Agentic Insurance Claim Processing Engine

Agentic Insurance Claim Processing Engine aims at processing the insurance claims end-to-end using AI agents targetting faster and reliable claim adjudication system. The engine developed using Azure foundry agents, Azure power apps, Azure power automate and Azure services.

The solution transforms traditional insurance claims processing into an intelligent, autonomous workflow where specialized AI agents collaborate to analyze, validate, and adjudicate claims while seamlessly incorporating human oversight whenever required. The architecture diagram below shows how different tools under Azure interact with each other to get end-to-end claims processing system.

The architecture follows an event-driven model, enabling the claims pipeline to dynamically respond to business events such as:

• Claim submission

• Document upload or modification

• Escalation requests

• Human review requests

• Claim adjudication completion

AI Agent Orchestration

Claim information is initially captured through Microsoft Power Apps and stored in Dataverse. Every update to Dataverse triggers Power Automate, which acts as the event bus for the platform.

Each business event invokes a dedicated Power Automate workflow that calls a centralized Claims Orchestrator hosted on Azure App Services.

The orchestrator intelligently coordinates multiple Azure AI Foundry Agents, where each agent is responsible for a specialized task within the claims lifecycle. Rather than operating independently, every agent receives contextual information accumulated from previous agents, allowing the system to build progressively richer understanding of the claim throughout the pipeline.

Example agent responsibilities include:

• Claim validation

• Document verification

• Policy compliance checks

• Fraud detection

• Risk assessment

• Coverage analysis

• Settlement recommendation

• Communication management

This multi-agent architecture enables modular, reusable AI capabilities that can evolve independently while maintaining a coordinated claim processing workflow.

Human-in-the-Loop Intelligence

While the platform maximizes automation, it incorporates Human-in-the-Loop (HITL) decision making for complex scenarios.

The orchestrator automatically pauses the pipeline and routes claims for human review whenever AI agents detect situations such as:

• Missing or incomplete documentation

• Potential fraud indicators

• High-value claims exceeding predefined thresholds

• Policy ambiguities

• Business rule exceptions

Human reviewers can intervene at any stage of the workflow, after which the orchestration engine resumes processing without losing execution context.

Proactive Communication Agent

A dedicated Communication Agent continuously monitors the orchestration pipeline.

Instead of waiting for manual follow-up, it proactively engages stakeholders whenever processing stalls by:

• Requesting missing documents from claimants

• Notifying human reviewers of pending actions

• Sending claim status updates

• Reducing turnaround time through automated follow-ups

This ensures continuous progress while improving customer experience and operational efficiency.

Event-Driven Claim Adjudication

Once all validation and review stages are complete, the orchestrator finalizes the adjudication outcome and writes the results back into Dataverse.

The adjudication status is immediately reflected in Power Apps, providing claim handlers and customers with real-time visibility into claim decisions and completing the end-to-end claims processing lifecycle.

BUSINESS IMPACT

1. Automated complex insurance claim workflows using AI agent orchestration.

2. Reduced manual intervention through intelligent multi-agent collaboration.

3. Enabled scalable event-driven processing capable of handling multiple claim lifecycle events.

4. Improved fraud detection and compliance through specialized AI agents.

5. Accelerated claim turnaround with proactive communication and automated follow-ups.

6. Increased transparency by supporting real-time claim tracking and human review at any stage.

7. Built a modular orchestration framework that allows new AI agents and business rules to be integrated without redesigning the overall workflow.