AI CLAIM HANDLING
AI-assisted claims processing and oversight
We automate routine claims processing and route exceptions to people, with policy checks and a traceable review process.
- Designed to move straightforward claims quickly, with exceptions routed for review
- Human control mandatory on every consequential decision
- Explainability and an audit trail on every automated call
We lead with the timeline, because the value is measured in each phase.
Each phase offers an opportunity to reduce avoidable delays.
Intake through triage is an early target for reducing avoidable cycle time. AI claim handling is one of our applied AI solutions, built on Intelligent Document Processing for intake and Structured Data Extraction for capture.
Each phase offers an opportunity to reduce avoidable delays. Intake through triage is an early target for reducing cycle time.
The system accelerates the work, but people stay accountable for the decisions that affect a claimant.
Intake, extraction, policy checks, and gated adjudication.
- Automated intake and structured extraction from claim documents.
- Policy and coverage checks against your reference data.
- Confidence-scored triage and routing.
- Auto-adjudication within your defined thresholds, with human control above them.
- Explainability and an audit trail on every decision.
Automation earns trust by knowing its limits.
In claim handling, the limit is the adjudication decision itself, and we draw it explicitly. This is the line that keeps claim handling defensible.
Auto-adjudication
Reserved for claims that are high-confidence, within clear policy, and below a value threshold you set. These flow straight through with a full audit trail. Aggressive where it is safe.
Human adjudication
Mandatory for anything consequential, high-value, ambiguous, potential fraud, or outside clear policy. The system prepares the claim, a person decides. People decide what matters.
Explainability
Which policy clauses applied, what evidence was read, why it was approved or routed, travels with every automated decision. No black-box denials.
Audit and oversight
Every decision, automated or human, is logged with its evidence, so the process withstands regulatory and internal review. Defensible end to end.
Fraud signals and low-confidence cases always route to a human rather than being auto-denied. Adjudication controls follow Responsible AI and Governance.
Five steps, from mapping the journey to a system that improves.
Map
Map the claim journey and agree where automation is safe and where a person must decide.
Automate
Automate intake, extraction, and policy checks first, the biggest cycle-time wins.
Gate
Gate adjudication with confidence and value thresholds set to your risk appetite.
Instrument
Instrument explainability and audit logging from day one.
Improve
Improve as adjuster decisions become feedback that sharpens triage and recommendations.
The solutions this workflow is built from and belongs to.
Generative AI Solutions
The parent portfolio this workflow belongs to, engineered to an accuracy bar with oversight.
Intelligent Document Processing
The document AI that reads and structures claim submissions on arrival.
Structured Data Extraction
Extraction with validation that posts structured claim data directly into your system.
Fraud Detection
The signals that route suspect claims to a human rather than through auto-adjudication.
Banking and Financial Services
The industry where claim handling is a signature, high-volume workflow.
Responsible AI and Governance
The controls that keep adjudication defensible under regulatory and internal review.
What claims leaders ask us first.
Only on straightforward, low-value, clearly-covered claims within thresholds you set. Consequential claims are prepared by the system but decided by a person, with fraud signals and low-confidence cases always routed to a human.
Every decision, automated or human, is logged with the evidence read, the policy clauses applied, and the rationale, so the process withstands regulatory and internal review.
Mostly from automating intake, data capture, and policy checks, the manual work surrounding the decision, rather than from removing human judgment where it is needed.
Tell us where your claims process loses days, and we'll show what automating intake and triage does.
Automated intake, extraction, and policy checks, with the human line drawn exactly where consequential decisions sit.