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Claims AI

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Claims AI is AI claims processing software for U.S. property and casualty carriers, MGAs and TPAs, developed by Decerto. It prepares claim files for adjusters and leaves claim decisions with licensed claims professionals. The software ingests unstructured claim documents, including FNOL submissions, police reports, medical bills, photographs, handwritten notes and contractor estimates. It extracts entities and assigns a confidence score to each field. Low-confidence fields are routed to the adjuster for verification. The system checks policy status on the date of loss through the policy administration system, identifies endorsements held only in scanned form and flags missing documentation by claim type and jurisdiction. Fraud indicators, such as image metadata, photo geolocation and duplicate documents, are combined into a weighted score by the Higson rules engine using carrier-defined weights. Relevant policy provisions are quoted with links to source documents. The adjuster reviews the recommendation packet and makes the coverage, reserve and payment decisions. Each step is recorded with a timestamp, rule version and user, supporting NAIC AI Model Bulletin governance requirements and state-level claim handling deadlines. Claims AI operates as a layer over existing core systems and does not require core replacement.

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