AI Driven Automated Claims Intake and Triage Workflow

Automated Claims Intake and Triage

1. Initial Claims Submission

1.1. Customer Interaction

Customers submit claims through various channels such as web portals, mobile applications, or chatbots.

1.2. AI-Powered Data Capture

Utilize Optical Character Recognition (OCR) tools like Google Cloud Vision or ABBYY FlexiCapture to extract data from submitted documents.

2. Data Validation and Verification

2.1. Automated Data Validation

Implement AI algorithms to validate the accuracy of the extracted data against predefined criteria.

2.2. Integration with Policy Database

Use AI-driven tools like Salesforce Einstein or IBM Watson to cross-reference claims data with existing policy information for verification.

3. Claims Triage

3.1. Risk Assessment

Employ machine learning models to assess the risk level of each claim based on historical data and patterns.

3.2. Prioritization of Claims

Utilize AI tools such as Claim Genius or Zeguro to categorize claims into high, medium, and low priority based on risk assessment results.

4. Claims Assignment

4.1. Automated Routing

Implement intelligent routing systems that assign claims to appropriate adjusters or teams based on expertise and workload using AI tools like ServiceNow.

4.2. Continuous Learning

Incorporate feedback loops where AI systems learn from past assignments to improve future routing accuracy.

5. Ongoing Monitoring and Updates

5.1. Real-Time Tracking

Provide customers with real-time updates on their claims status through AI chatbots, enhancing customer experience.

5.2. Predictive Analytics

Utilize predictive analytics tools such as SAS or Tableau to forecast claim outcomes and identify potential issues before they arise.

6. Final Resolution and Reporting

6.1. Automated Decision Making

Leverage AI algorithms to facilitate final claim decisions and automate approval processes where applicable.

6.2. Reporting and Insights

Generate comprehensive reports using AI-driven analytics tools to derive insights into claims trends and operational efficiencies.

7. Continuous Improvement

7.1. Performance Analysis

Regularly analyze the performance of the automated claims intake and triage process using AI analytics tools.

7.2. Feedback Implementation

Incorporate user feedback and system performance data to continuously refine and enhance the workflow.