Claims and Appeals Automation

Claims and appeals flows combine high volume with strict auditability requirements.

Use case goals

• Reduce manual queue handling time
• Improve throughput for repetitive claim follow-up tasks
• Preserve evidence trail for payer and compliance review

Recommended pipeline

1. Import claim queue with required identifiers.
2. Execute workflow to gather payer state and required artifacts.
3. Flag exceptions with reason taxonomy.
4. Export structured outcomes for downstream systems.

Pilot metrics to track

• Claim completion rate
• Flagged ratio by reason category
• Time saved vs manual baseline
• Cost per workflow run

Appeals-specific guidance

• Store appeal package references per case.
• Capture stop events with expected vs actual UI state.
• Provide operator review queue for flagged outcomes.

Evidence and reporting

For partner audits, maintain:

• Batch-level completion summaries
• Screenshot evidence for exceptions
• Export records aligned with contractual KPI definitions