Claims triage grounded in policy documents, with full audit trails.
Every triage decision now cites the policy language it rests on. Adjusters review the exceptions; auditors trace any decision in one click.
The situation
Claims arrived faster than the team could read them. Policy language changed quarterly, and consistency depended on which adjuster picked up the file. Audit season meant weeks of reconstructing why decisions were made.
What we did
We built a triage system that reads each claim against the policy documents in force on the date of service. Routine claims route automatically with the supporting language cited; anything ambiguous escalates to an adjuster with the relevant passages already pulled.
- Retrieval over versioned policy documents
- Citations on every routing decision
- Exception escalation with context attached
- Audit view: decision to policy passage in one click
The outcome
Adjusters spend their judgment on the claims that need it. Consistency stopped depending on staffing, and the audit trail writes itself as the work happens.