Data Validation (DV) Process

Claims data are subjected to intense scrutiny, including the standardization of data from
multiple sources; identification of erroneous data elements; comparison to past contributions,
contributions from other payors and industry norms; and detection of duplication and claim
versioning.

Validation Automation

With growing volumes of claims and limited resources, insurers face mounting pressure to
accelerate processing while minimizing costs and errors. Efforts to automate insurance claims
workflows, particularly automated claims validation, have emerged as essential solutions,
offering measurable improvements across multiple performance metrics. Automation can
reduce error rates while simultaneously accelerating processing times from weeks to hours.
Such transformation delivers substantial benefits:

 Processing cost reductions

 Real-time or same-day processing capabilities
 Elevated fraud detection accuracy
 Increased customer satisfaction through faster claim resolutions
 Optimal resource usage, enabling personnel to focus on complex cases
 As insurers strive to enhance operational efficiency without compromising accuracy,
automation has become a strategic imperative. With it, insurance professionals can
handle larger volumes of claims more precisely, fueling gains in both customer
satisfaction and overall business results.

 Document Processing and Data Extraction

Modern claims validation systems rely heavily on advanced document processing

technologies. The combination of Optical Character Recognition (OCR) and Intelligent
Document Processing (IDP) enables automated systems to handle various document formats
efficiently, including automating PDF data extraction. According to IBM, the insurance
industry contributes significantly to the creation of 2.5 quintillion bytes of data every day,
making automated document processing essential.

Such systems can:

 Convert different document types into searchable data

 Extract key fields like policy numbers and claim amounts using AI in data extraction
 Understand document context and structure
 Validate extracted information against existing records

 Implementing Automated Claims Validation

Successful implementation of automated claims validation requires a systematic approach that

balances technological integration with organizational readiness, and here's a comprehensive
guide to help you navigate this transformation.

 Purpose

This step ensures that all documentation is intact, appropriately categorized, and ready for
assessment.
Steps: (Productivity: On average, one DV user processes 50 claims per day)

1. Claim Enters Queue: After registration, the claim appears in the DV queue.

2. Document Sorting: An assigned user categorizes the documents into types (e.g., bills,
reports, prescriptions).

3. Bill Entry: Users enter and validate data from bills.

4. Forwarded to Assessment: Once organized and entered, the claim is routed to the
Assessment Team.

Assessment (AA) Process

Objective: To thoroughly review all claims against policy terms and determine final outcomes
- approval, denial, or further investigation.

Process Flow

1. Queue Entry & Auto Allocation: Claims are automatically queued and assigned based on
type and urgency.
2. Claim Picked by Assessor: Assessor selects a claim for review.
3. Eligibility Check:

 Policy term validation

 Sum insured balance
 Disease-specific limits
 Exclusions and waiting periods
4. Cross-checking for Suspicious Activities: Checks for forged or duplicated bills
consistency between diagnosis and treatment
5. Routing:

 Approve: Claim is valid and sent to the next level.

 Deny: Non-compliant claims are rejected with reasons.
 Move to Ops/Internal Ops/Investigation: Complex or suspicious claims are escalated.
 Send to DV for Reprocessing: If document corrections are needed.
 Documents required for health insurance claim process
When you are filing a health insurance claim, you must submit the following documents to
the insurance provider for a smooth claim process.

• Documents for cashless claims

Cashless claims require minimum documentation and are easy to file. The following are the
documents you must submit for cashless claims:
◦ Pre-authorisation claim form, duly filled and signed
◦ Your valid ID proof
◦ Health insurance e-card

When you opt for cashless treatment, the insurer will settle your bills directly with the
healthcare establishment. Therefore, you will not have to collect your bills from the hospital
and submit them to the insurance provider.

• Documents for reimbursement claims

If you choose a non-network hospital for your medical procedure, you must submit the
following documents to the insurance provider for reimbursement claim settlement:
▪ Your health e-card
▪ Your photo ID proof
▪ Proof of address
▪ Original discharge summary
▪ Doctor's prescription recommending hospitalisation
▪ Doctor's consultation slips and prescriptions for diagnostic tests
▪ Certificate from the attending doctor
▪ Prescription for medicines and original pharmacy bills
▪ Diagnosis reports of X-rays, blood tests, etc.
▪ Other original receipts from the hospital
▪ Breakup of the hospital bill
▪ Ambulance receipt, if applicable
▪ FIR, in case of an accident

“Cashless Claims Workflow”

Step 1: Claim Sources

Initial Final Request
(PRE-AUTH)

After submitting all initial bills are made after discharge only after
docs available at that time Submitting all mandatory documents

Pre authorization assessment Pre authorization Pending assessment done

Done (either approved or denied)

If approved

Now all communication will be done between

hospital and insurance company
Approve Decline

Initial approval decline & cashless approved awaiting invoice

letter sent closed

Enhancement Final Request approved > 48hr approved <48hr

Enhancement approved
(multiple enhancement request Customer SNP PA final invoice review
Can come & may or may till when invoice is pending review again by accessors
not be approved).

Final invoice tax review Approve & Pay

(whole new screen)
 Bot Payment
Four stages

Cashless approved payment

Pending because of staggered no. of days

1. approved 2. reject

Paid & Closed

3. It Error 4. Cashless approved
payment pending

After (approved) stage

Paid & Closed Closed awaiting UTR

Step 1: Claim Source

The cashless claim journey begins at the point when a claim is initiated from a hospital portal
by hospitals / TPA. There are two key stages involved:

A. Initial (Pre-Authorization) Request

B. Final Request (Post-treatment documentation)

I. Initial (PRE-AUTH) Request

A. Document Submission:
The hospital submits all available initial bills and supporting documents for the patient.

B. Pre-Authorization Assessment:
The insurer performs a pre-authorization check based on submitted details.

If Approved:

An initial approval letter is issued.

The hospital may raise enhancement requests for additional approvals if the treatment cost
increases.

Each enhancement request is separately reviewed and may or may not be approved.

This loop can repeat multiple times.

Once treatment concludes, the hospital raises a Final Request.

If Declined:

The case is marked as declined and closed at the pre-auth stage.

II. Final Request (Post-Treatment Submission)

A. Submission Timing:
The final request can only be made after patient discharge and once all mandatory documents
are available.

B. Pending Assessment:
A final pre-authorization assessment is conducted again:

If Approved:

The insurer now engages directly with the hospital for all further communication.

