Document Extraction Agent
Automate extraction, validation, and linkage of claims documents for structured, audit-ready processing
Description
Challenge:
Claims and underwriting processes are often slowed by manual document handling, inconsistent data extraction, and incomplete submissions. Discharge summaries, prescriptions, invoices, and diagnostic reports frequently arrive in diverse formats, with missing or misaligned ICD codes, tampered content, or unverified claimant information. Manual verification is time-consuming, prone to errors, and increases exposure to fraud. Without automated extraction and validation, insurers face longer processing times, higher operational costs, and reduced accuracy in claim adjudication.
How It Works:
The Document Extraction Agent leverages OCR, NLP, IDP, and predictive modeling to extract structured data from medical and financial documents. It classifies document types, validates ICD/CPT codes against policy coverage, checks treatment timelines, and flags missing diagnostics. The agent detects duplicates and altered files, verifies claimant identity, and ensures linkage with correct claim and policy records. Secure storage with audit-ready metadata ensures compliance, reduces manual intervention, and supports fraud prevention.
Benefits:
Achieves 90–95% accuracy in document classification and data extraction
Reduces manual sorting and validation by 75%
Speeds document processing turnaround by 60–80%
Ensures 100% automated mapping of files to claims and policies
Improves governance, fraud detection, and audit readiness
Resources
Features
The agent guarantees that every submitted claim document is accurately extracted, validated, and securely linked, ensuring complete, compliant, and structured processing for underwriting and claims adjudication.
Features & Capabilities:
Document Classification: Auto-detects type (invoice, prescription, discharge summary, diagnostic report)
Field Extraction: OCR/NLP-based extraction of diagnosis, treatment, dates, costs, provider info
ICD/CPT Validation: Verifies coverage eligibility and flags non-compliant codes
Timeline Consistency Check: Confirms chronological and logical coherence of treatment events
Document Authenticity: Detects tampering, altered files, or format irregularities
Duplicate Detection: Flags repeated or identical submissions to avoid redundant processing
Claimant Verification: Cross-checks identity across documents and IDs
Invoice-Service Alignment: Ensures invoices match services listed in medical reports
FNOL Alignment: Confirms timely submission of documents post-claim filing
Secure Metadata Storage: Retains structured, audit-ready data for compliance and downstream systems
Operating Blueprint
Knowledge Sources:
Document templates and layouts for standard claims
Policy checklists for required documents
Master document taxonomy (medical, financial, legal)
Historical document mappings and treatment timelines
Medical coding libraries (ICD, CPT)
Policy coverage definitions linked to medical codes
Document authenticity patterns
Historical claims and treatment datasets
Business Rules:
Mandatory Document Check: Verify all required documents are uploaded
Duplicate Document Rule: Identify and flag repeated documents
File Quality & Format Rule: Reject unsupported file types or low-quality scans
ICD/CPT Validation Rule: Ensure coverage eligibility for all extracted codes
Timeline Consistency Rule: Check treatment and event dates for logical sequence
Document Authenticity Rule: Flag tampered or altered files using templates and metadata
Claimant Identity Verification Rule: Cross-validate identity across documents and IDs
Invoice-Service Match Rule: Confirm invoice items match reported treatments
FNOL Alignment Rule: Ensure documents submitted within required timelines
Missing Diagnostics Rule: Flag any required lab or imaging reports absent from submission
Tool Workflow:
Capture uploaded claim documents
Auto-classify document type using OCR/NLP
Extract key fields: diagnosis, ICD codes, dates, costs, provider details
Validate codes, timelines, and completeness
Detect duplicates, inconsistencies, and tampering
Cross-check claimant identity and link to relevant policy/claim
Store documents securely with audit-ready metadata
Deliver structured, validated data to claims assessment and adjudication systems
Badges
Classification
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