Insurance Claims Approval with Fraud Escalation
Claims processors need to approve legitimate claims fast while routing suspicious claims for investigation and maintaining SLA compliance.
El problema
Submitted claims are evaluated against coverage policy, fraud signals, and payout authority limits. Low-risk, policy-compliant claims auto-approve within seconds. High-risk claims escalate to investigators with full context preserved — not rejected silently. Adjusters retain decision authority while AI handles triage volume.
Cómo lo resuelve Corules
ESCALATE: Fraud score 0.87 exceeds threshold 0.70. Escalating to fraud investigation with full claim context.
Ejemplo de política
// Claims policy (CEL)
context.claim_amount <= params.auto_approve_limit
&& context.fraud_score < params.fraud_threshold
&& context.coverage_verified == true
&& context.claim_type in params.covered_claim_typesOpciones de integración
Frequently Asked Questions
Why does a suspicious claim escalate instead of being auto-rejected?
Safe defaults: ambiguity escalates to a human. Silent rejection of a legitimate claim is a worse outcome than escalation overhead. Investigators receive full context to make an informed decision.
Can authority limits vary by adjuster tier?
Yes. Payout limits are parameterized by adjuster level and claim type. The policy evaluates context.adjuster_tier against params.authority_matrix.