EntPEP Insurance claims
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Insurance claims · LLM agents with a rulebook

Claims pour in. Every decision follows the book.

A live queue of claims, one click to take a claim, and an agent that checks it against the policy, the guidelines and past decisions before your adjuster or reviewer decides. Every decision is on the record.

Part 1

Property & Casualty

Every new claim, checked against the policy wording, claims guidelines, settlement authority, SIU red flags and past coverage decisions.

▶ video 1:40walkthrough ↓ Part 2

Life & Health

The health claims that pend for a person, worked through eight review steps against the plan, the medical policy and past decisions.

▶ video 1:40walkthrough ↓

Prefer one file? Both parts as one video (3:24) · both as one PDF. All data shown is sample data for a fictional insurer, Brightwater Mutual, and its health plan, Brightwater Health.

How it works

From a claim in the queue to a decision you can stand behind.

1 · QueueLive queueClaims from your claims system, ranked by priority, updated every few seconds.
2 · TakeOne person per claimTake locks the claim to you; the team sees who is working what.
3 · AgentThe question already askedA sealed agent reads the claim, policy and history, and your rulebook, and cites every line.
4 · DecideYou decideThe adjuster or reviewer records the decision; take, release and decision are audited.
The model never sees who.

Names, emails, addresses and policy or member numbers are replaced with stand-ins such as [Person 1] and [Policy 1] before anything reaches the model, and put back in its replies. Your adjuster sees real data; the model sees the facts a decision needs (dates, amounts, codes, coverages, places) and nothing that identifies the policyholder or member.

Part 1 · Property & Casualty

Thousands of claims a day, and a storm can triple them overnight.

Every claim is a rule check: is the policy in force, which coverage applies, is there an exclusion, a sublimit or an endorsement, whose authority is it, does it need an SIU referral?

The rules live in documents. Two adjusters can give two answers, and regulators, auditors and litigators ask why.

Read the walkthrough (PDF)

Sample report (PDF)
Written by the agent in a real run on a river flood claim. It recommends denial under the flood exclusion; the adjuster decides.

Part 2 · Life & Health

Most claims pay themselves. The rest each need eight checks.

A pend says where the automated check stopped, not what the answer is. Often it's fine; sometimes it hides another problem.

Each pended claim needs eligibility, other coverage, timely filing, network and referral, authorization, coding, benefit limits and medical necessity, against the clock, with a reason code for every denial. The walkthrough shows health claims; the same queue fits life and disability claims.

Read the walkthrough (PDF)

Sample report (PDF)
Written by the agent in a real run on a pended knee MRI. The pend was fine; medical necessity was not, so it goes to clinical review.

Under your control

Built for decisions that get second-guessed.

  • The model never sees who. Identifying values become stand-ins before each model call and are put back in its replies.
  • Read-only data, time-boxed access. Agents read claims through a role an admin grants for a set time.
  • Your own rulebook. Policy wordings, plan benefits, medical policies, guidelines and past decisions, cited line by line.
  • One person per claim, and every take, release and decision audited.
  • A Work Record for every agent: the queries it ran and the documents it read, for audits and appeals.
  • Sealed agents on your servers, with the model you choose.

Screens from the live demo at insurance.entpep.com, with sample data for a fictional insurer. Agent answers are quoted, abridged, from real runs on the claims shown; their wording is the model's.

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