The final invoice is marked as "cashless approved – awaiting invoice".

Depending on time:

If the final request is approved after 48 hours, the case is marked as Customer SNP till
invoice is received.

If approved within 48 hours, a final invoice review is conducted again by the accessor.

III. Final Invoice Tax Review & Assessment

This stage involves a detailed tax review and is treated as a new evaluation screen. There are
four possible outcomes of this assessment:

 Approved

 Reject
 IT Error

 Cashless Approved – Payment Pending

IV. Post-Assessment Closure

 After final assessment and approval:

 If everything is correct and payment is processed:

 The case is marked Paid & Closed.

 If UTR (Unique Transaction Reference) is awaited:

 The case is marked Closed – Awaiting UTR.

Additional Notes:

 If Bot Payment is used, the system directly Approves & Pays the amount.

 In cases with staggered number of days, the payment may be pending until all benefit
days are accounted for.

“Re-Imbursement Claims Workflow”

Description of the PREVIOUS workflow between DD (Digit Desk)
and DC (Digit Care) for claim creation

[POV: A fresh ticket is assigned and to register claim you are working on digit desk
after reimbursement claim Intimation ]

STEP 1: Claim Intimation via Email

The claimant initiates the reimbursement claim by sending an email

to [Link]@[Link]

The email must include:

 Hospital name and pincode
 Patient name
 Date of Admission (DOA)
 UHID or ID card number

STEP 2: Auto-Response from Digit

Digit replies with a generic acknowledgment email that:

 Provides a ticket/issue number (e.g., HC-0001)

 Lists all mandatory documents required for claim processing:
 From hospital: HFB (Hospital Final Bill), DS (Discharge Summary), DB (Discharge
Bill), MB (Medical Bill), test reports, pharmacy bills, original receipts, SOE
(Summary of Expenses).
 From insured: Claim form (CC), KYC documents.

STEP 3: Update Ticket on Digit Desk (DD)

On the Digit Desk platform, you must:

 Update basic ticket details: type, priority, status, timestamps, issue description, product,
process, sub-process, reason, and policy number.
 Set the status:
 Pending with Customer if documents are incomplete
 Auto Classification in Process if all documents are received

Once updated, initiate a call for claim intimation and push documents to Digit Care (DC).

Digit Care (DC) – Claim Registration Process

STEP 4: Access FNOL Dashboard

In the New Health FNOL Dashboard, enter the policy number to view:
 Intimation ID (SF-ID)
 First intimation date
 DD ticket number
 Claim type and reason
 Classification status (must show Auto Classification Completed)
 If classification is complete, proceed to create FNOL (First Notice of Loss).

STEP 5: Fill Mandatory Fields

After FNOL creation, a form opens. Fill in:

a) Policyholder name
b) Policy name
c) Patient name
d) Mobile number
e) Email ID
f) Claim class type
g) Coverage
h) Loss cause
i) Claim type
STEP 6: Document Verification

Verify and validate the following documents:

 Discharge Summary (DS): Must include DOA, DOD, diagnosis, patient and doctor
names, discharge advice, and hospital details (add hospital if not listed)

 Hospital Final Bill (HFB): Must include entity name, bill number, date, and amount

 KYC: Must include document number and name

Each document tag (DS, MB, DB, etc.) has an IR (Information Required) option with a
comment box for missing or unclear data.

STEP 7: Register the Claim

After verifying all documents and filling all fields:

 Click Register Claim
 A pop-up prompts you to re-check: DOA, DOD, Patient Name, and Loss Cause
 If any required data is missing, the system prompts to Generate IR and send a customized
email for pending documents
 If all is complete, proceed and receive a Claim Number confirming successful
registration

X
Claim has been Created Successfully
Claim Number: 00000000000
OK

 This all flow is generic with minor tailoring is of V1, V2, V3 systems,
but recent version (V4) of system based on Claim Automation

CHAPTER 5: HEALTH CLAIMS

AUTOMATION
Healthcare claims processing is a crucial component of the medical and insurance industries,
ensuring that healthcare providers get paid on time and patients have a smooth reimbursement
process. Nevertheless, the traditional claims processing methods are marred with
inefficiencies, human errors, and fraudulent activities, contributing to high administrative
costs and delays. Automation technologies, such as artificial intelligence (AI), machine
learning (ML), and robotic process automation (RPA), have recently emerged as game-
changing tools to improve efficiency, accuracy, and compliance in the management of claims
AI-assisted automation in claims processing uses algorithms to extract, validate, and process
claims with least human intervention. Natural language processing (NLP), for example,
allows for the corresponding automatic extraction of relevant information from unstructured
medical documents, while predictive analytics are utilized for fraud detection and risk
assessment.

Advantages of Automating Health Claims Processing

The key benefits of automating medical claims processing in the healthcare industry. It
highlights five major advantages -
• Faster Claim Processing – Automation significantly reduces processing time, leading to
quicker
reimbursements.
• Reduced Claim Denials – AI-driven verification improves accuracy and minimizes claim
rejections.
• Improved Patient Experience – Faster and more accurate processing ensures smoother
healthcare transactions.
• Cost Reduction – Automation lowers administrative expenses by reducing manual
intervention.
• Minimizing Errors – AI and machine learning help eliminate human errors, improving data
accuracy and compliance.

AI and Machine Learning in Claims Processing

Claims processing has become much more accurate and efficient due to the adoption of
Artificial Intelligence (AI) and Machine Learning (ML). According to the research by, the AI-
driven systems can help to identify patterns in healthcare claims data which can help in early
detection of the fraud and also reduce the processing errors. By grouping down the claim
information and measuring patterns, AI-powered models are getting used to examining past
claims trends and forecasting pathological activities while assisting with decision-making. A
deep learning based model presented in achieved automation of claim approvals in 92% of
the cases, eliminating the need for a manual verification process. "Additionally, the use of
reinforcement learning techniques has been investigated to improve claim adjudication
information processes .These innovations reduce operational costs for healthcare providers
and health insurance companies and improve efficiency. However, further development is
required on issues — biased AI models, and data privacy amongst others.
Robotic Process Automation (RPA) for Claims Processing

Robotic Process Automation (RPA) has proven to be a powerful technology for automating
repetitive tasks–like data entry, claims validation, and payment processing–in healthcare
claims processing. According to a recent study done by RPA based systems has
commoditized the information in the systems as well and mined some of the mundane
information out as they no longer require any human intervention at all-times which improved
the claim processing time and even made it faster. A similar study conducted in showed that
over 40% efficiency can be added to processing when we combine AI models with RPA.
Insurance companies can process tickets in bulk through bot-based automation without
sacrificing accuracy. Yet, as noted in there are issues related to system interoperability where
legacy healthcare systems are not able to easily interact with RPA-driven automation
frameworks. Moreover, in spite of the advantages, initial setup costs and employees pushing
back against automation continue to be impediments to mainstream uptake.

