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Compensation Claim Automation

Automate the end-to-end handling of workers' compensation claims using AI-powered medical report analysis — extract the clinical data you need and drive every downstream decision automatically.

Ivan Peresta

Template author

How It Works

The Process in 3 Steps

1. Extract clinical data using AI — An AI model reads the submitted medical report and pulls out everything needed to process the claim: injury type, severity, recommended treatment, recovery timeline, work capability, and any fraud signals present in the narrative.
2. Run all claim decisions automatically — The extracted data is fed into five Decision Tables that simultaneously calculate the reserve amount, validate coverage, check for fraud referral, assign the right adjuster, and determine settlement authority.

3. Return a complete claim decision — One structured response covers everything: injury details, handling instructions, financial figures, coverage status, fraud flags, and a full error log if anything could not be determined from the report.

Template Components

AI Agent: Medical Report Analyzer

What it does: Reads any free-text medical report and transforms it into structured clinical data that drives every decision in the Flow.

If no examination was performed or no clinical findings are documented, all fields return null — the rule never guesses. Downstream tables detect these nulls and raise explicit errors rather than producing a silent wrong answer.

Decision Tables: Claim Processing Rules

What they do: Once the AI Agent returns, five Decision Tables run automatically using the extracted data as their inputs. Together they cover every financial and operational decision the claims team would otherwise make manually:

Reserve Calculation — sets the opening financial reserve based on injury type, treatment approach, and severity.
Coverage Validation — confirms whether the treatment is covered under the submitted policy type and whether pre-authorization is required before the claimant can proceed.
SIU Referral Trigger — determines whether the fraud signal count, combined with the severity score and work capability, warrants referral to the Special Investigations Unit and at what priority.
Severity Routing — assigns the claim to the right processing queue and adjuster level based on how serious the injury is and whether fraud signals are present.
Settlement Approval — uses the calculated reserve to determine who has authority to approve a settlement and the maximum amount that can be settled without escalation.

Each table has null-guard rows and an ELSE fallback that return a specific error code when the AI extraction was incomplete, so no claim silently falls through with missing data.

Common Issues & Solutions

Problem: The AI Agent returns an error and produces no output.
Solution: Check that a Connector has been created and assigned to the Medical Report Analyzer rule. The rule cannot run without one.

Problem: All injury fields return null.

Solution: This is expected behavior when the submitted report contains no documented physical examination or clinical findings. The rule is designed to return null rather than guess — check the source report for complete clinical documentation before resubmitting.

Problem: A Decision Table returns an error code instead of a result.

Solution: The error code indicates that one or more required input fields were null after AI extraction. Review the AI Agent output to identify which fields are missing, then verify that the submitted report contains the corresponding clinical information.

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