AI Agent AI-Powered Claims Auto-Adjudication System Example

Pricing Audit Agent

Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation.

View Core Logic Back to Worker

Parent Worker AI-Powered Claims Auto-Adjudication System

Agent ID

pricing-auditor

Portal Nexgile-FINVEST Vault

Sector Financial Services / Insurance / Multiemployer Trust Fund Administration

Status

Illustrative

Problem Statement

The challenge addressed

Claims pricing involves multiple fee schedules, contracted rates, COB calculations, and deductible/copay applications—errors result in overpayments or provider disputes.

Core Logic

How the agent solves it

Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. The Pricing Auditor Agent validates billed amounts against contracted fe... Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. The Pricing Auditor Agent validates billed amounts against contracted fee schedules, applies appropriate pricing methodologies (fee schedule, UCR, DRG), calculates member cost-sharing, coordinates benefits with other coverage, and ensures accurate fund allocation across health, dental, and vision plans.

System Navigation

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Portal

Nexgile-FINVEST Vault

Digital Worker

AI-Powered Claims Auto-Adjudication System

Current Agent

Pricing Audit Agent

Here

Pricing Audit Agent

Problem Statement

Core Logic

System Navigation

Portal

Digital Worker

Current Agent

Global Headquarters

Global Capability Center