Catalog, value chain

Claims

Is this covered, how much, and is it genuine?

Claims is the promise being kept. It is also where document volume, time pressure and fraud exposure meet. The AI-native version prepares a cited coverage brief for every claim and keeps the adjudication with a person.

Every workflow, today and AI-native

Owned by claims operations, medical review, special investigations.

Workflow	Today	AI-native
Intake and triage	Claims arrive with missing documents and are routed by queue, not by severity or complexity.	Completeness, severity and complexity are assessed on arrival, and the claim is routed with its missing-document list.
Coverage adjudication	The adjuster reads the policy, the claim file and the medical evidence separately and writes up the decision.	Claim facts are set against the policy terms in a cited decision brief, with the clauses, the evidence and the open questions in one place.
Fraud and investigation	Fraud is detected by rules and referred to investigators who rebuild the pattern by hand.	Patterns across claims, providers and agents are surfaced with the evidence that links them, and the investigator directs the inquiry.
Settlement and reserving	Payment accuracy, delay interest and case reserves are checked by sampling after the fact.	Every payment is checked against the decision and the contract, delay interest is computed from the record, and the case reserve updates with the file.
Disputes and appeals	Appeals, mediation and litigation responses are drafted from scratch each time.	The response is drafted from the claim file, the policy and prior comparable decisions, for a claims lawyer to finish.
Recovery	Subrogation and salvage opportunities are found when an adjuster happens to notice them.	Recovery opportunities are identified from the claim facts and tracked to closure.