Smart Claim Check
Description
Smart Claim Check (SCC) reduces avoidable claims processing errors by addressing the problem of manually reviewing extensive documentation by Veterans Service Representatives (VSRs) to identify and resolve issues. Claims processing errors that can be avoided in the claims process leads to extended wait times for Veterans to receive the benefits to which they are entitled. SCC leverages natural language processing (NLP) and machine learning (ML) to analyze past deferral data and identify common patterns and themes.
Detailed example
The output of the AI system is timely guidance with relevant M21-1 linkage, that will appear in the User Interface (UI) automatically for the claims processors to review and act upon. SCC is referring to these a "Smart Claim Insights".
AI / analytics pattern
Generative AI: AI that generates new or synthetic content (e.g., images, videos, audio, text, code).
Automation level / stage
a) Pre-deployment – The use case is in a development or acquisition status.
Expected benefit
By leveraging these technologies described in #12, Smart Claim Check can automatically review claim documentation, identify common patterns, and offer structured recommendations, including context-specific guidance from the M21-1 manual, confidence scores, and links to relevant sections, thereby expediting the claims review process and reducing avoidable re-work and extended processing times.
Controls / human review
ATO: Not reported; PIA: Not published