Processes
Validate claims
How validate claims are reshaped as AGI capability advances.
ProcessesValidate claims
Business-as-Code
Read as an executable program — the work decomposed into Code, Generative, Agentic, and Human.
Validate 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 Validate claims inherits.
Where Validate claims sits
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How the work flows
Trigger: A medical claim is submitted by a healthcare provider or policyholder to the insurance carrier.
- Receive and ingest submitted claim data
- Verify member identity and active policy coverage
- Check provider credentials and network status
- Validate diagnosis and procedure codes against medical policies
- Detect duplicate submissions and identify missing information
- Route validated claims to adjudication or flag exceptions
Outcome: The claim is verified for completeness, member eligibility, and coding accuracy and is routed to adjudication.
Measured by
Clean Claim RateValidation Cycle TimeException RateFirst-Pass Yield