Natural Language Processing (NLP) for Claims Adjudication

A primary function of natural language processing (NLP) is automating claims adjudication

by converting unstructured medical records into structured [Link] algorithms have
shown that they can automatically classify claims by medical diagnoses and procedures
without significant coding errors. NLP Underwriting: Another study, the previous one
mentioned in, shines a light on NLP-powered chatbots that handle claims-related queries,
offering
the customers significant ease and shielding them from administrative work. In addition to
this, few papers mentioned about NLP models based on machine learning approach to detect
inconsistencies in medical records, avoiding wrong claims. However, a study in reports that
state-of-the-art NLP models rely on large training datasets to obtain good predictive
performance, and that, due to language ambiguities, they are often not reproducible in the
context of medical documentation.

OCR in Claims Processing?

In claims data management, OCR (Optical Character Recognition) technology automates text
extraction from scanned claim documents. It converts characters from images into machine-
readable text, enhancing data accuracy and speeding up processing by reducing manual entry
errors. This helps insurance companies improve efficiency and claimant satisfaction.

When handling claims, OCR can process different types of documents, like financial
statements, medical records, and insurance claim forms, to accurately record and convert all
important information into digital form.

With a grasp of OCR technology, we can now get into how this powerful tool plays a crucial
role in streamlining claims processing operations.

The Role of OCR in Claims Processing - Optical Character Recognition (OCR) technology
has emerged as a critical tool in modernizing and streamlining claims processing. Let’s learn
about it in detail.

 Facilitating Digitization and Organization:

Optical Character Recognition (OCR) technology is key in claims processing. It turns

physical documents into digital files, including insurance claims, medical records, and
financial statements. This step simplifies data management, making storing, finding, and
processing claims easier. As a result, operational efficiency improves.
 Extracting Relevant Information:

One of the primary roles of OCR in claims processing is extracting relevant information from
various documents. OCR software scans documents. Next, it identifies key data and converts
it into machine-readable text. The data includes policy numbers, claimant information, dates,
and amounts, which are crucial for accurate claims processing.

 Automating Repetitive Tasks:

OCR technology automates many repetitive tasks. These tasks are part of claims processing,
like data entry and document sorting. Traditionally, these tasks take a lot of manual effort and
are often subject to human error. OCR automates these processes, saving a lot of time and
money. OCR eliminates manual data entry. It reduces errors and speeds up processing. It also
frees employees to focus on more important tasks.

 Ensuring Compliance with Regulatory Requirements:

Compliance with rules is key in processing claims. OCR ensures claims are handled and
stored correctly, following industry rules. It organizes data, aiding audits and checks. This
step reduces legal risks and boosts the organization's credibility in Claims Processing.

Use cases for OCR in Claims Processing

OCR technology is changing claims processing. It does this across many sectors by
automating data extraction. It also improves efficiency. Here are some key use cases:

1. Health Insurance Claims Processing

OCR technology is vital in health insurance claims processing. It automates data extraction
from medical records. It also does this from insurance claim forms and other healthcare
documents. This saves time, reduces errors, and speeds up claim processing. OCR technology
efficiently converts handwritten and printed documents into digital formats. It ensures that
insurance claims are processed quickly and precisely. This leads to faster reimbursements and
happier patients.

2. Automotive Insurance Claims Processing

In the car insurance industry, OCR technology simplifies claims. It makes them for vehicle
damage and accidents. It quickly extracts details from documents like accident reports and
repair invoices. This speeds up the process. With OCR, insurers can swiftly evaluate damage,
assign fault, and process payments. This improves customer satisfaction and cuts processing
times.

Types of Data extracted From Claims Documents using OCR

In the claims processing industry, optical character recognition (OCR) technology is

revolutionary because it can consistently and swiftly extract a wide range of crucial data from
various documents. This section describes the many types of data that OCR may efficiently
obtain, expediting the process and providing more accuracy and compliance.

1. Policyholder Information
The policyholder's details, including full names, addresses, phone numbers, and policy
numbers, constitute the foundation of every claims document. By reliably extracting essential
facts from claims forms and other relevant documents, OCR technology reduces the
possibility of errors by guaranteeing that claims are associated with the correct policyholder.

2. Claim Details (Dates, Amounts, Descriptions)

Claim details are essential for processing and validating claims. OCR can effectively extract
crucial data such as claim submission dates, claim amounts, and detailed descriptions of the
claim. This precision helps in faster claim reviews and approvals, facilitating a streamlined
workflow.

3. Medical Records and Diagnosis Codes

Since OCR retrieves data from medical records, including diagnosis codes, dates of treatment,
and patient information, it is crucial to the processing of healthcare claims. This function
helps ensure that claims are processed accurately in line with the medical services provided,
which speeds up the reimbursement process and reduces discrepancies.

Extracting these many kinds of data via OCR makes claims processing more accurate,
compliant, and efficient. Facilitating speedier resolutions to claims increases customer
happiness and speeds up claims processing.

Now that we understand the types of data that can be extracted let's explore the practical steps
involved in extracting data from claims documents using OCR.

How to Extract Data from Claims Documents Using OCR

Using OCR software to extract data from claims documents involves several key steps. Here
is a step-by-step guide to streamline the process:

Step 1: Document Capture

The first step is capturing the physical or digital documents. This can be done either by
scanning paper documents using a high-resolution scanner or by uploading existing digital
images to the OCR system. The quality of these images is critical as clear, high-resolution
images significantly increase the accuracy of text recognition.

Step 2: Image Preprocessing

Before OCR processing, images undergo several preprocessing techniques to improve

readability for OCR algorithms.

Key steps include:

 Resolution Enhancement: Increase the DPI (dots per inch) setting to sharpen text details.
 Noise Reduction: Apply filters to remove background noise and artifacts that can obscure
characters.
 Contrast Adjustment: Enhance contrast to make text stand out more clearly from the
background.
 Deskewing and Despeckling: Correct any alignment issues and remove small specks on
the document.

