AI-Powered Claims Auto-Adjudication System
## The Solution A multi-agent AI orchestration system processes claims through parallel specialized agents using the ReAct reasoning pattern. Six coordinated agents simultaneously verify eligibility, detect fraud patterns, validate clinical appropriateness, audit pricing, and ensure compliance with full audit trails.
Problem Statement
The challenge addressed
Solution Architecture
AI orchestration approach
AI Agent Orchestration processing view showing five parallel agents (Eligibility Verifier, Fraud Hunter, Clinical Validator, Pricing Auditor, Compliance Guardian) actively processing a healthcare claim with real-time progress indicators, token usage metrics, and RAG-enabled ML inference status
Claims adjudication output displaying an APPROVED decision with 93% confidence score, executive summary of multi-agent consensus, key findings (Member Eligibility Confirmed, Medical Necessity Validated, Pricing Rules Applied), and comprehensive risk assessment with fraud detection and compliance status
Technical Deep Dive - Agents configuration panel showing model specifications for Eligibility Verifier (Custom ML Classifier), Fraud Hunter (SageMaker Ensemble), and Clinical Validator (Clinical BERT on AWS Bedrock), including RAG configurations with Pinecone vector store and runtime performance metrics
Technical Deep Dive - Kafka Event Stream showing real-time agent orchestration events with JSON payloads for claim processing phases (initializing, planning, agent.started), correlation IDs for distributed tracing, and timestamped workflow progression
AI Agents
Specialized autonomous agents working in coordination
AI Orchestrator Agent
Complex claims require coordinated analysis from multiple specialized systems, but sequential processing creates bottlenecks and lacks unified decision-making oversight.
Core Logic
The Orchestrator Agent serves as the central coordinator, managing workflow execution across all specialist agents using a state machine architecture. It handles agent activation sequencing, aggregates results from parallel processes, resolves conflicts between agent recommendations, and synthesizes final adjudication decisions with confidence-weighted voting.
Eligibility Verification Agent
Multiemployer eligibility involves complex hour-bank calculations across multiple employers, with rules varying by plan, coverage tier, and dependent relationships.
Core Logic
This agent performs real-time eligibility verification by querying member hour banks, validating coverage effective dates, checking dependent relationships against plan rules, and confirming benefit tier applicability. It calculates remaining coverage periods and flags approaching eligibility lapses requiring self-payment options.
Fraud Detection Agent
Healthcare fraud costs benefit plans millions annually through duplicate claims, phantom billing, unbundling schemes, and identity fraud—patterns difficult to detect in high-volume processing.
Core Logic
The Fraud Hunter Agent employs anomaly detection algorithms and pattern recognition to identify suspicious claims. It analyzes billing patterns against provider profiles, detects duplicate submissions across time windows, identifies impossible service combinations, and flags statistical outliers for human review while maintaining a continuously-learning risk model.
Clinical Validation Agent
Medical necessity review requires clinical expertise to match diagnoses with procedures, validate treatment protocols, and ensure services align with evidence-based guidelines.
Core Logic
This agent validates clinical appropriateness by cross-referencing diagnosis codes with procedure codes, checking against clinical editing rules (CCI/MUE), verifying age/gender appropriateness, and ensuring services match accepted treatment protocols. It integrates with medical policy databases and prior authorization records.
Pricing Audit Agent
Claims pricing involves multiple fee schedules, contracted rates, COB calculations, and deductible/copay applications—errors result in overpayments or provider disputes.
Core Logic
The Pricing Auditor Agent validates billed amounts against contracted fee schedules, applies appropriate pricing methodologies (fee schedule, UCR, DRG), calculates member cost-sharing, coordinates benefits with other coverage, and ensures accurate fund allocation across health, dental, and vision plans.
Compliance Guardian Agent
Healthcare claims must comply with HIPAA, ERISA, ACA, and Mental Health Parity regulations—violations expose funds to penalties and legal liability.
Core Logic
This agent performs regulatory compliance validation across all applicable frameworks. It verifies HIPAA transaction compliance, ensures ERISA fiduciary standards, validates ACA essential benefit coverage, checks Mental Health Parity Act requirements, and generates compliance attestation documentation for audit purposes.
Worker Overview
Technical specifications, architecture, and interface preview
System Overview
Technical documentation
Tech Stack
6 technologies
Architecture Diagram
System flow visualization