Evidence Validation & Policy Alignment Agent
Validates medical evidence, enforces policy rules, and flags unsupported treatments instantly
Description
Challenge:
Claims often include unclear, incomplete, or unsupported medical documents that delay processing or cause wrongful payouts. Many treatments are misaligned with diagnosis codes, exceed policy sub-limits, or lack required authenticity. Manual validation consumes time, adds risk of human error, and fails to ensure consistent enforcement of policy terms. The Evidence Validation & Policy Alignment Agent tackles this with intelligent document parsing, medical rule validation, and real-time policy matching—ensuring only compliant claims proceed.
How It Works:
Once supporting medical documents are uploaded, the agent initiates automated validation. It extracts key data like diagnosis, treatment, dates, and provider information from prescriptions, reports, and discharge summaries. These are then cross-verified against policy rules (inclusions, exclusions, sub-limits), ICD/CPT mappings, prior claim history, and pre-auth logs. The agent flags any mismatches, missing documents, duplicate treatments, or policy violations. Exceptional cases are routed for manual review, while valid ones proceed to adjudication. All checks are backed by audit logs and decision trails.
Benefits:
95%+ accuracy in matching diagnosis with treatment using medical coding standards
100% policy rule enforcement across submitted documentation
80–90% auto-validation for clean, complete document submissions
Early rejection of ineligible, incomplete, or misaligned claims
Eliminates financial leakage from unsupported treatments or duplicate submissions
Maintains a clear, auditable validation trail for regulatory scrutiny
Features
The Evidence Validation & Policy Alignment Agent ensures submitted claim evidence meets all medical, regulatory, and policy-related standards. It automates deep document checks using structured business rules and coding validation for fast, consistent adjudication support.
Features & Capabilities:
Medical-Coding Validation: Aligns diagnosis and treatment using ICD/CPT dictionaries
Policy Rules Enforcement: Applies inclusions, exclusions, sub-limits, and coverage restrictions
Duplicate Claim Detection: Matches claim inputs against past submissions.
Timeline Validation: Ensures treatment date falls within policy active period.
Pre-Auth Compliance Check: Verifies if treatment was pre-approved where required.
Format & Completeness Check: Flags missing, illegible, or poorly formatted documents.
Provider Authenticity Check: Confirms presence of digital signature or watermark.
High-Value Trigger: Escalates high-amount claims for additional scrutiny.
Escalation Logic: Automatically routes exceptions for manual review.
Validation Summary Builder: Prepares structured results for adjudicator review.
Eligibility Logic
Decision Logic Flow:
This agent applies a layered logic to ensure every medical document supports the claim and adheres to policy terms. Each validation stage eliminates unsupported or risky entries before they reach adjudication.
Key Logic Pathways Followed:
Document Completeness Check: If any mandatory report (e.g., discharge summary) is missing, flag for reupload.
Diagnosis–Treatment Alignment: If treatment doesn’t map to diagnosis via ICD/CPT standards, trigger rejection.
Policy Match Check: If policy excludes the treatment or it exceeds sub-limits, flag for denial.
Duplicate Treatment Check: Matches new claim with existing ones within a rolling 12-month window.
Treatment Timeliness Validation: Verifies if treatment date is within active policy duration.
Pre-Auth Compliance: If pre-auth required and absent, claim is flagged.
Document Authenticity & Format Check: Illegible or unauthenticated reports are blocked.
High-Value Escalation: Claims exceeding defined limits are routed for manual validation.