Step 3: OCR Processing

The OCR software analyzes the preprocessed images to detect and recognize text. It converts
the text from images into machine-readable formats. OCR technology has evolved to
recognize a wide range of fonts and handwriting, although the latter can still be challenging
and may require specialized OCR solutions.

Step 4: Data Extraction

After recognizing text, the OCR software extracts key data from documents. This includes
names, dates, policy numbers, and other crucial details for processing claims.

Step 5: Data Validation and Verification

After data extraction, the extracted data must be validated and verified for accuracy.
The steps involve:

 Rule-Based Validation: Apply specific rules (e.g., valid date ranges, policy number
formats) to ensure the data conforms to expected formats.
 Cross-Verification: Cross-check extracted data with other databases or systems to verify
accuracy. This could involve matching names with policy databases or checking codes
against medical billing standards.

Step 6: Output

Finally, the validated data is put into a structured format, like JSON or XML. It can then be
easily added to claims systems. This structured data facilitates automated workflows and
further processing of the claims.

OCR & NLP: Enhancing Data Extraction (in DIGIT)

1. Data Extraction from Custom Images & Forms:
By training bespoke models, OCR systems can pinpoint and standardize specific details,
capturing essential data from various types of healthcare imagery and forms.

2. Table Data Extraction:

OCR can identify and extract complete tables from scanned images, converting printed data
from sources like financial disclosures and lab results into structured, usable formats.

3. Entity Recognition in Scanned PDFs:

Utilizing a regular NER pipeline, OCR can import, pre-process, and recognize text from
scanned images, correcting errors to extract meaningful entities.

4. Skew Correction in Scanned Documents:

OCR, in particular, offers the ability to correct document skewness (alignment), significantly
enhancing OCR accuracy.

5. Text Recognition in Natural Scenes:

OCR can identify and extract text from natural scenes, using image segmentation and pre-
processing to handle complex backgrounds and layouts.

6. DICOM Text Recognition:

OCR technology can extract text not only from the visual content of DICOM(Digital Imaging
and Communications in Medicine) images but also from the accompanying metadata, offering
a comprehensive text extraction solution.

7. Have visual content (like X-rays, MRIs, CT scans) and metadata (patient information,
image acquisition details, etc.).

, causing delays and dissatisfaction. Hiring temporary staff is costly and inefficient.

How AI-Powered Solutions Transform Claims Processing

The implementation of claims automation technologies has fundamentally transformed how
insurers approach health claims processing. These solutions address each of the traditional
challenges while introducing new capabilities that were previously impossible with manual
systems.

 Intelligent Document Processing

Modern AI systems excel at extracting and interpreting information from complex medical
documents. Natural language processing algorithms can analyze physician notes, decode
medical terminology, and identify relevant treatment information with 95% accuracy rates.
This capability eliminates the need for manual data entry and reduces processing times from
hours to minutes.

Optical character recognition technology has evolved to handle handwritten medical notes,
insurance forms, and diagnostic reports. These systems can process thousands of documents
simultaneously, automatically categorizing information and flagging potential issues for
human review. The result is a streamlined workflow that processes routine claims without
human intervention while ensuring that complex cases receive appropriate attention.

 Automated Medical Code Verification

AI in health insurance applications now include sophisticated medical coding verification
systems. These platforms cross-reference submitted diagnostic and procedure codes against
established medical protocols, insurance policy coverage details, and regulatory requirements.
Machine learning algorithms continuously update their knowledge base by analyzing new
medical research and treatment guidelines.

The verification process extends beyond simple code matching to include

clinicalappropriateness assessments. AI systems can determine whether proposed treatments
align with diagnosed conditions, identify potentially unnecessary procedures, and flag cases
that may require specialist review. This comprehensive approach ensures that claims are not
only technically accurate but also medically appropriate.

 Real-Time Claims Processing

Perhaps the most significant advancement in claims automation is the ability to process
routine claims in real-time. AI systems can receive claim submissions, verify information,
check policy coverage, and approve payments within minutes of submission. This capability
transforms the customer experience from one of uncertainty and waiting to immediate
resolution and peace of mind.

Real-time processing requires sophisticated integration between multiple systems, including

electronic health records, insurance databases, and payment processing platforms. Agentic AI
systems orchestrate these complex workflows, making decisions and taking actions
autonomously while maintaining detailed audit trails for compliance and quality assurance
purposes.

 Personalized Customer Communication

AI-powered communication systems provide personalized updates throughout the claims
process. These systems can explain claim decisions in plain language, provide estimated
processing timelines, and proactively communicate any additional information requirements.
Natural language generation capabilities ensure that communications are clear, empathetic,
and appropriate for each customer’s specific situation.

The personalization extends to communication channel preferences, with AI systems

automatically selecting the most appropriate contact method based on customer history and
preferences. This approach significantly improves customer satisfaction while reducing call
center volume and associated operational costs.

The Role of Agentic AI in Modern Insurance Operations

Agentic AI represents the next evolution in insurance technology, moving beyond simple
automation to systems that can make independent decisions, learn from outcomes, and
continuously improve their performance. These advanced systems operate with minimal
human supervision while maintaining transparency and accountability in their decision-
making processes.

 Autonomous Decision-Making Capabilities:

Unlike traditional rule-based systems, agentic AI can evaluate complex scenarios, weigh
multiple factors, and make nuanced decisions that previously required human judgment.
These systems analyze vast amounts of data, consider contextual factors, and apply learned
experience to reach optimal outcomes for each unique situation.

The decision-making capabilities extend to handling exceptions and unusual cases that don’t
fit standard processing patterns. Agentic AI systems can research relevant precedents, consult
multiple data sources, and develop novel solutions while maintaining consistency with
established policies and regulatory requirements.

 Continuous Learning and Adaptation:

One of the most powerful aspects of agentic AI in claims automation is its ability to learn
from every interaction and continuously improve performance. These systems analyze
outcomes, identify successful strategies, and adapt their approaches based on real-world
results rather than relying solely on initial programming.

The learning capabilities include understanding seasonal patterns, regional variations, and
emerging trends that impact claims processing. This adaptive approach ensures that AI
systems remain effective even as medical practices evolve, regulations change, and customer
expectations shift.

