Transforming Appeals Management with Gen AI for a Leading U.S. Health Benefits Provider
Client Overview
The client is a prominent U.S.-based health benefits provider, recognized for delivering diverse and innovative health plans and services that improve care access, affordability, and health outcomes. Serving millions of members nationwide, the organization plays a critical role in both commercial and government health programs. Driven by a mission to advance whole-person health, the organization is committed to providing high-quality, personalized care by leveraging advanced technology, clinical expertise, and member-focused services.
Modernizing Appeal Processing with Intelligent Automation
To improve efficiency and decision-making accuracy, the client sought an AI-powered solution to streamline workflows, reduce manual effort, and support clinical staff with real-time, data-driven insights.
Accelerate Appeal Case Processing
Automate the appeals review process to improve decision turnaround time and reduce manual workloads on clinical staff.
Ensure Consistent, AI-Supported Decision Making
Leverage historical data to drive consistent, compliant, and explainable outcomes across a high volume of appeal cases.
Automate Document Generation & Translation
Enable automated generation of approval/denial letters and translations using AI/NLP to reduce dependency on manual interventions.
Enhance Workflow Integration
Implement an intuitive, plug-and-play solution that integrates seamlessly with existing infrastructure.
Protect Member Data with a Secure Solution
Deploy a secure, cost-effective, and home-grown solution that ensures the privacy and security of sensitive health data.
Supercharging Appeals Automation with a Spark of Gen AI
To address the growing need for intelligent claims processing, the client partnered with Indium to implement a GenAI-based platform tailored to automate and optimize the appeal review lifecycle. The platform delivered actionable insights and automated key decision points with the following core capabilities:
GenAI-Powered Case Review Engine
Leveraged historical appeal data to provide real-time recommendations, empowering nurses to make faster, more consistent decisions with AI-guided support.
Automated Justification & Letter Generation
Automatically selected appropriate templates and populates approval or denial justifications, streamlining the appeal letter generation process.
Integrated Translation & Document Automation
Applied NLP and translation engines to generate multilingual documents, enhancing communication with diverse member populations.
Plug-and-Play Workflow Integration
Easily integrated into the existing ecosystem, enabling rapid deployment without disrupting ongoing operations or infrastructure.
Secure and Scalable Infrastructure
The low-cost, internally developed platform ensured compliance with healthcare regulations while maintaining robust data privacy controls.
Driving Measurable Outcomes in Appeals Management
2X Faster Appeal Resolution
Drastically reduced decision-making time, accelerating the appeals lifecycle and improving member turnaround time.
90% Accuracy in AI-Supported Decisions
Consistent and explainable decisions across cases, reduced variability, and ensured compliance.
40% Increase in Nurse Productivity
Automation allowed clinical teams to focus on higher-value tasks, improving operational efficiency.
50% Workflow Streamlining
Enhanced team collaboration and communication, reduced bottlenecks, and improved end-to-end process performance.
About Indium
Indium is an Al-driven digital engineering company that helps enterprises build, scale, and innovate with cutting-edge technology. We specialize in custom solutions, ensuring every engagement is tailored to business needs with a relentless customer-first approach. Our expertise spans Generative Al, Product Engineering, Intelligent Automation, Data & Al, Quality Engineering, and Gaming, delivering high-impact solutions that drive real business impact.
With 5,000+ associates globally, we partner with Fortune 500, Global 2000, and leading technology firms across Financial Services, Healthcare, Manufacturing, Retail, and Technology-driving impact in North America, India, the UK, Singapore, Australia, and Japan to keep businesses ahead in an Al-first world.
