AI-Assisted Insurance Claims Review
Organise claim documents, policy evidence and missing information into a review workflow that helps claims specialists assess the next step.
Keep claim evidence together
Make missing information and exceptions visible
Support consistent specialist review
Illustrative workflow · An illustrative claims-review animation using a fictional claim. Coverage and payment decisions remain with authorised specialists. Open video · Read transcript
- Industry
- Insurance
- Focus
- Claims & underwriting
- Inputs
- Claim documents, policy evidence and review rules
- Teams
- Claims handlers, specialist reviewers and operations leaders
The business situation
Where this fits
A claim arrives with documents from several sources. Details may disagree, key information may be missing and the applicable policy wording may take time to locate. Claims specialists need a clear evidence trail before making a decision.
For insurers that want a more consistent way to assemble evidence and route exceptions to the right specialist.
- Handlers spend time gathering the same documents.
- Missing information is discovered late in review.
- Decision rationale is difficult to trace back to source evidence.
The solution
How the solution helps
An AI-assisted claims workflow can organise documents, connect a proposed finding to the relevant source and highlight questions that need attention. The focus is a useful review packet: evidence, open issues and a suggested route to the appropriate specialist.
Organise the claim packet
Bring the claim form, supporting records and applicable policy evidence together.
Identify what needs attention
Highlight missing information, inconsistent details and questions for specialist review.
Support the human decision
Keep the source evidence and rationale available when an authorised specialist decides the next step.
In practice
Review a claim with missing policy information
Follow a fictional claim from its document packet to specialist review.
A claim form, supporting records, the applicable policy wording and referral rules.
Assemble the evidence
Keep the source documents and their identities together in one review packet.
OutputA claim packet ready to inspect.
Surface the gap
Show which policy information is missing and why it matters to the review.
OutputAn explicit question for the claims specialist.
Record the next step
The authorised reviewer requests information or proceeds through the approved decision process.
OutputA traceable next step with its rationale.
How it works
How the workflow comes together
Evidence layer
Organise the documents and source references relevant to the claim type.
Review logic
Define the checks, missing-information rules and specialist referral conditions.
Decision workflow
Keep reviewer authority, evidence and decision records connected.
- Document evidence
- Policy retrieval
- Exception routing
- Human review and decision records
Customer value
What this means for your team
A more useful claim packet
A source-linked review packet gives the handler a clearer view of what is known, what is missing and which questions need expertise.
More consistent review
Help claims teams reduce repeated evidence gathering and make specialist hand-offs easier to follow.
Review and control
Keep people in control
- Confirm the applicable policy version before a coverage decision.
- Keep coverage, underwriting and payment decisions with authorised people.
- Record the evidence and rationale behind the chosen next step.
Get started
Start with your use case
Start with a claim type where document gathering and missing-information checks create recurring work.
Useful starting information
- One claim type and its review rules
- Representative anonymised claim documents
- Claims and policy specialists
Success measures to track
- Completeness of the review packet
- Missing information identified before decision
- Clarity of specialist referrals
Fit with your existing systems
Agree which claim and policy records are needed, how exceptions reach specialists and where approved decisions are recorded.
Your next conversation
Which claim type creates the most document-gathering work for your team?
Tell us how your team works today. We’ll explore the information, integrations and review process that fit your use case.
Discuss this use case