Claims Processing Automation

The Challenge

A regional insurance carrier with 400,000 policyholders was struggling with claims processing bottlenecks. Members filing claims waited days for initial contact, and even simple questions required calls to overwhelmed service centers.

The pain points were clear:

• 72-hour average for first meaningful contact on new claims
• High call volume for status checks and simple questions
• Inconsistent responses depending on which agent you reached
• Manual triage misrouting claims to wrong adjusters
• Compliance risk from inconsistent communication

"Members were frustrated before we even started working their claim. That three-day wait for first contact set a negative tone for the entire experience."

— VP of Claims

The Solution

We deployed a multi-layer AI orchestration system that handles initial claim intake, provides instant status updates, answers policy questions, and intelligently routes complex issues to the right human handlers.

flowchart TB
    subgraph Channels[Member Channels]
        Web[Web Portal]
        Mobile[Mobile App]
        Phone[Phone IVR]
        Chat[Live Chat]
    end
    
    subgraph Layer1[Intent & Triage]
        Intent[Intent Classification]
        Urgency[Urgency Detection]
        Complexity[Complexity Assessment]
    end
    
    subgraph Layer2[Processing]
        Status[Status Lookup]
        Policy[Policy Q&A]
        Intake[Claim Intake]
        Docs[Document Processing]
    end
    
    subgraph Layer3[Quality & Routing]
        Confidence[Confidence Scoring]
        Compliance[Compliance Check]
        Route[Smart Routing]
    end
    
    subgraph Output[Resolution]
        Auto[Auto-Resolution]
        Assist[Agent-Assisted]
        Escalate[Priority Escalation]
    end
    
    Web --> Intent
    Mobile --> Intent
    Phone --> Intent
    Chat --> Intent
    
    Intent --> Urgency --> Complexity
    
    Complexity -->|Simple| Status --> Confidence
    Complexity -->|Policy| Policy --> Confidence
    Complexity -->|New Claim| Intake --> Confidence
    Complexity -->|Documents| Docs --> Confidence
    
    Confidence --> Compliance --> Route
    
    Route -->|High Confidence| Auto
    Route -->|Medium| Assist
    Route -->|Complex/Urgent| Escalate
                

Intelligent Intake

New claims are guided through a conversational intake that:

• Collects required information through natural dialogue
• Validates policy coverage in real-time
• Requests relevant documents (photos, police reports, receipts)
• Sets accurate expectations for next steps
• Routes to appropriate adjuster based on claim type and complexity

Instant Status & Policy Questions

67% of inbound contacts are now handled without human involvement:

• "Where is my claim?" - Real-time status with next steps
• "What does my policy cover?" - Accurate answers with policy citations
• "How do I submit additional documents?" - Guided upload process
• "When will I get paid?" - Timeline based on claim status and type

Compliance-First Design

Every response passes through compliance checks:

• Required disclosures automatically included
• No coverage promises without verification
• Audit trail for all member communications
• State-specific regulatory requirements enforced

Results

Within 6 months of deployment:

• 4.2x faster first meaningful contact (from 72 hours to 17 hours)
• 67% auto-resolution for routine inquiries
• +18 point NPS improvement in claims experience
• $2.4M annual savings in service center costs
• Zero compliance issues in post-deployment audits

"The AI handles the routine stuff instantly, which means our adjusters can focus on the complex claims that actually need human judgment. Members get faster service, and our team is less burned out."

— Claims Operations Manager

Technical Details