Health Insurance Claim Validation AI Agent

This automation delivers streamlined claim validation through an intelligent AI agent that automates how health‑insurance teams process customer claim requests. The workflow begins when new emails arrive in Outlook, using the email body, subject, and attached documents as its primary inputs. OneDrive serves as the storage location for all claim files, giving the process a clean and auditable structure. Once triggered, the AI agent scans up to ten inbox messages, classifying each email to determine whether it relates to an insurance claim. If relevant documents are attached, the automation saves them to a timestamped OneDrive folder and extracts text for deeper analysis. The extracted content is then evaluated by a trained AI skill that determines whether the claim is Clear or Shortfall, identifies missing documents, and extracts key fields such as patient name, policy number, dates, diagnosis, and claimed amount. All these details are automatically passed into a HITL form, where an insurance specialist reviews the information, confirms accuracy, and adds final remarks. After validation, the automation generates a clear output: a customer email indicating whether their claim is approved, incomplete, or rejected, complete with policy‑specific details. All processed emails are moved to a designated Outlook folder, and all claim documents remain stored in OneDrive for future verification or compliance checks. This automation addresses common pain points for insurance teams—high email volumes, repetitive document review, slow turnaround times, and inconsistent decision‑making. Without automation, staff must manually open each message, verify attachments, extract data, look for missing information, and craft customer responses, which is time‑consuming and error‑prone. With the AI agent in place, teams gain faster processing, improved accuracy through AI‑assisted checks, a streamlined HITL review, and a fully traceable workflow that reduces operational load.