Health Claim Document Extraction

• Head of Claims
• TPA Operations Manager
• Claims Assessor Team Lead
• Chief Operating Officer

A single cashless or reimbursement claim can arrive as dozens of pages: scanned bills, pharmacy receipts, discharge summaries, lab reports and ID proofs, often photographed on a phone. Assessors re-type the same fields into the claims system before they can start the real work of adjudication.

We build a claim document pipeline that accepts the whole claim file, splits it into individual documents, classifies each one and extracts the fields your adjudication process needs. A large language model reads the documents in context, so a field that appears differently on two hospitals' bills is still captured. Every extracted value carries a confidence score and a link back to the page it came from. Low-confidence fields and rule failures go to an assessor queue, and clean claims move straight to the claims system with an audit trail.

• Splits and classifies mixed claim files: bills, discharge summaries, lab reports, prescriptions, KYC
• Extracts header fields and bill line items, including handwritten and phone-photographed pages
• Cross-checks dates, room category, diagnosis and procedures across documents
• Applies configurable policy rules such as sub-limits, room-rent caps and waiting periods
• Flags possible duplicates against previously submitted claims
• Shows every value with its source page so assessors can verify in one click

1. 01Receive the claim fileDocuments arrive from the hospital portal, email or a TPA upload, and are grouped by claim number.
2. 02Split and classifyEach page is assigned to a document type so the right extraction schema is applied.
3. 03Extract fieldsOCR plus an LLM extract structured fields and bill line items, each with a confidence score and page reference.
4. 04Check confidenceFields below the agreed threshold are sent to an assessor for confirmation instead of being guessed.
5. 05Run policy and consistency checksRules compare documents with each other and with the policy schedule, and flag duplicates.
6. 06Hand over to the claims systemStructured data, flags and the evidence trail are pushed to the core claims system for adjudication.

1. Ingestion
   • Email and portal connectors
   • SFTP or API intake from TPA systems
   • Claim-level document grouping
2. Document understanding
   • OCR with layout detection
   • Document classifier
   • LLM field and line-item extractor with JSON schemas
3. Validation
   • Confidence scoring
   • Policy rule engine
   • Cross-document consistency checks
   • Duplicate detection
4. Review
   • Assessor review screen with source-page highlights
   • Exception queue
5. Integration and audit
   • Claims system API adapter
   • Audit log of every extracted value and reviewer change

Assessors confirm any field below the confidence threshold and decide every flagged exception. The system never approves or rejects a claim; it prepares the file so the assessor starts with clean, verifiable data.

• Core claims or TPA platform (via API or SFTP)
• Hospital and provider portals
• Email inboxes used for claim intake
• Document management system
• Data warehouse for MIS reporting

• Confidence thresholds per field, agreed with the claims team
• No auto-decision on claims; humans adjudicate
• Personal and health data masked in logs and kept in your cloud region
• Every value traceable to a source page
• Regular sampling of auto-cleared claims for quality review

• Designed to support data minimisation and purpose limitation under India's DPDP Act 2023.
• Keeps the audit trail insurers need to evidence how each claim was assessed under IRDAI expectations.

• Insurance

  Pre-Authorisation Request Triage for TPAs

  Read incoming cashless requests, check completeness, policy terms and tariffs, and put a prioritised, source-linked summary in front of the TPA medical officer.

• Insurance

  Tampered and Fraudulent Document Detection

  Score claim documents for signs of editing, fabrication and reuse, explain each signal, and route high-risk files to your investigation team instead of labelling anyone a fraudster.

• Insurance

  Claim Status Voice Helpline for Policyholders

  An inbound voice agent that verifies callers, explains live claim status in plain language, sends pending-document lists on WhatsApp and transfers complaints and sensitive cases to people.

• Healthcare & Hospitals

  Insurance Pre-Auth and Claim File Preparation for Hospitals

  Assemble cashless pre-auth, enhancement and final claim files for TPAs, insurers and government schemes, and check each against the payer's checklist before submission.