Progress Report & Document Request Agent
Issues targeted, time-bound requests for missing or additional documents based on claim handler needs
Description
Challenge:
Claim processing is frequently delayed due to missing or incomplete documentation. Claim handlers spend valuable time following up, rechecking submissions, and clarifying unclear uploads. These communication gaps not only slow down case progression but also frustrate claimants and strain compliance timelines. The Progress Report & Document Request Agent eliminates these inefficiencies by automatically generating structured document requests based on policy and claim-stage logic, tracking submissions in real-time, and escalating delays where needed.
How It Works:
The agent is triggered either manually by a claim handler or automatically when predefined document rules are unmet. It references policy-specific document checklists, claim stage requirements, and handler notes to generate a personalized request. The request includes a clear list of missing documents, formats, deadlines, and upload links. It then monitors for uploads through integrated DMS systems and confirms receipt, flagging any discrepancies or invalid submissions. If deadlines are missed, the agent sends reminders or escalates the case to internal teams. All communication and status updates are logged in real-time for transparency and compliance.
Benefits:
60–75% faster document turnaround compared to manual follow-ups
85–90% first-time document correctness based on format and content validation -Reduces internal back-and-forth by 3x for incomplete claims
Ensures <10% escalation rate for delayed or missing documents
Builds a complete audit trail for every document request and response
Enhances claimant satisfaction with clear, consistent, and guided communication
Features
The Progress Report & Document Request Agent automates document follow-ups based on rules, timelines, and claim context. It eliminates guesswork for claimants and improves handler productivity through real-time tracking, personalized checklists, and integrated escalation workflows.
Features & Capabilities:
Dynamic Document Generation: Creates request messages tailored to policy, treatment type, and claim stage
Checklist Repository Lookup: Pulls required docs based on claim type (e.g., hospital bill, diagnostics, discharge summary)
Format & Completeness Validation: Ensures submitted files meet size, naming, and type requirements
Deadline Configuration: Applies standard or handler-defined submission timelines per document
Real-Time Submission Tracking: Monitors uploads via DMS, timestamps receipts, and version histories
Escalation Engine: Notifies internal users if deadlines are missed or files are invalid
Reminder System: Sends automatic reminders mid-way through deadline windows
Handler Notes Integration: Includes manual overrides or specific file requests from claims officers
Claim Record Sync: Updates internal claim records upon receipt of valid documents
Multi-Channel Delivery: Sends requests via Email, SMS, WhatsApp, or mobile app with upload links
Eligibility Logic
Decision Logic Flow:
This agent applies time-bound, stage-sensitive document logic. It identifies missing or pending documentation based on claim rules, validates incoming uploads, and ensures SLA-compliant progression.
Key Logic Pathways Followed:
Trigger Rule: → If a required document is missing at a defined claim stage, generate a request.
Deadline Rule: → Assign standard turnaround times per document type (e.g., 2 days for reports, 3 for invoices).
Reminder Logic: → If submission is not received at 50% of deadline window, issue an automated reminder.
Submission Validation Rule: → Validate file format, size, type, and checklist match before accepting.
Escalation Rule: → If deadline is breached, escalate to claim handler and re-notify claimant.
Document Grouping Rule → If multiple documents are pending, bundle in a single request for clarity.
Audit Logging: → Timestamp every action—request sent, file received, validation complete—for compliance and reporting.
