About the Agent
The Claims Triage & Adjudication Agent brings intelligence, consistency, and speed to one of the most complex parts of insurance operations. Instead of relying on manual reviews, scattered documentation, and subjective decision-making, this agent applies structured AI reasoning to every claim. It reads and interprets claim forms, supporting documents, invoices, medical summaries, and repair estimates using advanced OCR and NLP. Once the data is extracted, the agent automatically evaluates policy coverage, checks eligibility, analyzes deductibles and exclusions, and maps medical or repair codes to the correct rulesets.
By simulating the decision logic of experienced claim adjudicators, the agent ensures that every claim is triaged and processed in a uniform, rule-aligned manner. It identifies which claims can be straight-through approved, which require partial adjustments, and which should be routed for manual review based on risk, complexity, or anomalies. Whether used for health, auto, property, or life insurance, the system integrates smoothly with existing platforms like Guidewire, Duck Creek, and Salesforce to deliver predictable, auditable, and highly efficient adjudication outcomes.
This modern approach allows insurers to reduce cycle times, improve compliance, and eliminate inconsistencies—ultimately creating a faster and more transparent claims experience for customers
Problem Statement
Traditional claims triage and adjudication require manual review, cross-checking policy rules, medical codes, coverage limits, and claim histories.
This process is slow, inconsistent, and prone to human error, leading to:
Delayed payouts
Customer dissatisfaction
Higher administrative overhead
Increased risk of improper approvals
Insurers struggle to scale adjudication operations, especially during seasonal spikes or major events (storms, disasters, health claim surges).
💡 Overview
The Claims Triage & Adjudication Agent by Codersarts AI automates claim sorting, eligibility analysis, rule-based adjudication, and decision routing.
Using AI-driven document parsing, risk scoring, policy rule intelligence, and machine reasoning, it performs triage and adjudication with real-time accuracy and explainability.
It integrates seamlessly with CMS, ERP, and core policy systems, enabling insurers to process claims 3× faster, improve decision consistency, and reduce leakage caused by improper payouts or missed fraud signals.
📊 Detailed Breakdown
Section | Details |
Who It’s For | 🧾 Claims Adjusters, Claims Triage Teams, Health Insurance Adjudication Units, Auto & Property Insurers, BPOs, InsurTech Providers, Audit & Compliance Teams |
Business Results |
|
Workflow Summary |
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Performance Metrics | ⚡ 3× faster adjudication time 📊 90% rule-aligned decision accuracy ⏱ 70% fewer escalations 🛡 Better compliance with regulatory requirements |
Industry Example | 🏥 Health insurers automate medical claim adjudication with ICD & CPT code validation. 🚗 Auto insurers classify severity and repair estimate alignment. 🏠 Property insurers triage damage claims with policy-based thresholds. |
Integrations & APIs | 🔗 Claim Systems: Guidewire, Duck Creek, Salesforce Insurance 🔗 Code Databases: ICD-10, CPT, HCPCS, Auto Repair Databases 🔗 Tools: OpenAI GPT API, LangChain, Rule Engines 🔗 Databases: PostgreSQL, MongoDB, Redis |
📈 Key Highlights
Metric | Result |
⚙️ Efficiency | 70–85% automated adjudication |
📊 Accuracy | 90% rule-compliant decisions |
🛡 Compliance | Reduced regulatory errors & improper payments |
🔄 Automation | Real-time triage & routing to adjusters or systems |
🌍 Industry Impact
“AI-driven adjudication transforms how insurers handle complex claims — improving speed, fairness, and cost efficiency.”
Health insurers benefit from automated code validation and benefit determination.
Auto insurers automate severity scoring and repair cost alignment.
Property insurers use AI for damage category assignment and policy rule checks.
This leads to better customer experience, lower operational overhead, and improved claims integrity.
💬 Client or Industry Quote
“Codersarts’ Triage & Adjudication Agent enabled us to automate 75% of medical claim decisions — improving accuracy and dramatically cutting processing time.”— Head of Claims Adjudication, Leading Health Insurance Company
🚀 Modernize Your Claims Decisioning with Codersarts AI
Scale your adjudication team and eliminate manual errors with Codersarts' intelligent AI agents trained for triage, policy rule alignment, and adjudication accuracy.
📩 Email: contact@codersarts.com
💬 Request a Demo: ai.codersarts.com/contact
Primary Keywords: Claims Adjudication Automation, AI Claims Triage, Health Claims Adjudication, Insurance AI Agents, Codersarts AI
The Claims Triage & Adjudication Agent automates claims sorting, eligibility analysis, and adjudication using AI, OCR, and rule engines.
AI Agent that automates triage and adjudication workflows with 90% accuracy and 3× faster claim decisioning.
🔧 Tech Stack Snapshot
Languages & Frameworks: Python, FastAPI, LangChainAI Models: GPT-4/5 reasoning models, Code Mapping Models, Custom ClassifiersDatabases: PostgreSQL, MongoDB, PineconeIntegrations: ICD, CPT, ERP, CMS, ClaimCenterAutomation Tools: RPA Bots, Rule Engines, WebhooksDeployment: AWS Lambda, Dockerized Microservices, GCP Cloud Run