How to automate insurance claims in 5 steps

Key takeaways

• Decide the path based on claim complexity. Simple claims settle automatically, while ambiguous claims get flagged for review, where AI agents prepare the investigation file for adjusters to make their decision.
• Reserve experienced adjusters for the claims that need them. Experienced adjusters are scarce and many are retiring soon. So automation can settle low-risk claims and hand AI agents the document comparison and information gathering, which lets experts handle more complex cases.
• Let claims teams own the rules, and test every change. Update rules without waiting for engineering, and backtest changes on historical claims before they go live.

Step 1: Map your claims workflow and define routing

Start by listing every task an adjuster performs between first notice of loss and settlement, then sort each task into one of three types: deterministic, investigative, or judgment-based. Only the third type needs an adjuster's expertise. The first two can be automated with rules and AI agents.

The first two rows of the table usually hold most of the work. BCG's How AI Agents Cut Costs for Health Insurers (2026) estimates that between 60% and 80% of health claims reimbursement can be automated. Your own mix will differ, so the next task is to decide which claims take which path.

Risk-based routing decides which claims settle automatically and which reach an adjuster. Set three tiers, and define each one from your own historical claims data, not from generic thresholds. Taktile’s claims solution helps you auto-settle simple claims and route exceptions to experienced adjusters with full context and an audit trail.

• Simple claims: Coverage is clear, documents are complete, and the amount sits below your auto-settlement limit. The system checks the rules and settles the claim without manual handling.
• Ambiguous claims: Information is missing or documents need interpretation. AI agents prepare the file, and an adjuster confirms the recommendation.
• Complex claims: Coverage is disputed, severity is high, or a data source returns conflicting information. An adjuster takes the claim with the full evidence file and the reason for escalation.

Write the escalation reason into the case record. An adjuster who knows why a claim arrived starts at the unresolved question, not at the beginning of the file.

Track how much time each task takes today. These timings become the baseline for Step 5.

Step 2: Automate intake and document verification

The routing from Step 1 only works when each claim arrives as structured, verified data, so intake is the first process to automate.

Intake can be automated using an AI agent to read, classify, and validate the documents attached to a claim before an adjuster opens it.

At Greenlight Rent, Taktile's Document Intelligence Agent verifies and categorizes leases, ledgers, apartment photos, and move-out inspections. It extracts the data, cross-checks it against policy details and business rules, and then either recommends that the claim is ready to be adjusted or flags missing information with context.

The result was an 80% reduction in claims processing time and a 50% reduction in manual claims work, with the system deployed in six weeks. Allianz Partners applies the same approach to health claims, with a document classification agent that lets only valid invoices proceed and a data extraction agent that standardizes dates, provider details, currency, and itemized costs.

Step 3: Automate coverage verification and data enrichment

Once each claim is turned into structured data, the next question is whether the policy covers the loss. Coverage verification checks each claim against the policy in force, using rules for fixed conditions and an AI agent for policy wording. Taktile’s claims solution states the goal that coverage is checked the same way every time: agents read the policy, validate coverage, and add context before an adjuster opens the case.

Split the check into two layers:

1. Rules for fixed conditions: policy active on the date of loss, covered damages, limits, deductibles, and waiting periods.
2. An agent for interpretation: matching the facts of the claim to the policy wording, and flagging clauses that need an adjuster's attention.

Taktile combines rules, ML models, AI agents, and human review, with explainability and clear ownership at each point. Every coverage outcome then carries the rule or the agent finding behind it.

A coverage decision is only as reliable as the facts behind it, and the policyholder's own account is only one source. Third-party data confirms or contradicts what the policyholder submitted. Taktile's claims flow includes third-party data alongside intake, coverage checks, and decisioning.

Prioritize sources by the question they answer: Is the policyholder who they say they are? Does the loss match the policyholder's history? Do the documents agree with each other?

Data from earlier stages of the customer relationship also helps. Greenlight Rent runs KYC, underwriting, and claims on the Taktile platform, so a claims decision draws on what the company already knows about the customer, and the company can predict loss ratio more accurately.

Step 4: Build adjuster review gates with decision-ready files

An adjuster review gate passes a claim to a person together with everything needed to decide it. In Taktile, agents read policies, validate coverage, gather evidence, and add context before an adjuster opens the case. The claim moves through five layers: data (known facts), deterministic rules (policy), AI (for investigation of ambiguous information), workflows (routing and coordination), and human review (judgment).

At Allianz Partners, straight-through processing handles clear-cut health claims, while nuanced cases go to experts. They can trace each decision from the original document through every agent step, and their feedback on high-risk claims refines agent prompts and decision logic.

The aim is not to remove adjusters from decisions. It is to remove the document reading that fills their day before the decision starts.

Step 5: Control rule changes, audit trails, and performance

Steps 1 to 4 build the claims flow. Step 5 keeps it reliable over time. Claims teams need to change rules without waiting for engineering support, trace every decision, and measure results against the baseline from Step 1.

Change rules without waiting for engineering. Claims rules change when products, regulations, or loss patterns change. Taktile lets claims teams update handling rules, coverage checks, and escalation paths directly, while engineering keeps control of data, integrations, and guardrails. Rules also keep adjuster expertise inside the process.

Keep every decision traceable. Letting claims teams change rules directly only works if every change and every decision can be traced afterward. Taktile provides monitoring, alerting, model risk management, versioning and sign-off procedures, granular permissions, and detailed audit trails for every decision.

Measure the results. Taktile's Insights feature lets you set a baseline and track improvement against it, so you can show leadership how key claims KPIs changed after automation. Track these measures against the baseline you set in Step 1:

• Cycle time from first notice of loss to settlement
• Share of claims settled automatically
• Claims leakage
• Cost per claim
• Adjuster time per file
• Adjuster override rate on agent recommendations

Claims automation is an orchestration challenge

Each step above is a small task. The difficulty is connecting them so that intake, coverage checks, data, agents, adjusters, and audit records work as one flow alongside your existing core systems. Taktile's claims solution is built for that: it unifies the claims journey from first notice to settlement, so simple claims settle quickly and complex claims reach adjusters prepared, while fitting in with your existing tech stack.

Frequently asked questions