Every claim checked before a handler opens it.
01The situation
Claims arrive all day, by email and portal. Policy documents, discharge summaries, bills, photographs. Before a handler can start, someone checks the file is complete. Then sorts it. Then sends it on.
02What the agent does
The agent reads every incoming claim. It checks the documents against the checklist for that policy type, pulls out the fields handlers search by, and routes the file. It may read the intake channels and write to the intake queue. Nothing else.
An unreadable scan, documents that don't match, an unusual policy: those files wait for a claims handler, evidence attached. Only a person can reject a claim. The agent never does.
03Where it stops for a person
- SCOPE
Read the intake channels · write to the intake queue only
- ROLE
Classify and route · never decide or reject a claim
- LIMITS
A spend limit on each run, set in the signed manifest
- REVIEW
Low-confidence files held for a named claims handler
- SEAL
Each routing decision in the audit trail, with its reason
W/01In brief
- SCOPE
- intake channels in, intake queue out
- HELD
- low confidence → named claims handler
- LIMIT
- spend limit per run
- SEAL
- each routing decision, with reason
04The outcome
The first pass runs around the clock now. Every routing decision is on the record, with its reason.
Every file it stopped on says what it could not decide, and why.
Run something like this? Start with a teardown. We measure how much comes in and how much goes wrong. You keep the write-up.
Book a teardownMore work we run
The real mismatches, found. The small ones, cleared.
Real mismatches got lost among the small differences.
Clean invoices go through as ERP drafts. Every exception shows its sources.
Every answer cites its clause. Or a person answers.
The same easy questions every day. The hard ones waited behind them.
People only get answers the library backs up. Every correction becomes a worked example.