Dynamic Claim Adjudication
Deploy Large Action Models (LAMs) to autonomously extract unstructured data from claim PDFs, verify coverage rules, and execute API payouts for straight-through processing.
The Baseline
Manual insurance claim processing is a high-volume, low-margin bottleneck. Adjusters waste thousands of hours performing data entry from unstructured PDFs and manually checking standard policy rulebooks instead of investigating complex or high-value cases.
The Orchestration Engine deploys LAMs to extract unstructured claim data from PDFs, cross-reference the data against internal policy rules, and automatically trigger payout APIs via MCP.
Achieves straight-through processing (STP) for standard claims, drastically reducing operational costs. Resolution times drop from weeks to seconds, significantly improving customer satisfaction while eliminating data-entry errors.
Architecture Flow
Document Ingestion (LAMs)
A policyholder uploads an unstructured medical bill or auto repair invoice (PDF). A Large Action Model parses the document locally to extract structured entities (line items, total amounts, diagnostic codes, dates).
Policy Verification (Y-Ray Data)
The agent securely queries the specific user's policy ledger via Y-Ray Data to verify coverage limits, deductibles, and specific exclusions against the extracted claim data.
Decision Logic (Orchestration Engine)
The engine evaluates the synthesized data. If the claim is standard and unambiguously meets all policy criteria, it is approved for automated processing. Exceptions or anomalies are routed to a human adjuster.
Action Execution (MCP)
Using the Model Context Protocol (MCP), the LAM securely authenticates and triggers the internal financial API to authorize the bank payout, automatically updating the CRM and claims management system.
Core Infrastructure
| Component | Role |
|---|---|
| Large Action Models (LAMs) | Transforms static natural language processing into active execution, handling both complex PDF extraction and sequential software commands. |
| Model Context Protocol (MCP) | Acts as the strict, secure bridge to execute state-changing actions (triggering the payout API) in internal financial systems. |
| Orchestration Engine | Manages the logic gates, routing anomalies to human adjusters while orchestrating the multi-step approval flow for straight-through processing. |
Technical Specifications
AES-256 for data at rest; TLS 1.3 for data in transit
SOC2, PCI-DSS, and HIPAA (for health-related claims) compliant architecture
Deploys natively on your existing Kubernetes clusters (AWS, Azure, or bare metal)
Build this architecture
Map this workflow to your internal data models. Deploy AVELIN AI to gain sovereign control over your enterprise intelligence.
Book a Call