Processes
Adjudicate claims and process reimbursement
How adjudicate claims and process reimbursement are reshaped as AGI capability advances.
ProcessesAdjudicate claims and process reimbursement
Business-as-Code
Read as an executable program — the work decomposed into Code, Generative, Agentic, and Human.
Adjudicate claims and process reimbursement 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 and process reimbursement inherits.
Where Adjudicate claims and process reimbursement sits
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How the work flows
Trigger: A healthcare provider or policyholder submits a medical claim for services rendered.
- Ingest and validate the submitted electronic or paper claim data
- Verify member identity, active policy status, and specific coverage limits
- Review diagnostic and procedural codes for medical necessity and billing compliance
- Calculate patient responsibility including deductibles, copayments, and coinsurance
- Determine the final reimbursement amount payable to the provider or member
- Disburse the payment and distribute the Explanation of Benefits and remittance advice
Outcome: The claim is resolved with funds routed to the designated payee and an Explanation of Benefits issued to the member.
Measured by
Auto-Adjudication RateClaim Processing Cycle TimePayment Accuracy RateFirst-Pass Resolution Rate