check: If empaneled, suggest cashless route. If not, guide toward reimbursement process.
Pre-Authorization Check: If required and missing, request submission before claim proceeds.
Sub-Limits Enforcement: Applies limits on ICU charges, room rent, surgery capping etc.
Territory Validation: Checks if treatment occurred in an allowed location.
Claimant Validity: Verifies if the claimant is the insured or valid nominee.
Document Completion Check: Based on the treatment type, ensures all required documents are present before proceeding.
