Automated Claims Triage and Processing with AI Integration

Automated Claims Triage and Processing

1. Claim Submission

1.1. Initial Claim Entry

Claims are submitted by policyholders through multiple channels including online portals, mobile applications, and email.

1.2. Data Capture

Utilize Optical Character Recognition (OCR) technology to extract relevant information from submitted documents.

• Example Tool: ABBYY FlexiCapture

2. Claims Triage

2.1. Automated Risk Assessment

AI algorithms evaluate the risk level of each claim based on historical data and predefined criteria.

• Example Tool: IBM Watson for Insurance

2.2. Categorization and Prioritization

Claims are categorized into various types (e.g., fraud, high-value, low-value) and prioritized for processing.

• Example Tool: Salesforce Einstein Analytics

3. Claims Processing

3.1. Automated Decision Making

AI-driven models make preliminary decisions on claims based on established guidelines and risk assessments.

• Example Tool: ClaimVantage

3.2. Human Review (if necessary)

Claims flagged for human review are sent to adjusters for further investigation and validation.

4. Claims Resolution

4.1. Automated Communication

AI chatbots provide real-time updates and responses to policyholders regarding their claims status.

• Example Tool: Zendesk Chatbot

4.2. Payment Processing

Once approved, payments are processed automatically through integrated financial systems.

• Example Tool: SAP Concur

5. Post-Processing Analysis

5.1. Data Analytics and Reporting

Utilize AI analytics tools to generate reports on claim trends, processing times, and fraud detection.

• Example Tool: Tableau

5.2. Continuous Improvement

Feedback loops are established to refine AI models and improve the overall claims process based on performance metrics.