Agentic Journeys for Insurance
Automating Health Insurance Workflows with Agentic AI
Creating intelligent journeys infused with IDP, AI and GenAI that elevate onboarding, underwriting, and claims management. From dynamic benefit design to early fraud risk detection and auto-adjudication, Newgen’s AI agents enable adaptive decisioning, reduce turnaround times, and enhance compliance – creating a seamless, proactive, and intelligent experience for members, providers, and teams.
Key Features of Newgen’s Agentic Automation for Health Insurance
Smart Member Onboarding with Document Intelligence
Automatically extract and validate data from KYC, income proof, and health declarations using intelligent OCR and AI verification. AI agents check for data consistency across uploaded documents, detect anomalies, and dynamically generate follow-up questionnaires, reducing manual intervention and ensuring seamless, compliant onboarding experiences for new health policyholders.
AI-driven Risk Scoring & Chronic Risk Assessment
Evaluate lifestyle, historical claim data, family history, and wearable health inputs to assign dynamic risk scores. Tailor underwriting decisions in real-time, including product suggestions, benefit limitations, and premium customization. The model continuously adapts to incoming data to refine the policyholder’s risk profile.
Predictive Pre-authorization & Fraud Detection Agent
Predict the likelihood of pre-authorized (pre-auth) fraud or inflated billing by comparing hospital/provider behavior, member risk, treatment pattern, and procedural codes. Automatically trigger alerts, recommend downgrading cases, or flag for audit—reducing fraud and overutilization while ensuring timely care delivery.
Auto-adjudication with Real-time Decision Rules & NLP
Enable intelligent straight-through processing of hospitalization claims by matching diagnosis, treatment plan, billing codes, and policy terms using AI and NLP. Claims are scored for risk, coverage compliance, and red flags, minimizing manual touchpoints while enhancing accuracy and turnaround time.
Smart Member Onboarding with Document Intelligence
Automatically extract and validate data from KYC, income proof, and health declarations using intelligent OCR and AI verification. AI agents check for data consistency across uploaded documents, detect anomalies, and dynamically generate follow-up questionnaires, reducing manual intervention and ensuring seamless, compliant onboarding experiences for new health policyholders.
AI-driven Risk Scoring & Chronic Risk Assessment
Evaluate lifestyle, historical claim data, family history, and wearable health inputs to assign dynamic risk scores. Tailor underwriting decisions in real-time, including product suggestions, benefit limitations, and premium customization. The model continuously adapts to incoming data to refine the policyholder’s risk profile.
Predictive Pre-authorization & Fraud Detection Agent
Predict the likelihood of pre-authorized (pre-auth) fraud or inflated billing by comparing hospital/provider behavior, member risk, treatment pattern, and procedural codes. Automatically trigger alerts, recommend downgrading cases, or flag for audit—reducing fraud and overutilization while ensuring timely care delivery.
Auto-adjudication with Real-time Decision Rules & NLP
Enable intelligent straight-through processing of hospitalization claims by matching diagnosis, treatment plan, billing codes, and policy terms using AI and NLP. Claims are scored for risk, coverage compliance, and red flags, minimizing manual touchpoints while enhancing accuracy and turnaround time.
Built-in AI models for Health Insurers
Smart Onboarding Agent for KYC & Medical Validation
Use intelligent OCR and data-matching models to verify health declarations, identity, and age against official documents and medical records. In case of mismatch or ambiguity, trigger dynamic questionnaire generation or request additional documentation, automating the onboarding process and ensuring high-quality proposals.
Chronic Risk Model for Personalized Underwriting
Apply predictive AI to lifestyle, prescription data, and family history to forecast chronic illness risks like diabetes or hypertension. Underwriters use this to offer tailored plans, suggest add-ons, or require medical tests for high-risk cases, improving portfolio health and engagement.
Auto-adjudication of Low-risk Claims
Use NLP and business rule engines to instantly approve low-risk claims, such as daycare procedures or minor hospitalization events, based on treatment codes and past claim history. Auto-pay clean claims while routing ambiguous ones for deeper review, boosting operational efficiency.
Pre-auth Anomaly Detection Model for Provider Behavior
Detect behavioral anomalies across network providers using historical billing, turnaround times, and approval rates. Agentic models predict misuse patterns, such as upcoding or repeated unnecessary pre-auth requests, and suggest interventions, including provider audits or blacklisting.
Smart Onboarding Agent for KYC & Medical Validation
Use intelligent OCR and data-matching models to verify health declarations, identity, and age against official documents and medical records. In case of mismatch or ambiguity, trigger dynamic questionnaire generation or request additional documentation, automating the onboarding process and ensuring high-quality proposals.
Chronic Risk Model for Personalized Underwriting
Apply predictive AI to lifestyle, prescription data, and family history to forecast chronic illness risks like diabetes or hypertension. Underwriters use this to offer tailored plans, suggest add-ons, or require medical tests for high-risk cases, improving portfolio health and engagement.
Auto-adjudication of Low-risk Claims
Use NLP and business rule engines to instantly approve low-risk claims, such as daycare procedures or minor hospitalization events, based on treatment codes and past claim history. Auto-pay clean claims while routing ambiguous ones for deeper review, boosting operational efficiency.
Pre-auth Anomaly Detection Model for Provider Behavior
Detect behavioral anomalies across network providers using historical billing, turnaround times, and approval rates. Agentic models predict misuse patterns, such as upcoding or repeated unnecessary pre-auth requests, and suggest interventions, including provider audits or blacklisting.
Learn what Newgen’s Health Insurance Solutions can do for you
Non-journey Use Cases for Insurance
Find Your Winning Strategy with Newgen
Discover how Newgen transforms health insurance with AI-driven onboarding, underwriting, and claims automation, making healthcare access seamless, secure, and scalable.
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