The Business Challenge

The insurer’s manual adjudication workflow caused significant inefficiencies and operational bottlenecks:

• Lengthy Claims Processing: Claims took 5–12 days to process, delaying customer payouts and reducing satisfaction.

• Heavy Manual Verification: Staff were highly dependent on manually reviewing claim forms, medical reports, and invoices, increasing workload and processing time.

• Delays in Critical Validations: Medical code validation and policy coverage checks were frequently slow, further extending claim resolution times.

• Higher Error Rates and Fraud Risk: Manual processes contributed to increased errors and potential fraudulent claims slipping through undetected.

• Limited Visibility and Escalation Delays: During peak periods, lack of real-time monitoring caused delayed escalations and slowed overall workflow.

The legacy systems were unable to scale with growing claim volumes or meet rising customer expectations, creating a pressing need for an intelligent, automated solution to accelerate claims processing while maintaining accuracy and compliance.

Amantra Solution

Amantra implemented an end-to-end AI-driven claims adjudication workflow, combining automation with intelligent decision-making to accelerate processing, reduce errors, and improve customer experience.

Core Solution Components:

• Intelligent Document Processing (IDP): Automatically extracted critical data from claim forms, discharge summaries, invoices, and pre-authorization documents, eliminating manual data entry.

• Medical Code Validation Engine: Verified CPT, ICD codes, and policy-specific exclusions in real time, ensuring compliance and accuracy.

• AI-Powered Decision Tree: Applied pre-set rules and learned from historical claims outcomes to approve, deny, or escalate claims efficiently.

• Fraud Detection Algorithms: Identified suspicious patterns, including duplicate submissions, value mismatches, and blacklisted providers, mitigating fraud risk.

• Seamless Core System Integration: Connected with existing policy administration systems, hospital networks, and TPA APIs, enabling end-to-end automation without disrupting legacy workflows.

This intelligent workflow allowed the insurer to process claims faster, reduce errors, and maintain regulatory compliance, while freeing staff to focus on complex or exceptional cases.

Results & Business Impact

Amantra Agentic AI transformed the claims process, delivering faster, more accurate, and transparent resolutions while enhancing customer satisfaction and operational efficiency.

• Faster Claims Processing: Average claim turnaround reduced from 7 days to under 48 hours.
• Claims Auto-Adjudicated: Minimal human intervention required for approvals and validations.
• Reduced Payout Errors: Real-time code validation and automated cross-checks ensured accuracy.
• Increase in Policyholder NPS: Customers benefited from faster, transparent claim resolutions.
• Live SLA & Compliance Dashboards: Enhanced internal tracking, monitoring, and audit readiness.

Client Testimonial

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