A US vision insurer automates 178,000+ out-of-network claims in six months with robots and a validation agent

In-network claims were more than 98% automated, but more than 60% of out-of-network claims, over 180,000 a year, still needed manual intervention. The top recurring error codes had no automated resolution, dozens of staff spent significant time on repetitive remediation, and manual processing slowed overall claims turnaround. Only a fraction of the claims the robots processed could be reviewed by hand each day, so errors could go unnoticed for days.

TSP proved the idea with an on-site proof of concept in under a day, then built 12 robots with UiPath RPA and Document Understanding to resolve the top 12 error codes behind out-of-network claim issues. They run throughout the day, processing 2,000 to 3,000 claims daily. A claim validation agent identifies the robot and error code for each claim, reviews its full processing history in the claims system, checks it against the business rules and confirms every step ran in the right order. Correct claims are logged for audit, and only claims with issues go to a reviewer, with the reason and logs attached.