 Multi-System Integration and Orchestration:

Modern insurance operations involve numerous interconnected systems, from policy
administration platforms to medical databases and payment processing systems. Agentic AI
excels at orchestrating complex workflows across these multiple systems, ensuring seamless
data flow and coordinated processing activities.

The integration capabilities include real-time synchronization between systems, automated

error handling, and sophisticated workflow management. These systems can detect system
failures, implement backup procedures, and maintain service continuity even when individual
components experience issues.

 Ethical Decision-Making and Bias Mitigation:

Advanced agentic AI systems incorporate ethical decision-making frameworks that help
ensure fair and unbiased claims processing. These systems actively monitor for potential bias
in their decision-making processes and implement corrective measures to maintain equitable
treatment across different demographic groups.

The ethical frameworks include transparency mechanisms that explain decision rationale,
audit trails that document processing steps, and feedback systems that allow for continuous
improvement in fairness and accuracy. This comprehensive approach addresses growing.

CHAPTER 6: Claim Automation Process

(Description of the CURRENT workflow Claim Automation for claim
creation)

HC ticket generated - (DD Ticket)

DD “ FNOL Automation”
(ticket)
(internally)
AI (ARIA)
Response Submit documents (s-doc) {AI service call - KVP classificatn.}

(backend)

Table Structure (docs) KVP extracted

(once ALL mandatory docs are extracted) BE LOGIC

[3 SCENARIOS]

All Mandatory docs & When only policy No. When nothing is
fields are available. is available. available.

(After This) -:

THE CLAIM STATUS:

[In DD]

If all mandatory docs and fields are available = In DD new status will show = PENDING FOR DD

1. AI RESPONSE FAILED CLAIM INTIMATION CLAIM CREATED

(Admissibility docs received)

which means everything has means SF-ID is created & in DC means in DC claim dashboard
to be done manually in DC Auto-Classification Completed status- Admis./Sub- Doc Received

* meaning aria analyses the mail that is it for claim intimation or not. If it is then only aria will
response.

Claim Automation Process

The claim automation process begins when a Health Claim (HC) ticket is generated on the
Digit Desk (DD) platform. This is referred to as the DD ticket, and it triggers the First
Notification of Loss (FNOL) Automation process internally.

Once the ticket is initiated, relevant documents are submitted, termed as S-docs. These
documents are then passed to an AI system (ARIA) for classification and key value pair
(KVP) extraction. ARIA performs backend processing where the documents are parsed and
structured in a tabular format. If successful, all mandatory fields and documents are extracted,
which allows the process to proceed to BE LOGIC, where business rules are applied for
further decision-making.

At this stage, there are three possible scenarios:

 All mandatory documents and fields are available – The automation continues
seamlessly.

 Only the policy number is available – Partial automation may proceed based on available
data.

 Nothing is available – Manual intervention is required, and the process is halted until
data is provided

Step-by-Step Explanation of the New Process:

1. Customer Replies to the Email

 The system reads the email.
 It checks if this email is a reply to the earlier request for documents.
 It looks for the claim number or policy number in the email.

2. System Checks the Documents

The system compares the documents in the email with the list of documents that were asked
for. If all documents are there:

 The system uploads them to the claim.

 It updates the claim status to show that documents were received.
 It starts the next step in the claim process.
 If some documents are missing:
 The system uploads whatever is available.
 It updates the status to show that the response is incomplete.

3. Customer Sends a New Email (Not a Reply)

 Sometimes the customer sends a new email instead of replying to the old one.
 The system tries to figure out if this new email is related to an existing claim.
 It looks for claim or policy numbers in the email.
 If it finds a match:
 It links the new email to the correct claim.
 Then it checks and uploads the documents just like before.

How the System Understands Emails

The system uses Artificial Intelligence (AI) to:

 Understand what the email is about.

 Find claim or policy numbers.
 Check if the claim is still waiting for documents.
 Decide what to do next.
 Summary in One Line:
 The system will automatically read customer emails, check if the right documents are
sent, and update the insurance claim without needing a person to do it manually.

1. Post-Extraction Processing

If all mandatory documents and fields are available, the status in the DD system updates to
“Pending for DD”, indicating readiness for downstream processing. From here, three further
outcomes are possible based on system evaluation:

i. AI Response Failed: In this scenario, ARIA is unable to classify or extract the required
details, and hence the process must be handled manually within the DC (Digit Claims)
team. No automation proceeds beyond this point.

HC tickets which are currently pending for AI response and is present s_document is
considered as in this status.

If AI failed to extract the data - the ticket will be stuck into - OPEN Status in AI master_table.

When call back service failed to same the extracted status.

[RETRY] Mechanism: It tries again to either: Extract the missing data, or Save the data that
couldn’t be saved earlier

[Scheduler]: the tickets which are in Pending For DD - AI Response will be changed to “AI
response failed”. - Scheduler Checks for Stuck Claims, there’s a scheduler (like a digital
supervisor) that regularly checks for claims that are still waiting.

If a claim is stuck in a status called “Pending for DD” for too long, the system updates it to
say “AI response failed”—basically marking it as something that needs human attention.
ii. Claim Intimation: If the AI successfully identifies and classifies documents, an SF-ID is
created, and in the DC system, the status reflects “Auto-classification completed”. This
confirms that the claim has been successfully intimated using automation.

In this particular status , Sf-id is created for the particular ticket. Mandatory Field is “Policy
number” from ECARD or Email content. Following are the conditions to restrict for SFID
creation and will charge status to AI Response Failed. Hence not creating “Short FNOL ID”:

 If the multiple patient names(more than one) found in Discharge Summary.

 If the multiple DOA found in Discharge Summary.
 If the SFID is already present for the same policy number.

 DOA & DOD are same and status of ticket is “Pending for DD-AI Response” or “AI
response failed”: Claim can be registered.
 DOA & DOD are same and not mentioned status :Claim not need to register.
 If Policy number is master Policy.
 If Claim Number is present in Subject Line.

iii. Claim Created: If admissibility documents are successfully received and validated, the
DC system updates the claim dashboard status to “Admissibility/Sub-doc received”,
indicating that the backend process can now advance to the next stages of assessment.
If only following mandatory fields and documents are available, if not found claim should not
be created.

 DS, Discharge card, HFB, KYC, CC - Mandatory Fields.

 MB, PB, CP, DR - Optional Docs.

A) the KVP’s are maintained in document.t_lookup for particular document category.

