Adjudicate claims
How adjudicate claims are reshaped as AGI capability advances.
The bottom line
Roughly 85% of the work in Adjudicate claims is information-shaped — already within reach of AI delivery. The question here is not whether it shifts, but which tasks go first and who staffs the residual.
Why: With no seeded child occupations available, the scalar is derived directly from the process name and industry lens: 'Adjudicate claims' within 'Direct Health and Medical Insurance Carriers'. Claim adjudication is fundamentally an information-transformation task—reviewing documentation, verifying billing codes, and checking policy coverage—which characterizes high-digital knowledge work. It is assigned a heavily digital scalar accordingly.
grounded in the economy graph · digital scalar 0.85 · digital
Business-as-Code
Read as an executable program — the work decomposed into Code, Generative, Agentic, and Human.
Adjudicate claims sits inside a larger value-flow — 1 parent structure it composes into. The hierarchy is grounding, not the story: it tells you which aggregate exposure Adjudicate claims inherits.
Where Adjudicate claims sits
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How the work flows
Trigger: A medical claim submitted by a healthcare provider or member passes initial data intake and enters the core administration system.
- Verify member eligibility and plan coverage for the dates of service
- Check provider network status, credentials, and contract terms
- Review diagnostic and procedural codes against medical policies and clinical edits
- Apply benefit rules to calculate deductibles, copayments, and coinsurance
- Determine the final allowed amount and insurer payment responsibility
- Generate the Explanation of Benefits (EOB) and electronic remittance advice
Outcome: The claim is finalized as approved, adjusted, or denied, with financial responsibilities calculated and remittance advice generated.