Multi-Agent Insurance Claims Processing Digital Worker
## The Solution A **10-agent AI claims processing pipeline** with 4-phase workflow execution, distributed tracing for full transparency, and real-time model inference using GPT-4-Turbo, Claude-3-Opus, and Med-PaLM-2. Achieves **sub-second adjudication** with complete audit trails.
Problem Statement
The challenge addressed
Solution Architecture
AI orchestration approach
Claim Submission - Configure member, pharmacy, and prescriber information with real-time agent assignment showing 6 AI agents ready to process the claim
Real-Time Processing - Live agent orchestration showing 10 agents processing in parallel with status tracking, processing pipeline visualization, and event log
Tool Invocations - Detailed transparency view showing AI model usage (GPT-4-Turbo, Claude-3-Opus, Med-PaLM-2) and tool execution including fraud detection and database queries
Claim Adjudication - Final approval decision with complete financial breakdown, 95.8% confidence score, detailed agent decisions, and processing metrics audit trail
AI Agents
Specialized autonomous agents working in coordination
Eligibility Verification Agent
**30% of claim denials** stem from eligibility errors—patients present with inactive coverage, exhausted benefits, or plan limitations unknown at point of service.
Core Logic
Performs **real-time eligibility verification** against payer databases. Validates coverage status, effective dates, benefit limits, and plan-specific exclusions. Uses GPT-4-Turbo for complex eligibility rule interpretation.
Formulary Validation Agent
Formulary complexity causes **prescription rejection** at pharmacy—patients and prescribers unaware of tier restrictions, step therapy requirements, or quantity limits.
Core Logic
Validates prescriptions against **payer formulary databases** including tier placement, prior authorization requirements, step therapy protocols, and quantity limits. Suggests formulary-compliant alternatives when prescribed medications face restrictions.
Fraud Detection Sentinel Agent
Healthcare fraud costs **$68B+ annually** in the US alone—fraudulent claims, identity theft, and billing manipulation drain payer resources and increase premiums.
Core Logic
Implements **anomaly detection models** trained on fraud patterns: unusual claim volumes, geographic impossibilities, provider billing anomalies, and identity inconsistencies. Uses Claude-3-Opus for complex fraud pattern analysis with explainable risk scoring.
Drug-Drug Interaction Analyzer Agent
Polypharmacy patients face **adverse drug interaction risks**—claims processing ignores clinical safety, approving dangerous medication combinations.
Core Logic
Analyzes prescription against **patient medication history** using Med-PaLM-2 clinical reasoning. Identifies contraindicated combinations, severity classifications, and recommends therapeutic alternatives. Integrates clinical decision support into claims workflow.
Medical Necessity Evaluator Agent
Medical necessity determinations are **subjective and inconsistent**—similar cases receive different outcomes based on reviewer interpretation.
Core Logic
Applies **clinical guidelines and evidence-based criteria** using Med-PaLM-2 for medical reasoning. Evaluates diagnosis-treatment alignment, clinical appropriateness, and guideline compliance with consistent, auditable decision logic.
Prior Authorization Engine Agent
Prior authorization creates **treatment delays**—manual PA processes take days, causing medication gaps and patient harm.
Core Logic
Automates **prior authorization workflows** using rule-based and ML-driven decision engines. Evaluates PA criteria, requests additional documentation when needed, and provides instant determinations for straightforward cases while routing complex cases for clinical review.
Cost Optimization Agent
Claims processing focuses on **approval/denial binary**—missing opportunities to reduce costs while maintaining therapeutic outcomes.
Core Logic
Identifies **cost reduction opportunities**: generic substitutions, therapeutic alternatives, quantity optimization, and mail-order savings. Calculates member and payer savings, presenting alternatives that maintain clinical efficacy at lower cost.
Real-Time Pricing Agent
Drug pricing fluctuates constantly—claims processed with **stale pricing data** result in incorrect copays and reimbursements.
Core Logic
Integrates with **real-time pricing feeds** (AWP, WAC, NADAC, contract pricing). Calculates accurate member cost-sharing, applies manufacturer rebates, and ensures reimbursement accuracy reflecting current market pricing.
Patient Risk Analytics Agent
Claims processing ignores **patient risk stratification**—high-risk patients receive standard processing despite needing intervention.
Core Logic
Calculates **patient risk scores** using claims history, diagnosis patterns, and medication adherence signals. Identifies high-risk patients for care management outreach, flagging claims that indicate deteriorating health status.
Specialty Pharmacy Logistics Agent
Specialty medications require **complex handling**—temperature control, limited distribution networks, and patient support programs not addressed in standard claims processing.
Core Logic
Manages **specialty pharmacy workflows**: limited distribution drug routing, cold chain requirements, patient support program enrollment, and specialty pharmacy network coordination. Ensures high-cost specialty medications reach patients safely.
Worker Overview
Technical specifications, architecture, and interface preview
System Overview
Technical documentation
Tech Stack
5 technologies
Architecture Diagram
System flow visualization