Automated Claims Adjudication

System ↔ System

Claim event triggers policy lookup, rules engine, benefit calc, and payment.

6 nodes · 5 edgesinsurance

eventsystemdbapi

Visual

Claim Submission Eventevent

EDI 837 or API claim received from provider.

↓sequential→ Policy Lookup

Policy Lookupdb

Retrieve member eligibility, plan details, and benefit schedule.

↓sequential→ Coverage Rules Engine

Coverage Rules Enginesystem

Apply medical necessity, pre-auth, and network status rules.

↓conditional→ Benefit Calculation

Benefit Calculationsystem

Compute allowed amount, copay, coinsurance, and deductible applied.

↓sequential→ Payment System

Payment Systemapi

Submit ERA 835 remittance and initiate EFT/check payment.

↓sequential→ EOB Notification

EOB Notificationapi

Send explanation of benefits to member and provider.

Open in Editor

uc-claims-adjudication.osop.yaml

osop_version: "1.0"
id: "claims-adjudication"
name: "Automated Claims Adjudication"
description: "Claim event triggers policy lookup, rules engine, benefit calc, and payment."

nodes:
  - id: "claim_event"
    type: "event"
    name: "Claim Submission Event"
    description: "EDI 837 or API claim received from provider."

  - id: "policy_lookup"
    type: "db"
    name: "Policy Lookup"
    description: "Retrieve member eligibility, plan details, and benefit schedule."
    timeout_sec: 10

  - id: "rules_engine"
    type: "system"
    name: "Coverage Rules Engine"
    description: "Apply medical necessity, pre-auth, and network status rules."

  - id: "benefit_calc"
    type: "system"
    name: "Benefit Calculation"
    description: "Compute allowed amount, copay, coinsurance, and deductible applied."

  - id: "payment"
    type: "api"
    subtype: "rest"
    name: "Payment System"
    description: "Submit ERA 835 remittance and initiate EFT/check payment."
    security:
      risk_level: "high"
    retry_policy:
      max_attempts: 3

  - id: "notification"
    type: "api"
    name: "EOB Notification"
    description: "Send explanation of benefits to member and provider."

edges:
  - from: "claim_event"
    to: "policy_lookup"
    mode: "sequential"
  - from: "policy_lookup"
    to: "rules_engine"
    mode: "sequential"
  - from: "rules_engine"
    to: "benefit_calc"
    mode: "conditional"
    when: "claim.eligible == true"
  - from: "benefit_calc"
    to: "payment"
    mode: "sequential"
  - from: "payment"
    to: "notification"
    mode: "sequential"

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