B) DOA and DOD logic to check in DS and then in other docs.
C) For Loss Cause and Loss Type , the present logic is as follows:

 Auto Learning is done for the same == not in production.

If the given keys are present then , Claim Intimation (SFID Creation) process flows.

Claim has been Created Successfully

Claim Number: 00000000000

# Hence, CLAIM CREATED

2. Now we will go on V4 screen

(We will see a ‘dashboard screen’ which is divided into three parts)

1. Today’s Cases

This section gives you a quick overview of the current workload. It has two parts:

a) Donut Chart: Each slice shows a type of case and how many are in that category. For
example:
 3 cases are waiting for KVP’s review.
 1 case is waiting to be assigned to V4.
 2 cases are waiting for classification.

b) AI Pipeline: This is like a smart assistant that reads the data and tells you the exact
numbers behind the pie chart. It helps you understand how many cases are in each stage
without guessing.

2. Health Claims Pipeline

This part works automatically. It connects directly to the database and pulls in health claim
cases based on certain rules. You don’t have to do anything manually—it updates itself and
shows the latest information on the V4 dashboard.

3. Admissibility V4

This is your “manual mode.” If you want to take control and pick a case yourself, you can do
it here. It’s like choosing a task from a list instead of waiting for one to be assigned to you.

4. Failure/Error Pipeline

This section is like a notice board for problems. If there’s a system error or something goes
wrong, it shows up here. It helps users stay informed about any issues that need attention or
fixing.

3. Data Verification Screen

After you’ve seen the dashboard, the next screen you’ll go to is the Data Verification Screen.
This is where the real checking happens -

The AI has already looked at all the documents and tried to figure out what type each one is.

For example:
If it sees a Discharge Summary, it will tag it under the D.S. (Discharge Summary) category.
If it sees a Lab Report, it will tag it under the Lab Reports category.
So, the AI has already sorted everything into folders, like a super-fast assistant.

What do you need to do?

Your job is to double-check the AI’s work. You don’t have to start from scratch. Just look at
each document and ask:
“Is this document really what the AI says it is?”
“Is this Discharge Summary actually a Discharge Summary?”
It’s like proofreading—just making sure everything is in the right place.

Accuracy Percentage

To make the job easy, the AI also shows you an accuracy percentage. This tells you how
confident it is about the tag. For example:

If it says 95%, it’s very sure the document is correctly tagged.

If it says 60%, you might want to take a closer look.

#Extra Insight: Tagging vs. Sorting

 Tagging: The Identity Check

In document terms, it means identifying what each file is: Medical Bill, Discharge
Summary, Lab Report, and so on. It’s the “What am I?” step.
Purpose: Helps the system and users recognize the document type at a glance.

 Sorting: The Shelf Placement

Once tagged, sorting is like arranging the tagged documents in a particular order,
usually grouped chronologically.

4. De-duplication Screen

Understanding the Document De-duplication Feature

At the top left corner of the screen, there is a section labeled “D-Duplication.” This feature
helps identify duplicate documents within a specific category, using AI.

For example, if you see “1/13 Discharge Summary,” it means there are 13 discharge summary
documents in total, and the system has flagged 1 of them as a possible duplicate. This helps
reduce errors and avoid reviewing the same document more than once.

Next to this, you’ll see a percentage with a reversible arrow symbol (for example, 80% ⇌).
This shows how similar the two documents are. In this case, the system believes the two
documents are 80% alike, which suggests they might be duplicates.

As an assessor, you have a few options:

 You can mark the document as a duplicate if you agree with the system.
 You can undo the action if you think the documents are not actually duplicates.
 You can move on to the next document in the same category (e.g., the remaining 12
discharge summaries).
 Once all documents in that category are reviewed, by clicking on the system will
automatically take you to the next category, such as Medical Bills (MB) or Hospital
Final Bills (HFB).
This feature saves time, improves accuracy, and ensures that only unique and relevant
documents are reviewed during the claim assessment process.
 5. Data Entry Screen

After document classification, the next step in the workflow is the Data Entry screen. This
screen is designed to allow assessors to review and, if needed, edit the information extracted
from documents.

At the bottom of the screen, you’ll find two navigation buttons:

Previous – to go back to the last document category.

Proceed – to move forward to the next document category (e.g., from Hospital Final
Bill to KYC).

Between these buttons, there is a data entry section that displays fields relevant to the current
document being reviewed. These fields are automatically filled using AI-powered such as
Google OCR. However, all fields remain editable, allowing assessors to make corrections if
needed.

Examples:

 For a Hospital Final Bill (HFB), the fields may include:

 Entity Name (type of document)

 Bill Number
 Bill Date
 Page Number

 For a KYC Document, the fields are simpler:

 Entity Name
 ID Number
 Page Number

Common Fields: Some fields, such as Entity Name and Page Number, are common across all
document types.

Mandatory Fields: Fields that are required for submission are marked with an asterisk (*),
indicating their importance and ensuring they are not left blank.
This structured layout ensures that data is captured accurately while giving assessors the
flexibility to make adjustments when necessary.

6. Data Sorting Screen

The Data Sorting screen is designed to help users organize documents in a desired order—
typically in a chronological or logical sequence. This step ensures that all documents are
grouped and arranged correctly before moving on to the next stage of processing.
On this screen, you’ll see three folder icons, each serving a specific purpose:

i. Current Document Folder (e.g., E-Card)

This folder displays the name of the document category currently being sorted. All
documents tagged under this category will appear here for review and arrangement.
ii. Individual Bills Folder
This is a fixed folder that automatically collects all entered bills related to the current
document type. It helps in grouping similar bills together for easy access and
verification.

iii. New Bill Folder

This folder acts as a safety net. If a document was incorrectly tagged under the current
category (for example, a non-E-Card document mistakenly placed under E-Card), it can
be moved here. This ensures that misclassified documents are not lost and can be
reassigned correctly.

Once sorting is completed for the current category, the system will automatically move to the
next document category, streamlining the workflow and reducing manual navigation.
This structured sorting process improves accuracy, reduces errors, and ensures that all
documents are in the right place before assessment.

Now for further process we will automatically re-directed to V2 assessment health screen L4
Bill Entry for bill entry -

7. Bill Entry Process (V4 system)

The V4 Bill Entry system is designed to streamline and automate the process of entering and
verifying bills, while still allowing manual edits when necessary. Below is a step-by-step
explanation of how the process works:

1. Bill Entry Table Setup

Each bill entry (e.g., for HFB or MB) may contain multiple individual bills. For example:
HFB may have 2 bills
MB may also have 2 bills
Each of these bills must be entered into the system individually.

