GenAI-Powered Claims Processing

About project

The Challenge

One of our Client’s key business processes is claims adjudication. Claims are evaluated against individual insurance policies for regulatory reasons. The process requires accuracy and attention to detail, making it time-consuming—an experienced adjudicator processes 3-5 claims daily. Because of this, the Client decided to build a GenAI solution to streamline the process.

Business Flow & Key Features

Our solution was designed to seamlessly integrate into Client’s internal claims adjudication flow, ensuring minimal disruption to existing operations while enhancing efficiency and scalability.

• Seamless CRM Integration – The AI-powered adjudication system is fully embedded within Client’s internal CRM, enabling adjudicators to review AI-processed claims without switching platforms.
• Dynamic Policy & Vendor Management – Automated pipelines allow real-time addition and versioning of insurance policies and vendor data, ensuring adaptability to evolving business needs.
• Configurable AI Rules & Thresholds – Business users can fine-tune confidence thresholds and adjudication rules without requiring manual code changes.
• Scalable & Modular Architecture – Built on AWS cloud-native services, the solution scales effortlessly with growing transaction volumes.

Technology & Approach

To transform claims processing, we implemented a modular Generative AI-powered automation system, implementing separate AI flows for each key process step. This approach ensures high accuracy, scalability, and seamless integration with existing infrastructure. 

Key Components

• Policy Preprocessing & Claim Validation 
  AI-driven validation ensures claims align with individual policy terms by extracting key conditions and coverage details.
  
  
• Claim Preprocessing
  Structured data extraction and classification streamline claims before adjudication, reducing manual effort.
  
  
• Intelligent Document Processing (IDP)
  Extract relevant details from medical reports, invoices, and other claim-supporting documents.
  
  
• AI-Powered Claim Confidence Scoring
  A rules-based AI engine evaluates claim eligibility and documentation compliance, assigning confidence scores based on extracted data.
  
  
• Automated Workflows & Decisions
  Platform orchestrates claim assessments, automating repetitive tasks while integrating human validation where needed.

Case study

Dmytro Petlichenko

5 min to read

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Results & Business Impact

The GenAI-powered solution transformed claims processing, turning it from a bottleneck into a competitive advantage. By automating routine assessments, claims adjudicators can now focus on complex cases that require more attention while customers benefit from faster and more consistent claim resolutions.

Key Outcomes

• Confidence scoring for the adjudicators to inform their decisions.
  
• Seamless integration into the business workflow.
  
• Manual document processing effort cut by 70%.
  
• Improved accuracy by eliminating human error in document reviews.

Business Impact

1. Scalable framework that adapts to increasing transaction volumes.
   
2. Continuous learning enhances claim assessment accuracy over time.
   
3. A standardized evaluation process ensures compliance and reduces risk.
   
4. Advanced data analytics unlocks new insights for process optimization.