Insurance · Claims workflow
Agentic Insurance Claims Processor
- Who this is for
- P&C and health claims teams handling routine, high-volume claims where evidence quality decides speed.
- Outcome
- Route routine claims from first notice through evidence validation, fraud-signal screening, and prepared communication faster, with every handler decision audit-ready.
- Boundary
- Coverage, fraud, clinical, settlement, payment, and outbound communication decisions stay with authorised claims staff. The processor prepares, evidences, and routes — it does not decide.
The workflow behind a routine claim is not a single step.
A routine claim touches intake, extraction, policy validation, triage, fraud-signal assembly, handler review, and outbound communication. Each hand-off drops evidence, repeats work, or waits on the next queue.
Handlers spend most of their time chasing missing documents, reconciling conflicting figures, and re-typing information that already exists in the pack. The decisions that need a human — coverage, clinical judgement, settlement, communication tone — get the least time.
End-to-end claims flow
Nine coordinated steps. Deterministic checks run where the rules are stable; agents assemble evidence and prepare drafts; authorised handlers approve every consequential decision.
- Accept notices from configured channels (portal, email, broker feed) into a single claim record.
- Deduplicate against existing claim numbers and policyholder identifiers.
- Emit an intake event with a stable claim ID for downstream steps.
- Classify by product, peril, and policy family from the pack contents.
- Route ambiguous packs to a handler with the classifier's confidence and reasons.
- Extract to the configured claim schema; keep a source link for every field.
- Reject values that cannot be located in a source page rather than infilling.
Example reviewer states on this step
Date of lossVerified Injury descriptionNeeds review
- Run the configured field-presence, format, and cross-field consistency rules.
- Flag missing evidence and conflicting figures for handler review with the shared reviewer copy.
Example reviewer states on this step
Vehicle VINMissing Amount claimedConflicting
- Apply the configured policy rules: cover in force, exclusions, deductibles, limits, waiting periods.
- Present findings with citations to the specific policy clauses used.
- Suggest a triage lane; the handler confirms or overrides.
- Auto-escalate claims that meet configured severity thresholds.
- Screen against the configured signal library; assemble the evidence a reviewer needs to decide.
- This step does not investigate or determine fraud. Fraud investigation belongs to the separate Fraud, Waste & Abuse Investigation workflow.
- Every consequential decision — cover, quantum, settlement, payment, communication tone — stays with the handler.
- Handler actions are recorded against the claim with the evidence and the reason.
- Prepare the outbound notification from an approved template; a human approves before sending.
- Hand off to the payment, salvage, or specialist workflow with the full case record attached.
Which decisions belong to which actor
Four responsibility lanes so the boundary between deterministic rules, AI-assisted suggestions, agentic orchestration, and authorised human decisions stays legible.
Stable, testable rules where the answer is not judgement.
- Intake schema and deduplication.
- Policy schedule application: cover in force, exclusions, deductibles, limits.
- Field-presence and format checks on extracted data.
The system proposes a classification or triage lane; a person confirms or overrides.
- Claim type and line-of-business classification.
- Triage lane suggestion.
- Notification tone suggestions from approved templates.
Specialist agents coordinate multi-document work under configured tools and permissions.
- Cross-document extraction with source links.
- Evidence assembly for validation and fraud-signal review.
- Handoff-pack preparation for downstream workflows.
Coverage, quantum, fraud, clinical, settlement, payment, and outbound communication decisions.
- Handler decision to approve, decline, or request more.
- Investigator decision on fraud signals routed for review.
- Communication approval before an outbound notification sends.
Human boundaries
These decisions stay with authorised staff. The processor prepares evidence and drafts — it does not decide.
Claims handler
- Coverage and quantum decisions.
- Request further information or documents.
- Approve or decline the outbound notification draft.
Fraud investigator
- Whether a routed fraud signal warrants investigation.
- Fraud determination — always outside this workflow.
Clinical reviewer (where relevant)
- Clinical necessity and treatment appropriateness.
Payment / settlement approver
- Payment authorisation, settlement value, and disbursement.
Reviewer states you'll see on a claim
Every extracted field carries one of four states so a handler can see at a glance what the system trusts, what needs a look, and what is missing.
Date of lossVerified Injury descriptionNeeds review Vehicle VINMissing Amount claimedConflicting
What we measure
Operating measures agreed with the customer at the Workflow Proof stage. Public results are attested per customer before they appear on this page.
Time from intake to handler-ready pack
Baseline captured in Discover; target agreed in Bound; observed value tracked from Prove onwards.
Handler rework rate on assembled packs
Rework signals evidence-gap or extraction-quality issues; drives model, rule, and schema iteration.
Missing-evidence resolution time
Time from a missing-evidence flag to the field being present or reviewer-cleared.
Fraud-signal routing accuracy
Investigator feedback on whether routed cases warranted review.
How we prove it before scaling
Under the Glacien Governed Agentic Workflow Framework, the first commercial unit is a Workflow Proof: one workflow, one user group, one document/data family, one measurable outcome, and one downstream handoff. Only after the agreed thresholds are met does the workflow move from shadow to reviewer-assist to approved low-risk actions, and only then do we scale to more teams, regions, or document families.
Frequently asked
- Does this replace claims handlers?
- No. Handlers remain the deciders on coverage, quantum, settlement, and communication. The processor removes evidence chasing and re-typing so handlers spend more time on the decisions that need judgement.
- How does this differ from fraud investigation?
- This workflow assembles fraud signals and routes material findings to an investigator. Fraud investigation itself belongs to the separate Fraud, Waste & Abuse Investigation solution.
- What runs inside our AWS account?
- Deployment, residency, and integration specifics are configured per customer during Discover and Bound. We do not publish a deployment claim on this page.
- How is customer data protected?
- Data controls, retention, and access boundaries are agreed with your security team during Discover and enforced by the configured tool and permission scope for each agent.
Ready to review your claims workflow with us?
A one-hour workflow review is the fastest way to see whether a Workflow Proof fits your team.