Smart Claim Check

Overview

Development stage

In development or acquisitionSource: a) Pre-deployment – The use case is in a development or acquisition status.

High-impact designation

Not high-impactSource: c) Not high-impact

Impact justification

Not reported

Start date

Not reported

Withheld from public reporting

Not reported

Mission

Topic area

Government Benefits Processing

Operational functions

Claims and case processing Derived by keyword rules; see methodology

Problem the AI is intended to solve

Smart Claim Check (SCC) reduces avoidable claims processing errors by addressing the problem of manually reviewing extensive documentation by Veterans Service Representatives (VSRs) to identify and resolve issues. Claims processing errors that can be avoided in the claims process leads to extended wait times for Veterans to receive the benefits to which they are entitled. SCC leverages natural language processing (NLP) and machine learning (ML) to analyze past deferral data and identify common patterns and themes.

Expected benefits

By leveraging these technologies described in #12, Smart Claim Check can automatically review claim documentation, identify common patterns, and offer structured recommendations, including context-specific guidance from the M21-1 manual, confidence scores, and links to relevant sections, thereby expediting the claims review process and reducing avoidable re-work and extended processing times.

System outputs

The output of the AI system is timely guidance with relevant M21-1 linkage, that will appear in the User Interface (UI) automatically for the claims processors to review and act upon. SCC is referring to these a "Smart Claim Insights".

Technology

AI classification

Generative AISource: Generative AI: AI that generates new or synthetic content (e.g., images, videos, audio, text, code).

System name(s)

Not reported

Custom-developed code

Not reported

Public source code

Not reported

Sourcing

How it was built

Not reported

Vendor (as reported)

Not reported

Vendors (standardized)

None on the standard list

A vendor is the supplier named by the agency. It does not identify the underlying model or AI technology.

Data and privacy

Involves PII

Not reported

Privacy Impact Assessment

Not reported

Authorization to Operate

Not reported

Demographic features

Not reported

Training and evaluation data

Not reported

Federal Data Catalog

Not reported

Governance

0 of 8 minimum-practice questions answered. A blank answer means the agency reported nothing; it does not mean the practice is absent.

Potential impacts and how they were identified

Not reported