Processes
Prepare and process claims
How prepare and process claims are reshaped as AGI capability advances.
ProcessesPrepare and process claims
Business-as-Code
Read as an executable program — the work decomposed into Code, Generative, Agentic, and Human.
Prepare and process 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 Prepare and process claims inherits.
Where Prepare and process claims sits
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How the work flows
Trigger: A healthcare provider or policyholder submits a medical claim for services rendered.
- Receive and digitize incoming EDI or paper claim submissions
- Verify patient eligibility and active policy coverage for the date of service
- Validate medical codes against billing rules and contracted fee schedules
- Adjudicate the claim to calculate payer liability and patient responsibility
- Route complex or flagged claims for manual administrative or clinical review
- Generate the Explanation of Benefits and issue payment to the provider or member
Outcome: The claim is fully adjudicated and resolved, resulting in a scheduled payment and a generated Explanation of Benefits, or a formal denial.
Measured by
Auto-Adjudication RateClaims Processing Cycle TimeFirst-Pass Resolution RatePayment Accuracy Rate