AgentHack submission type
Enterprise Agents
Name
Naveen Kumar Srivastwa
Team members
@JananiDurairaj
How many agents do you use
Multiple agents
Industry category in which use case would best fit in (Select up to 2 industries)
Insurance
Complexity level
Intermediate
Summary (abstract)
In the healthcare sector, insurance or reimbursement claim processing often involves patients or providers disputing a denial due to coverage issues, incomplete documentation, billing errors, or misinterpretation of policy terms. These cases require manual review by claims staff, including evaluating medical records, coordinating with departments, and reassessing the claim. The process is time-consuming, inconsistent, and can lead to dissatisfaction among those who feel the decision was unfair or unclear.
Detailed problem statement
Denied insurance or reimbursement claims often involve complex documentation, diverse data sources, and strict regulatory requirements. Traditionally, these claims require significant manual intervention to collect supporting evidence, verify information, cross-reference patient or policy data, and initiate appeal processes. This approach is not only time-consuming but also susceptible to human errors, inconsistencies, and delays.
Detailed solution
By leveraging intelligent automation agents—powered by AI and machine learning—the entire review and resolution process for denied claims can be streamlined. These agents can:
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Automatically extract and interpret relevant data from structured and unstructured sources, such as scanned documents, EHRs, and payer correspondence.
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Classify denial reasons using natural language processing (NLP) and rules-based logic.
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Cross-verify claims against policy rules and documentation to identify missing or conflicting data.
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Generate appeal letters or resubmission documents with minimal human input.
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Send email to both parties for valid denial appeal options.
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Track and monitor denial resolution workflows, providing transparency and audit trails.
Demo Video
Expected impact of this automation
Automating the end-to-end review, validation, and decision-making workflows. They leverage AI to analyse supporting documents, integrate seamlessly with existing systems, and ensure faster, more accurate outcomes. This reduces manual effort, minimizes errors, and significantly shortens turnaround times. As a result, insurers can handle high volumes efficiently while improving customer satisfaction through timely and consistent resolutions.
UiPath products used (select up to 4 items)
UiPath Agent Builder
UiPath Apps
UiPath Maestro
UiPath Orchestrator
UiPath Robots
Integration with external technologies
Open AI, Email
Agentic solution architecture (file size up to 4 MB)
Sample inputs and outputs for solution execution
- Denial Claim Details:-
Input: The claim details extracted from email.
Output: Patient Details, Denial Reason code - Denial Reason Code Validation:
Input: Validate patient details from data in storage bucket
Output: Reason Code validity - Remedial Action:
Input: Denial Reason Code
Output: Remedial Action from storage bucket based on reason code of denial claims