NIGO Handler
Eliminate NIGO delays with proactive document validation and compliance
Description
Challenge:
Incomplete or inconsistent submissions—commonly referred to as Not-In-Good-Order (NIGO)—are a major source of delays in health claims and underwriting workflows. Missing documents, mismatched identifiers, non-compliant evidence, or altered records lead to rework, escalations, and high rejection rates. Without automation, NIGO handling consumes significant manual effort, increases turnaround times, and exposes insurers to compliance and audit risks.
How It Works:
The NIGO Handler & Evidence Validation Orchestrator automates both detection and resolution of NIGO cases. Once a submission is received, the agent checks for required documents, validates evidence against policy coverage rules, and enforces regulatory completeness. It verifies authenticity, detects alterations or duplicates, and cross-checks consistency of key identifiers across all files. If discrepancies are found, the agent generates a structured NIGO report with precise correction instructions. If validations pass, the case is greenlit for adjudication or underwriting assessment. This dual function—error detection plus guided correction—ensures smoother workflows, fewer rejections, and higher compliance readiness.
Benefits:
90–95% accuracy in NIGO detection and resolution guidance
50–70% reduction in delays caused by incomplete or invalid submissions
30–40% fewer case rejections due to document or evidence mismatches
Accelerates compliant cases directly to adjudication with minimal human intervention
Improves compliance posture with audit-ready validation trails
Provides clear, actionable correction guidance to claimants and agents
Resources
Features
The orchestrator unifies document completeness checks, evidence-policy matching, regulatory validations, and fraud prevention into a single workflow. It ensures that all “in-scope” cases are either cleanly advanced or clearly corrected before resubmission.
Features & Capabilities:
Document Completeness Validation: Confirms presence of all mandatory documents.
Evidence-Policy Match: Cross-verifies treatments, services, and codes against policy inclusions, exclusions, and limits.
Consistency Checks: Validates identifiers (names, IDs, dates) across all files.
Authenticity Validation: Detects tampering via digital signatures, stamps, and watermark checks.
Coding Standards Compliance: Ensures medical/service codes align with ICD/CPT reference standards.
Duplicate Detection: Flags duplicate or overlapping submissions.
NIGO Report Generation: Produces structured, actionable correction instructions.
Escalation Management: Routes high-value or sensitive discrepancies to manual review.
Workflow Integration: Holds or releases cases based on NIGO resolution status.
Audit Trail Logging: Maintains a complete record of validations, gaps, and resolutions.
Operating Blueprint
Knowledge Sources:
Policy & Coverage Rulebooks: Define inclusions, exclusions, and sub-limits.
Regulatory Checklists & Filing Mandates: Ensure compliance with KYC, health, and filing rules.
Medical Coding Standards (ICD, CPT): Reference mappings for service classification.
Historical NIGO Case Repository: Patterns from past evidence gaps and resolution outcomes.
Authenticity Templates & Libraries: Standard formats for signatures, stamps, and security features.
SLA & Escalation Timelines: Benchmarks for NIGO correction and compliance adherence.
Business Rules:
Mandatory Document Verification: Required files must be present, else flagged.
Evidence-Policy Match Rule: Service/treatment must align with coverage terms.
Consistency Rule: All identifiers must match across documents.
Authenticity Check: Validate against known templates/signatures.
Timeline Rule: Service dates must fall within active policy window.
Coding Standards Rule: Extracted codes must be compliant with ICD/CPT standards.
Duplicate Prevention Rule: Detect and avoid re-processing overlaps.
Escalation Rule: High-value discrepancies escalate for human review.
Tool Workflow:
Receive eligible claim or underwriting submission package.
Validate completeness against policy and regulatory requirements.
Perform cross-document consistency checks (names, IDs, dates).
Match evidence (medical/service) to policy rules and coverage limits.
Validate authenticity and detect potential alterations.
Run coding standards compliance checks (ICD, CPT).
Identify duplicates or overlaps.
If discrepancies exist → generate structured NIGO report with correction steps.
If compliant → release for adjudication/next-step processing.
Maintain full audit logs for compliance and traceability.
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Classification