2. Basic Details (Mandatory Fields)

For every bill, the following basic details must be filled in:
 Entity Name
 Bill Number
 Bill Date
 Patient Full Name
 Total Bill Amount
If any of these fields are not applicable for a particular bill, the user can mark them as “BE
NA” (Bill Entry Not Applicable) using a checkbox.

3. AI-Generated Tables
The system uses Google OCR to automatically extract data from uploaded bills and generate
one or more AI-generated tables. These tables contain headers and values based on what the
AI could read from the bill.
Users can:
Proceed with the AI-generated table as-is, or
Create a new custom table by mapping the bill’s headers to predefined Digit Columns, which
include:
 Description
 Quantity
 Per Day Charge
 Discount Amount

4. Finalizing the Bill Table

Once the table is ready (either AI-generated or user-created), the user must:
Fill in all required fields
Select an Expense Category (this is mandatory)
Map other relevant fields as needed

5. Verification and Submission

After completing the bill entry:
Click ‘VERIFY’ to confirm that all data is accurate.
Once verification is successful, click ‘SAVE & CONTINUE’ to proceed to the next step in
the workflow.

Document Classification in Health Claims Processing

In the health insurance domain, accurate classification of documents is essential for efficient
claim processing and assessment. To streamline this process, documents submitted as part of
a health claim are categorized into 12 predefined classes. These categories help in organizing,
verifying, and assessing the claim with greater accuracy and speed.

The 12 standard document classes are as follows:

a) Claim Form – The primary form submitted by the claimant to initiate the claim process.
b) Discharge Summary – A medical report detailing the patient’s diagnosis, treatment, and
discharge instructions.
c) Hospital Final Bill – The comprehensive billing statement issued by the hospital at the
time of discharge.
d) Pharmacy Bill / Medical Bill – Invoices for medicines and medical supplies purchased
during treatment.
e) Diagnostic Bill – Bills related to diagnostic tests such as X-rays, MRIs, or blood tests.
f) Payment Receipts – Proof of payments made by the claimant to the hospital or other
service providers.
g) Diagnostic Reports – The actual test results and findings from diagnostic procedures.
h) Consultation Report – Notes or summaries from doctor consultations during the
treatment period.
i) KYC Documents – Identity and address proof documents required for verification (e.g.,
Aadhaar, PAN).
j) Cancelled Cheque / Bank Passbook / NEFT Details – Banking information for claim
settlement.
k) Any Other Document – Miscellaneous documents that do not fall under the above
categories but are relevant to the claim.

This classification system ensures that each document is reviewed in the correct context,
improving both the accuracy and efficiency of the claims process.

CLAIM INTIMATION AUTOMATION:

1) Claim Created - If only following mandatory fields and documents are available, if not
found claim should not be created.
  DS, Discharge card, HFB, KYC, CC - Mandatory Fields.
 MB, PB, CP, DR - Optional Docs.

D) the KVP’s are maintained in document.t_lookup for particular document category.

E) DOA and DOD logic to check in DS and then in other docs.

F) For Loss Cause and Loss Type , the present logic is as follows:

 Auto Learning is done for the same. ==not in production.

 If the given keys are not present then , Claim Intimation (SFID Creation) process
flows.

2) Claim Intimation & AI Response Failed - In this particular status , sfid is created for the
particular ticket. Mandatory Field is “Policy number” from ECARD or Email content.
Following are the conditions to restrict for SFID creation and will charge status to AI
Response Failed. Hence not creating “Short FNOL ID”:

 If the multiple patient names(more than one) found in Discharge Summary.

 If the multiple DOA found in Discharge Summary.
 If the SFID is already present for the same policy number.

 DOA & DOD are same and status of ticket is “Pending for DD-AI Response” or “AI
response failed”: Claim can be registered.
 DOA & DOD are same and not mentioned status :Claim not need to register.
 If Policy number is master Policy.
 If Claim Number is present in Subject Line.

3) Pending For DD & AI Response -

HC tickets which are currently pending for AI response and is present s_document is
considered as in this status.

If AI failed to extract the data - the ticket will be stuck into - OPEN Status in AI master_table.

When call back service failed to same the extracted status.

[RETRY] Mechanism: It tries again to either: Extract the missing data, or Save the data that
couldn’t be saved earlier

Scheduler: the tickets which are in Pending For DD - AI Response will be changed to “AI
response failed”. - Scheduler Checks for Stuck Claims, there’s a scheduler (like a digital
supervisor) that regularly checks for claims that are still waiting.

If a claim is stuck in a status called “Pending for DD” for too long, the system updates it to
say “AI response failed”—basically marking it as something that needs human attention.

4) Pre-post Claim: DOA in DS ---- main claim ----- if present then only need to create Pre-
post claim.

 CP/MB/DB/CB, lab and pharmacy , KYC , CC , DS.

 Loss cause - Pre-post hospital expenses.
 Loss type - In-patient hospitalization.
 SFID - claim intimation & remarks as pre-post & (SFID created against main claim).

5) OPD Claims: DOA - Latest date of any bill need to take for SFID and claim creation.

 CP/MB/DB/CB, lab and pharmacy , KYC , CC.

 Loss Cause : Consultation/Pharmacy/Diagnostics : (For loss cause we can use collection
of diagnosis also).
 Loss Type : Outpatient Treatment.
 Policy coverage need to check before claim creation or SFID.

a) need to check if in that particular policy number OPD is covered or not , if yes then only
need to process for SFID or claim creation.
b) if not covered then need to send to AI response failed with comments “OPD is not
covered under the policy”.

Documents required for health insurance claim process

When you are filing a health insurance claim, you must submit the following documents to
the insurance provider for a smooth claim process.

• Documents for cashless claims

Cashless claims require minimum documentation and are easy to file. The following are the
documents you must submit for cashless claims:
◦ Pre-authorisation claim form, duly filled and signed
◦ Your valid ID proof
◦ Health insurance e-card

When you opt for cashless treatment, the insurer will settle your bills directly with the
healthcare establishment. Therefore, you will not have to collect your bills from the hospital
and submit them to the insurance provider.

