p_ieeQkCY
Healthcare Claims Processing
Validate healthcare claim inputs and evidence, apply approved checks, and prepare an authorized review queue.
WORKFLOW BOUNDARY
Starts: when a healthcare claim enters an approved intake or pre-adjudication stage.
Uses: claim, member, provider, coverage, coding, and permitted clinical or supporting documentation.
Agent work: check completeness, validate approved coding and policy rules, organize evidence, and flag exceptions.
Stops: when authorized claims staff review the claim and make the adjudication decision.
Excludes: clinical judgment, final coverage determination, and payment release without authorization.
Before: claims staff reconcile member, provider, coding, coverage, and supporting records across systems.
After: required evidence and approved checks are assembled into a focused review queue.
Authorized claims and clinical staff own adjudication, medical necessity, exceptions, and payment. Protected data follows strict role-based access.
