Claims Adjudication & Straight-Through Processing
Faster claims automation that ignores reliability just accelerates your error rate. ActionAI processes clean claims straight through while ensuring every adjudication decision carries verified.
88%
Straight-through rate
99.2%
Decision accuracy
<4 wks
Time to deploy
01
The Problem
The Challenge
Claims volume is increasing while headcount stays flat, and most automation tools optimize for throughput rather than reliability. A coverage error on a large loss, a missed subrogation recovery, or a payment routed without full verification forces adjusters to re-check upstream outputs before making decisions.
02
How It Works
How ActionAI Solves It
ActionAI processes claims from FNOL and ACORD forms by extracting data, verifying coverage against policy terms (including endorsements and exclusions), and applying your adjudication logic with a confidence score attached. Claims that meet your criteria and pass the threshold move from intake to payment routing automatically, with documentation that includes the supporting data and reasoning.
Complex claims—subrogation candidates, coverage ambiguities, and unusual loss patterns—are routed to adjusters with structured packages: extracted data, coverage analysis, comparable prior claims, and the specific reason for escalation. The platform incorporates adjuster decisions over time, increasing your straight-through processing rate.
03
The Outcome
Key Capabilities
Your automation becomes reliable with clean claims processing alongside a full audit trail, and adjusters receive escalated claims with complete context. Subrogation opportunities surface early and your straight-through rate improves as the system learns your team's resolution patterns.
Results that speak for themselves
88%
Auto-adjudication rate
Claims processed without manual review
99.2%
Per-claim accuracy
Every decision scored and documented
4x
Per-claim accuracy
Reduced cycle time to resolution
Insurance
Misread an exclusion and a claim goes out that should have been denied, landing as a subrogation failure and a reserve adjustment at the next close. File a DOI rate submission against the wrong rate table version, and SERFF bounces the form three business days before the filing deadline. In insurance, ground truth is the policy language on the schedule the day the loss occurred. ActionAI scores every automated coverage decision against the controlling policy in revision control, and high-confidence decisions release without an adjuster opening the file. Below threshold, ExEx (Explainable Exceptions) holds the claim and routes it to the adjuster with the coverage gap and controlling policy form attached, so they open the file knowing what's missing.
Related Use Cases
Frequently asked questions
Claims decisions, coverage verification, underwriting checks, and premium reconciliation — any process where an AI is scoring against policy forms or rate tables. Each automation deploys with its own ROI and can expand from there.
The claim holds and goes to an adjuster for review, with the coverage question flagged and the relevant policy form surfaced. Nothing below threshold is auto-decided.
No. ActionAI sits on top of the core platform your adjusters and underwriters use, connected via API or data export. The verification runs underneath.
Yes. Emirates NBD runs 1M+ daily transactions through ActionAI with auto-match moving from 90% to 99%+; Wynn Resorts runs 3-5K monthly reconciliations at 12-24 hours of daily manual work eliminated. Reconciliation mechanics translate directly to claims and premium work.
SOC2 compliant, deployed in your chosen environment — cloud, VPC, or on-premises. After the scoping call, a free pilot runs on real data in days to weeks.