Claims Processing Automation Quality Auditor POC
Description
In an automation-driven claims process, this tool will act as an entry point for quality reviews: Perform claims quality audits to identify and request NQA reviews or VCE corrections based on automated claims processing anomalies/errors. Function of the model: Perform claims quality audits to identify and request NQA reviews or VCE corrections based on automated claims processing anomalies
Detailed example
Within that automation workflow, the claim will be offramped (based on the criteria of the claim and resulting automated decision) to a human to be worked.
AI / analytics pattern
Classical/Predictive Machine Learning: Models trained on data to make predictions or classifications based on identified patterns or relationships.
Automation level / stage
a) Pre-deployment – The use case is in a development or acquisition status.
Expected benefit
Increased efficiency, improved benefit outcomes, faster decisions for Veterans.
Controls / human review
ATO: Not reported; PIA: Not published