AI Agents

Context

Built for insurance within the Fraud detection & alerting stack, this agent is used when assessment signals indicate elevated risk and a claim should be escalated for specialist review. Typical scenarios include pre-payment holds after adverse checks, SIU referrals with multiple red flags, and regulator-timed cases that require a defensible summary and evidence bundle.

What it does

The agent collects risk signals produced during the claim (behavioral patterns, policy inconsistencies, authenticity anomalies, risky associations), evaluates them against your escalation policy, and issues a clear escalate/hold decision. It compiles a structured case synopsis—what triggered the risk, when, and where in the file—attaches clause-level and page-level evidence, and applies the correct routing (SIU queue, senior adjuster, or compliance). It also prepares the required notifications and holds (payment suspension, vendor alerts) so action starts immediately while the case is reviewed.

Core AI functions

Policy-driven rule evaluation over normalized risk signals; confidence aggregation and thresholding; generation of a one-page rationale with linked exhibits; queue and workflow selection based on claim type, jurisdiction, and severity; and templated downstream actions (payment hold, request for information, internal notification) with full lineage to the originating checks. Version awareness ensures the escalation criteria applied match the effective policy period.

Problem solved

High-risk claims often bounce between teams without a single, defensible rationale. Evidence sits across tools and documents, escalation rules are applied inconsistently, and payments can proceed before review—creating leakage and remediation work.

Business impact

Escalations become faster, consistent, and defensible. Payments pause when policy requires, investigators start with a complete evidence bundle, and findings stand up to audit. Leakage decreases, SIU hit-rates improve, and cycle time from flag to expert review shortens.

Integration and adjacent use cases

Integration is light–moderate: read risk outputs and claim artefacts from your claims workflow, DMS, or analytics layer; write the escalate/hold decision, synopsis, and routing into the same workflow—no core changes required.

Common combinations in this stack:

• Behavioral pattern analyzer (claims SIU),

• Claim vs policy consistency checker,

• Image & document authenticity detector, and

• Network association risk detector—whose findings the agent aggregates and cites in the escalation packet.