Reducing reimbursement turnaround through intelligent adjudication
About the Customer
This customer is one of Indonesia's leading providers of health and life insurance, serving individual and group customers across a large member population and provider network. The organization manages significant reimbursement claim volumes across multiple health products.
Summary
The customer wanted to reduce claim turnaround times while improving adjudicator productivity. Health reimbursement claims required extensive manual effort to categorize expenses, reconcile invoices, identify missing information, and prepare claims for adjudication.
Kamios orchestrated the entire reimbursement workflow, automating document extraction, categorization, reconciliation, and NIGO management while ensuring adjudicators remained responsible for complex decisions and exceptions.
The Challenge
The insurer wanted to reduce reimbursement turnaround times without increasing adjudication risk. While adjudicators were responsible for making claim decisions, much of their time was spent preparing files, validating information, and managing missing documentation rather than assessing claims. This resulted in:
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01
Manual Categorization
Manual categorization of claim expenses
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02
NIGO Volume
High volumes of NIGO claims
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03
Follow-Ups
Repeated follow-ups for missing information
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04
Data Inconsistency
Inconsistent invoice and supporting document data
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05
Capacity
Limited adjudicator capacity for complex cases
The Kamios Approach
Kamios orchestrated intake, extraction, categorization, NIGO management, adjudication support, and claim summarization under a single mandate-driven workflow. The solution combined:
Medical Document Processing
Extracted data from invoices, receipts, and medical records.
Expense Categorization
Mapped expenses against benefits and coverage rules.
Claims Reconciliation
Validated totals and identified discrepancies.
NIGO Management
Generated targeted requests for missing information.
Duplicate Detection
Identified related or potentially duplicate claims.
Settlement Recommendations
Prepared recommendations and escalated exceptions.
Business Impact
Kamios reduced the administrative effort required to prepare claims for adjudication.
Better-prepared files and more targeted information requests helped accelerate claim processing while allowing adjudicators to focus on higher-value assessment activities.
Outcomes
- Administrative effort was reduced through workflow automation.
- Claims entered adjudication with more complete information.
- NIGO management became faster and more targeted.
- Claim turnaround times improved.
- Adjudicators focused more time on complex cases.
Who is Kamios?
Kamios is the AI agent orchestration platform purpose-built for Insurance and regulated industries: one governed place for insurers, banks and financial services firms to run AI agents on live cases, from claims and underwriting to onboarding and credit decisions, with every action declared, evidenced and metered. A Neutrinos business, built by founders with decades in insurance and banking technology.