• Documents for reimbursement claims

If you choose a non-network hospital for your medical procedure, you must submit the
following documents to the insurance provider for reimbursement claim settlement:
▪ Your health e-card
▪ Your photo ID proof
▪ Proof of address
▪ Original discharge summary
▪ Doctor's prescription recommending hospitalisation
▪ Doctor's consultation slips and prescriptions for diagnostic tests
▪ Certificate from the attending doctor
▪ Prescription for medicines and original pharmacy bills
▪ Diagnosis reports of X-rays, blood tests, etc.
▪ Other original receipts from the hospital
▪ Breakup of the hospital bill
▪ Ambulance receipt, if applicable
▪ FIR, in case of an accident
Tips for a smooth health insurance claim process
Whether you have individual health insurance, family floater or a senior citizens health
insurance policy, the following tips can ensure a smooth claim process —

1. Understand your health insurance policy:

Before you file a claim, familiarise yourself with your health plan. Check the inclusions,
exclusions, sum insured, waiting periods, deductibles, copayment and coinsurance clauses,
network hospitals, and other details. Knowing these will make the claim filing process easier.

2. Opt for network hospitals:

If you have to undergo a planned procedure, choosing a network hospital for it will make the
claim process smoother and quicker. Therefore, it is advisable to keep a list of network
hospitals handy for medical emergencies.

3. Inform the insurance provider in advance:

In case of a planned procedure, you must inform the insurer at least 48 hours in advance or as
mentioned in your policy documents. If it is a medical emergency, inform them as soon as
possible or within 24 hours of hospitalisation. If you fail to notify the insurer within the
stipulated period, they may reject your claim.

4. Collect all bills and documents:

If you choose a non-network hospital for a medical procedure, you must collect all bills,
receipts and relevant documents, such as discharge summary, doctor’s prescriptions, and
diagnostic test reports from the hospital. Keep them in one place to avoid hassles during the
claim filing process.

5. File claims correctly:

Before you file a claim, go through the claim filing process in your policy documents. Follow
the steps carefully to avoid discrepancies and claim rejections.

6. Submit claims promptly:

If you have to file a reimbursement claim, submit your claim within 1 week of getting
discharged from the hospital or as mentioned in your policy terms and conditions. Many
insurance providers do not entertain late claims. Late submission can also lead to a longer
processing time.
CHAPTER 7: Future Trends and Predictions
The landscape of AI in health insurance continues to evolve rapidly, with new technologies
and applications emerging regularly. Understanding future trends helps organizations prepare
for upcoming opportunities and challenges while making informed investment decisions
about AI technologies.

 Advanced Predictive Analytics

The next generation of AI systems will incorporate more sophisticated predictive analytics
capabilities that can anticipate claim patterns, identify emerging health trends, and proactively
adjust processing approaches. These systems will analyze social determinants of health,
environmental factors, and demographic trends to provide more accurate risk assessments and
personalized service delivery.

Predictive analytics will extend beyond individual claims to include population health
management, provider network optimization, and product development insights. This
comprehensive approach will enable insurers to shift from reactive claims processing to
proactive health management and risk mitigation.

 Integration with Internet of Things (IoT) Devices

Wearable devices, smart home sensors, and connected medical devices will increasingly
provide real-time health data that can be integrated into claims automation systems. This
integration will enable more accurate risk assessment, fraud detection, and personalized
service delivery based on actual health behaviors and outcomes.

IoT integration will also support preventive care initiatives and wellness programs that can
reduce overall claim volumes while improving customer health outcomes. The combination
of real-time health monitoring and AI-powered analytics will create new opportunities for
value-based care models and personalized insurance products.

 Blockchain Integration for Security and Transparency

Blockchain technology will increasingly be integrated with agentic AI systems to provide

enhanced security, transparency, and auditability for claims processing activities. This
integration will address growing concerns about data privacy and AI decision transparency
while enabling new forms of collaboration between insurers, providers, and patients.

Blockchain integration will also support new payment models, automated smart contracts, and
cross-organizational data sharing that can improve processing efficiency while maintaining
security and privacy protections.

 Enhanced Natural Language Processing

Future AI systems will include more sophisticated natural language processing capabilities
that can understand context, emotion, and intent in customer communications. These systems
will provide more empathetic and personalized customer service while maintaining the
efficiency benefits of automation.

Enhanced language processing will also support better integration with electronic health
records, improved medical literature analysis, and more accurate interpretation of complex
medical documentation. These capabilities will enable AI systems to handle increasingly
complex claims scenarios with minimal human intervention .
REFERENCE LINK’S:
DATA VALIDATION: How to Automate Claims Forms Validation |
Datagrid | Datagrid

AI in Health Insurance Claims: Complete Automation Guide 2025 -

health claim automation.

What Is Health Insurance: How It Works & Benefits – Forbes

Advisor INDIA - HEALTH INSURANCE.

Health Insurance Claim Process: A Complete Guide - Tips for a smooth

health insurance claim process
Step-by-Step Process

Step 1: Pre-Authorization Request Form from Hospital

The hospital where the patient is admitted sends a pre-auth form detailing the diagnosis,
proposed treatment, estimated cost, and duration of stay.
This initiates the request for cashless treatment.

Step 2: Pre-Auth by Assessment

Digit's Assessment Team reviews the form for completeness and evaluates the eligibility of
the
claim.
Key checks include:
Policy coverage
Waiting periods
Exclusion clauses
Sum insured availability

Step 3: Back to Insurer for Final Assessment

If additional information or clarification is needed, the insurer communicates back to the

hospital
for further [Link] step helps mitigate fraud or overbilling.

Step 4: Final Approval by Assessment

Once validated, the Assessment Team gives final authorization for the estimated treatment
cost.

Step 5: Bill Entry by Data Validation (DV)

After discharge, the final hospital bill is submitted.

The DV team performs bill entry, validating the line items and ensuring alignment with
pre-authorization terms.

Step 6: Invoice Team & Payment Bot

The invoice team verifies and prepares the file for final settlement.
A Payment Bot automatically triggers the payment to the hospital, ensuring speed and
accuracy.

Claim Intimation (By Insurance Company)

 Patient selects a network hospital from the list provided by the insurer.
 At the hospital - Provide your e-card and JD (Job Description) card at the TPA Desk.
 The hospital initiates the cashless claim through Digit's hospital portal.
 WORK FLOW:

Turnaround Time (TAT)

1. Initial Authorization: Within 2 hours

2. Final Approval: Within 2 hours