Claims FNOL Agent
Captures incident details instantly to initiate accurate, real-time claim logging
Description
Challenge:
The First Notice of Loss (FNOL) step often suffers from delays and rework due to incomplete or inconsistent incident details. Manual data capture—via calls, emails, or unstructured forms—leads to missing fields, policy mismatches, and routing delays. Without standardization, urgent claims may be buried in queues, while invalid claims proceed unchecked. The Claims FNOL Agent solves this by initiating structured, real-time data collection across channels, auto-classifying the case, and triggering downstream claim workflows seamlessly.
How It Works:
Triggered as soon as a user shows intent to report a claim—via app, chatbot, IVR, or form—the agent begins guided data capture using product-specific templates. It validates inputs such as policy number, date and type of incident, hospitalization details, and claimant identity. Using real-time checks against the Policy Admin System and Claims History Log, it ensures policy activeness and flags duplicates. Based on urgency rules and completeness checks, it either auto-triages the case or sends it for manual review. A claim case ID is generated, next steps are communicated, and alerts are triggered for critical cases.
Benefits:
Cuts FNOL initiation time by 70–85% through automation.
Achieves 95%+ data completeness during intake.
Reduces rework and follow-up by 2x with real-time validations.
Auto-flags 100% of urgent claims for priority routing.
Lowers support call volumes by 60–75%.
Delivers standardized, auditable claim initiation across all channels.
Features
The Claims FNOL Agent delivers fast and structured claim initiation across mobile, chatbot, IVR, and assisted channels. It captures essential incident data, validates it on the spot, and routes the case using urgency-based logic—kickstarting the claims lifecycle without delays.
Features & Capabilities:
Multi-Channel Intake: Initiates claims from app, chat, IVR, or assisted channels
Policy Validation: Confirms activeness, coverage type, and claimant linkage
Incident Type Detection: Classifies hospitalization, accident, or death claims
Real-Time Field Validation: Ensures mandatory fields like date and location are captured
Duplicate Detection: Flags prior FNOLs for the same policy and timeline
Urgency Rules: Fast-tracks critical events like ICU, death, or accident claims
Claim ID Generation: Instantly assigns unique IDs and logs structured case files
Instant Confirmation: Sends next-step guidance and alerts to claimants and internal teams
Auto-Routing: Classifies cases for fast-track or manual review based on completeness and urgency
Geo-Validation: Confirms treatment location is within policy-permitted boundaries
Eligibility Logic
Decision Logic Flow:
The agent applies real-time logic to validate eligibility and completeness at FNOL, ensuring accurate intake and routing without manual touchpoints.
Key Logic Pathways Followed:
Policy Validity Check: → If inactive, flag and halt case initiation.
Coverage Match Check: → If treatment/event isn’t covered, route for manual review or rejection.
Timeliness Check: → Flags claims initiated beyond policy filing limits.
Duplicate FNOL Detection: → Checks historical data for repeated incidents.
Urgency Classification Rule: → Fast-tracks events like ICU, accidents, or death.
Minimum Field Completeness Rule: → Ensures date, location, and incident type are entered before progressing.
Geo-Validation Rule: → Flags FNOLs outside permitted treatment geographies.
