Claims processing

Claims processing is the end-to-end workflow that insurance companies follow to evaluate, validate, and settle claims filed by policyholders. The process typically includes:

• Claim submission

  A customer submits a claim via an online portal, email, or phone, providing required documentation (e.g., medical records, photos, invoices).

• Claim intake and data capture

  The submitted information is captured, categorized, and entered into the claims management system.

• Verification and validation

  The claim is reviewed against policy terms, coverage limits, and required documents. Third-party data (e.g., police reports, medical records) may be verified.

• Assessment and adjudication

  The insurer evaluates the claim’s legitimacy and determines the payout amount based on rules and policy conditions.

• Approval or denial

  The claim is either approved, denied, or routed for further investigation if flagged as suspicious or incomplete.

• Settlement and payment

  Once approved, the claim amount is disbursed to the claimant or service provider.

How Maestro adds value

UiPath Maestro™ strengthens claims processing by enabling insurers to:

• Automate decision logic for eligibility, coverage checks, and fraud detection at scale.
• Ensure consistent, rule-based adjudication while allowing human-in-the-loop exceptions when needed.
• Integrate AI tools for document understanding, medical record analysis, and anomaly detection.
• Improve transparency with full audit trails and compliance monitoring across the claims lifecycle.
• Accelerate claim resolution and payment, improving customer satisfaction and reducing operational costs