Claims Summarisation Agent
Automates structured claim summaries for faster review and triage
Description
Challenge:
Health claims often include multiple documents—discharge summaries, prescriptions, invoices, diagnostic reports, and policy details. Manually reviewing and summarizing this information is time-consuming, error-prone, and inconsistent across claim handlers. These inefficiencies slow down triaging, increase adjudication delays, and create audit gaps. Without standardized summaries, claims teams spend excessive time rechecking details, leading to poor turnaround times and higher administrative costs.
How It Works:
The Claims Summarization Agent uses OCR and NLP pipelines to parse structured and unstructured claim data. It extracts key information including diagnosis, treatment codes, hospital details, admission/discharge dates, billed amounts, and coverage utilization. This information is compiled into a clear, structured, human-readable summary that aligns with clinical, financial, and policy perspectives. The summaries are routed to claims triaging workflows or adjudication systems, ensuring claims handlers receive a concise and complete snapshot for decision-making.
Benefits:
Cuts manual summarization effort by 80–90%
Reduces average summarization time to under 45 seconds per claim
Ensures 99% accuracy in mapping extracted fields to claim records
Provides consistent and complete claim snapshots for handlers
Improves triaging speed and adjudication turnaround
Enhances audit readiness through standardized formats
Resources
Features
The Claims Summarization Agent transforms raw, multi-document claim submissions into structured summaries that support faster triage and decision-making. It ensures completeness, consistency, and accuracy while reducing manual dependency.
Features & Capabilities:
Automated Parsing: Extracts information from medical, financial, and policy documents using OCR/NLP.
Structured Summaries: Organizes data into standardized sections—diagnosis, treatment, provider, costs, coverage usage.
Code Mapping Support: Integrates ICD/CPT standards for clinical data normalization.
Cross-System Integration: Links with claims management, policy administration, and triaging systems.
Validation Layer: Ensures completeness and accuracy by cross-checking extracted data with policy records.
Audit-Ready Format: Generates summaries with traceable document references.
Real-Time Processing: Produces summaries in under a minute for high-volume workflows.
Context Awareness: Uses historical claims and provider profiles for contextual alignment.
Operating Blueprint
Knowledge Sources:
Medical Documents Repository: Discharge summaries, prescriptions, diagnostic reports
Financial Records: Itemized invoices, hospital bills, and cost breakdowns
Policy & Benefits System: Coverage terms, sub-limits, exclusions
Historical Claims Database: Past claims for same policyholder or family reference
Provider Profile Database: Hospital/provider details, accreditation, and treatment context
Business Rules:
Required Field Rule: Block summary generation if mandatory fields are missing; trigger re-request workflow
Linkage Rule: Ensure extracted data correctly maps to claim and policy records
Consistency Rule: Maintain standardized summary structure across claims
Completeness Rule: Include mandatory sections (diagnosis, admission/discharge, treatment, costs) in all summaries
Tool Workflow:
Claim and documents received by system
OCR/NLP parses structured and unstructured inputs
Key fields (diagnosis, treatment codes, provider details, financials, coverage) extracted
Structured, human-readable summary generated
Summary routed into claims triaging/adjudication workflow
Summary logged and stored with audit references
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Classification
