Processes

What will AGI do for Adjudicate claims?

AI-deliverabilitydigital

With no seeded child occupations available, the scalar is derived directly from the process name and industry lens: 'Adjudicate claims' within 'Direct Health and Medical Insurance Carriers'. Claim adjudication is fundamentally an information-transformation task—reviewing documentation, verifying billing codes, and checking policy coverage—which characterizes high-digital knowledge work. It is assigned a heavily digital scalar accordingly.

A medical claim submitted by a healthcare provider or member passes initial data intake and enters the core administration system.

Trigger: A medical claim submitted by a healthcare provider or member passes initial data intake and enters the core administration system.
Outcome: The claim is finalized as approved, adjusted, or denied, with financial responsibilities calculated and remittance advice generated.

The work itself

Grounded Work Profile

Measured by

Auto-Adjudication RateprocessProfile
Claims Processing Cycle TimeprocessProfile
Financial Payment AccuracyprocessProfile
First-Pass YieldprocessProfile

Key steps

Verify member eligibility and plan coverage for the dates of serviceprocessProfile
Check provider network status, credentials, and contract termsprocessProfile
Review diagnostic and procedural codes against medical policies and clinical editsprocessProfile
Apply benefit rules to calculate deductibles, copayments, and coinsuranceprocessProfile
Determine the final allowed amount and insurer payment responsibilityprocessProfile
Generate the Explanation of Benefits (EOB) and electronic remittance adviceprocessProfile

How AGI delivers it

Four ways AGI delivers for Adjudicate claims

Services-as-Software
Get the professional outcome delivered as software, priced on results, not headcount.
Services.do
Autonomous Agents as digital employees
Hire a digital employee that does the job under earned, supervised autonomy.
Agents.do
Business-as-Code
Encode how your work runs, once, as software that executes itself.
Platform.do

Value flow

How Adjudicate claims connects

automated by

Applying Adjudication Rulesmodel
Calculating Benefit Paymentmodel
Validating Member Eligibilitymodel
Auto Adjudication Systemmodel
Claims Adjudication Enginemodel

optimizes (incoming)

Number of invalid or fraudulent claims that are approved per $1 million revenuemodel
Claim Cycle Timemodel
Claim Denial Ratemodel
Claims Cycle Timemodel
Payout Accuracymodel
Payout Accuracy Ratemodel
Number of repeat repair%2Freplace claims approved as a percentage of total claims processedmodel
Claim Approval Ratemodel

runs (incoming)

Claims Examinationmodel

Go deeper

Explore Adjudicate claims

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