NIGO Requirement Analysis - Document
Detect missing, forged, or inconsistent claim documents instantly.
Description
Challenge:
Missing or tampered documents—such as death certificates, medical reports, or invoices—create compliance risks, processing delays, and financial exposure. Errors like mismatched treatment dates, altered reports, or forged signatures are often detected late, leading to claim rejections, disputes, or fraud payouts. Manual document review is time-intensive, error-prone, and lacks standardization, causing inefficiencies across underwriting and claims.
How It Works:
The NIGO Requirement Analysis – Document Agent validates completeness, authenticity, and compliance of every document submitted for claims and underwriting. Using IDP for extraction, NLP for consistency checks, template-matching, and forensic image analysis, it detects missing files, mismatched data, or altered evidence. The agent enforces policy and regulatory checklists, validates invoices against treatment codes and sub-limits, and verifies provider authenticity via registries. It generates structured NIGO reports with corrective instructions, automates claimant/agent notifications, and tracks resubmissions until cleared or escalated.
Benefits:
90–95% accuracy in detecting missing or tampered documents
50–70% faster resolution of document discrepancies
40% faster correction cycles with AI-generated guidance
30–40% fewer rejections due to documentation errors
Up to 30% improvement in early fraud detection
Resources
Features
The Document-Level NIGO Agent ensures all claims and underwriting document packages are complete, consistent, and policy-compliant before adjudication. It reduces rework, accelerates resolution, and strengthens fraud detection through automated document intelligence.
Features & Capabilities:
Document Classification: Identifies and tags all submitted files (medical, legal, invoices, ID proofs).
Checklist Validation: Matches submitted documents to policy/product-specific requirements.
Cross-Document Consistency: Ensures IDs, names, and dates align across files.
Authenticity Detection: Uses template checks, signature/watermark validation, and forensic analysis.
Invoice-to-Evidence Match: Confirms invoices align with treatments or events in records.
Coverage & Limit Validation: Maps codes and amounts to policy sub-limits and exclusions.
Timeline Verification: Checks treatment, admission, or death dates against policy coverage windows.
Fraud Scoring: Flags suspicious anomalies or potential forgeries for investigation.
Correction Guidance: Issues structured reports with precise resubmission instructions.
Audit Trail: Captures all validation actions and corrections for compliance.
Operating Blueprint
Knowledge Sources:
Policy & Product Checklists: Defines required documents per claim type
Regulatory Mandates: Compliance rules for document submission timelines
Authenticity Libraries: Templates, signatures, stamps, watermark rules
Medical Coding Standards (ICD/CPT): For invoice-treatment validation
Provider Registries: Verification of healthcare providers and facilities
Historical NIGO & Fraud Patterns: Reference for anomaly detection
Forensic Heuristics: Image metadata and tamper-detection rules
Business Rules:
Mandatory Document Rule: Missing required files trigger immediate NIGO
Template & Format Rule: Only accepted formats and templates allowed
Consistency Rule: IDs, names, and dates must align across all documents
Authenticity Rule: Stamps, signatures, and metadata must match authenticity thresholds
Invoice-to-Evidence Rule: Invoices must be supported by medical/legal records
Coding & Limits Rule: Costs must align with ICD/CPT coding and policy limits
Timeline Compliance Rule: Dates must fit within policy and regulatory windows
Confidence/Escalation Rule: Low-confidence or high-risk cases routed to manual review
SLA Resubmission Rule: Enforces claimant resubmission deadlines, escalates if unmet
Tool Workflow:
Submission package received and metadata captured
IDP classifies and extracts fields from each document
Rules engine validates completeness against checklist
NLP checks cross-document consistency (IDs, dates, codes)
Forensic & authenticity checks validate document integrity
Invoice-treatment mapping applied to detect mismatches
Predictive scoring ranks fraud risk and processing priority
NIGO report generated with precise corrective instructions
Claimant/agent notified via portal, SMS, or email
Resubmissions tracked, revalidated, auto-cleared, or escalated
All actions logged for compliance and audit readiness
Badges
Classification
