Agentic Claims Triaging Center

Challenge

Claims arrive via emails, portals, forms, medical documents, and legal correspondence, forcing adjusters into manual triage and error-prone routing. Intake is fragmented across multiple channels. Manual triage with re-keying and misrouting inflates adjuster workload and cycle times. Fraud blind spots mean indicators go undetected at intake across segments.

 

 

Solution

 

ClaimsTriageAI is purpose-built for P&C, Life and Annuity, Group Benefits, and Specialty lines. It converts unstructured claim inputs into structured, prioritized, context-rich workflows by scoring complexity, detecting fraud, and routing claims instantly. It serves as the digital front door for claims.

 

The solution is powered by the following AI agents:

• Claims Intake Intelligence Agent: interprets claimant intent across channels and identifies claim type, product, and jurisdiction
• Document Classification Agent: classifies documents and validates completeness against claim-type requirements
• Claims Complexity Scoring Agent: scores financial exposure, complexity, and risk for triage paths
• Fraud and Anomaly Detection Agent: flags suspicious patterns, document inconsistencies, and unusual activity
• Claims Routing Agent: routes claims by type, authority limits, complexity, and SLA commitments

 

The underlying base agents include:  

• Quasar Document AI for classifying and extracting data from claim forms, medical documents, and legal correspondence  
• AI Business Analyst Agent for analyzing claim context, identifying processing requirements, and routing logic  
• Quasar Vision AI for processing image-based claim evidence including damage photos and scanned documents  
• Predict AI for scoring claim complexity, fraud risk, and financial exposure for triage prioritization  
• Agent Sphere for orchestrating claims workflow agents for routing, RFI triggering, and SLA management

 

 

How It Works

Intake intelligence interprets intent across emails, portals, forms, and attachments. Document classification classifies and validates completeness of claim documents per requirements. Data extraction and validation extracts and validates claim, policy, and medical data across systems. Complexity and fraud scoring scores complexity, flags fraud indicators, and assesses exposure. Routing and prioritization routes claims to the right handler by type, complexity, and SLA.

Why This Matters

 

Coforge’s agentic claims triaging center delivers faster triage decisions, consistent intake, improved fraud detection, and a better claimant experience.