System Overview

What it is: Anthem developed a custom AI model to streamline insurance claim handling by automatically processing and flagging claims for review. The system reduces manual workload for adjusters, accelerates claim resolution, and improves overall accuracy in processing.

Core capabilities

AI-driven claims intake and classification
Automated flagging of suspicious or high-risk claims
Real-time policy validation and eligibility checks
Integration with claims management and fraud detection systems
Reduction of manual review workload for adjusters
Dashboards for monitoring claim flow and exceptions
Continuous model improvement from historical claims data

Business problems solved

Long delays in traditional insurance claims review
High costs from manual processing workloads
Inconsistent accuracy and human error in claim handling
Fraudulent claims slipping through manual checks
Difficulty scaling claim operations during peak demand

Industries served

Insurance, financial services, health insurance, InsurTech.

Actor Identification

Primary actor: Policyholder submitting an insurance claim.
Secondary actors: Anthem’s AI claims model, claims management system, human claims adjusters, fraud detection tools, compliance officers.

Actor Goals

Policyholder: Get claims processed quickly and accurately.
Claims Adjuster: Focus on complex cases while AI handles routine ones.
AI Model: Process claims, validate details, and flag anomalies.
Claims System: Maintain structured, compliant records of all claims.

Context and Preconditions

AI model trained on Anthem’s historical claims data
Claims management system integrated with AI engine
Fraud detection logic embedded into AI workflows
Escalation rules defined for suspicious or complex claims
Compliance approvals for AI-driven claims processing

If your data is ready, AI can optimize claims workflows - let’s map your strategy.

Basic Flow (Successful Scenario)

Policyholder submits a new claim via Anthem’s portal.
AI model processes the claim and validates policy coverage.
Routine claims are approved and processed automatically.
High-risk or suspicious claims are flagged for manual review.
Claims system logs outcomes, and adjusters receive flagged cases.
Feedback loop retrains AI model for improved accuracy.

Ready to accelerate your claims processing while maintaining compliance? Let’s build your AI-powered solution.

Alternate Flows

A1: Suspicious claim escalated: If AI flags a claim as potentially fraudulent, it is routed to adjusters for deeper review.
A2: Missing documentation: If required documents are missing, AI prompts claimant for resubmission.
A3: System downtime: If claims platform is unavailable, AI queues claims until restored.
A4: False positive flag: If AI incorrectly flags a valid claim, adjusters resolve it and system retrains to improve.

Transform your insurance claims workflow like Anthem. Automate routine processing, flag anomalies intelligently, and improve customer satisfaction with AI-driven claims solutions. Let’s design your system today.

Anthem - AI Powered Insurance Claims Automation for Faster Processing