Claims Adjuster Assistant
Streamlines investigation, applies rules, and guides adjusters in real time
Description
Challenge:
Health claim adjudication often faces delays due to missing facts, inconsistent documentation, and manual interpretation of complex policy clauses. Adjusters spend valuable time reviewing case details, cross-checking hospital records, and interpreting exclusions—leading to prolonged investigations, inconsistent verdicts, and customer dissatisfaction.
How It Works:
Once a claim enters the investigation phase, the agent presents the adjuster with a dynamic view of all submitted records, prefilled forms, and hospital/TPA notes. It connects to the policy system and claims history to highlight pre-existing conditions, prior treatments, and policy-level exclusions. It also interprets doctor's notes and discharge summaries using document models to detect potential fraud or mismatches. The agent applies rule sets in real time to recommend whether to approve, reject, or request further evidence. It tracks every decision and rationale, creating a full audit trail for compliance and review.
Benefits:
Cuts investigation time by up to 60%
Auto-highlights red flags and mismatches in documents
Applies rule-based decisions with 90–95% consistency
Guides adjusters with smart prompts and evidence-based suggestions
Reduces dependency on manual interpretation of policy clauses
Enables transparent decision-making with audit-backed justification
Features
The Claims Adjuster Assistant acts as a co-pilot for human adjusters by combining document intelligence, rule evaluation, and investigation support into one guided workspace. It interprets unstructured documents, applies adjudication rules, and highlights red flags in real time—enabling faster, more consistent decisions with full transparency.
Features & Capabilities:
Case Overview Dashboard: Provides a structured view of submitted medical records, pre-authorization forms, and hospital/TPA notes in one unified workspace.
Document Parsing with NLP: Extracts and interprets data from discharge summaries, diagnosis reports, prescriptions, and other medical documents using advanced NLP models.
Mismatch & Red Flag Detection: Automatically highlights inconsistencies across documents, such as mismatched dates, billing discrepancies, or forged inputs.
Policy Clause Interpretation: Applies coverage rules to detect exclusions, sub-limit breaches, and waiting period violations relevant to the treatment type.
Pre-existing Condition Tracing: Analyzes past claim history to identify recurrence of ailments or ongoing conditions not covered under the policy.
Duplicate Treatment Check: Flags duplicate or suspiciously similar claims by matching treatment codes, timelines, and provider details with past data.
Dynamic Document Checklist: Generates a case-specific list of required documents based on treatment type, policy terms, and claim stage.
Decision Recommendation Engine: Uses real-time rule evaluation to suggest next steps—approve, reject, or request clarification—along with rationale.
Evidence Cross-Referencing: Links every decision with relevant documents and extracts, enabling adjusters to trace and validate conclusions quickly.
Audit-Ready Log Generator: Maintains a complete trail of actions, system recommendations, and final verdicts to support compliance and internal reviews.
Eligibility Logic
Decision Logic Flow A multi-step verification and validation process supports the adjuster’s decision-making, using rules, document intelligence, and system integrations.
Key Logic Pathways Followed
Document Consistency Check: → Parses discharge summary, cross-checks with diagnosis, treatment, and pre-auth details.
Policy Clause Application: → Flags exclusions, sub-limits, or unapproved treatments based on product rules.
Pre-existing Condition Rule: → Detects recurrence of past ailments within restricted periods.
Duplicate Claim Check: → Identifies similar treatments claimed previously or across insurers.
Fraud Detection Triggers: → Uses pattern-based checks for inflated billing or forged prescriptions.
Hospital Validation Rule: → Confirms treatment occurred at authorized/empaneled hospitals.
Medical Necessity Validation: → Cross-checks line of treatment with standard protocols and necessity criteria.
Decision Assistance Rule: → Recommends action based on accumulated findings—auto-approved, flagged, or sent for manual review.
Document Checklist Rule → Ensures all required evidence is present for final closure.
