AI Agents for Health Insurers, Supplementary Insurance, Care Offices, and PGB Management | Match-AI

Health insurers, supplementary insurance, care offices, and PGB management operate in a sector where claims processing, fraud detection, healthcare procurement, authorizations, and customer service must be simultaneously optimized. AI agents automate the claims processing, fraud detection, and healthcare procurement flows.

Claims Processing and Authorization Management

An AI agent manages the claims flow: submitted claims are automatically validated on completeness, coding correctness, and policy conditions. Claims falling within automatic acceptance criteria are automatically paid out. Authorization requests are automatically tested against the care policy and medical guidelines. Missing information on claims is automatically requested from the care provider.

• Claim: automatically validated on codes and policy
• Payment: automatically for approved claims
• Authorization: automatically tested against care policy
• Information: automatically requested from provider

Customer Service and Care Mediation

Customer service and care mediation are essential for health insurers for customer satisfaction and retention. An AI agent manages the customer service flow: insured persons calling or chatting about their policy, reimbursements, or claims automatically receive an answer to their question. Care mediation requests are automatically handled.

• Policy info: automatically answered per insured person
• Reimbursement: automatically calculated based on policy
• Mediation: automatically selected providers
• Switch: automatically guided in switch campaign

Match-AI implements AI agents for health insurers, supplementary health insurers, care offices, PGB management organizations, healthcare advisory firms, and combined health/pension/income insurers that want to automate their claims processing, fraud detection, and healthcare procurement.