Insurance Claims Approval with Fraud Escalation
Claims processors need to approve legitimate claims fast while routing suspicious claims for investigation and maintaining SLA compliance.
Le problème
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.
Comment Corules le résout
ESCALATE: Fraud score 0.87 exceeds threshold 0.70. Escalating to fraud investigation with full claim context.
Exemple de politique
// 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_typesOptions d'intégration
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.