Use Case · AI Claims Intake

Automated Insurance Claims Processing & Pipeline Intelligence Platform

Built for TPAs, carriers, and self-insured operators. Unify every claim from EDI, email, PDF, and photo into one AI-driven pipeline with real-time visibility, automated validation, and audit-ready traceability at every step.

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founders

A Decade of Turning Fragmented Data Into Executive-Grade Intelligence

Craig and Michael have spent 10+ years helping over 1,000 organizations aggregate the complex. In insurance, fragmented data does not look like a data problem. It looks like a claim that sat for six days, a payout that cleared late, and a regulator asking for an audit trail no one can assemble. Truzer.ai is everything they learned, built for this.

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WHO THIS IS FOR

This is the team using Truzer to unify multi-channel claims intake and

This Use Case shows how a real-time Control Tower can automates and simplify high-volume insurance claims intake for Third Party Administrators (TPAs). By intelligently ingesting both structured EDI transactions and unstructured email attachments (PDFs, medical records, invoices, and photos), AI performs instant OCR extraction, validation, and routing — giving the team complete visibility, automated exception handling, and immutable audit trails across auto, property, health, and workers’ comp claims. From chaotic multi-channel intake to accurate, audit-ready processing — faster payouts, fewer denials, and dramatically increasing operational efficiency and the scaling possibilities for a TPA.

Alex Rivera

Claims Intake Supervisor (Internal User)

Monitors incoming queues, reviews AI extraction results, ensures timely routing to adjusters

Jordan Patel

Operations Manager (Internal User)

Oversees pipeline performance, tracks metrics, identifies bottlenecks, monitors audit compliance

Taylor Kim

Senior Adjuster (Internal User)

Reviews flagged claims in Adjudication stage, benefits from clean pre-validated data

Morgan Ellis

Carrier Representative (External User)

Gains shared visibility into claim status and audit trails for reconciliation/reporting

Fragmented intake (EDI + unstructured emails)

Centralized AI-driven pipeline with real-time visibility across all claims

Manual errors in data extraction and validation

OCR + intelligent validation to automate processing and improve accuracy

Lack of visibility and control over claim status

Real-time dashboard with proactive alerts and full audit traceability

01 Initiation & Queue Monitoring
02 Processing Stage
03 Adjudication Stage
04 Claims Processing
05 Audit Trail

01 / 05

Initiation & Queue Monitoring

The live dashboard automatically ingests new claims from EDI portals and email inboxes. Alex sees a clear overview: “19 emails waiting” and “3 EDI transactions pending,” with color-coded status (Waiting/Pending). The system pulls in claim metadata and begins AI processing immediately.

02 / 05

Processing Stage

Truzer AI performs intelligent OCR extraction and validation on PDFs and attachments, cross-checking policy numbers, claim amounts, dates of loss, diagnoses, and codes. Any issues are highlighted in real time on the dashboard. Jordan monitors the Processing stage and receives instant alerts for anomalies, reducing manual re-keying errors by over 90%.

03 / 05

Adjudication Stage

Validated claims move seamlessly into Adjudication. The dashboard shows rule-based reviews, fraud checks, and automatic adjuster assignments with “LIVE” environment status. Taylor opens the Current Claim view to see key fields instantly: Policyholder, Claim #, Date of Loss, Carrier, Amount, and Status — enabling faster, more accurate decisions.

04 / 05

Claims Processing

If bottlenecks appear (e.g., stuck files or validation failures), the dashboard flags them visually. The system logs every step with timestamps and source tagging (edi_837, email_submission, etc.), creating an immutable audit trail. Proactive alerts notify the team before issues impact SLAs.

05 / 05

Audit Trail

Processed claims appear in Recent Claims with full history and timestamps. The Metrics Overview updates live:

58–82%

of insurers are already using AI in operations, including claims workflows, according to industry reports.

Feature

Without Truzer

With Truzer

Intake

✕ EDI, email, fax, and scans landing in four systems

✓ Every channel unified into one pipeline at ingest

Data extraction

✕ Manual re-keying from PDFs, photos, and medical records

✓ AI OCR with policy, amount, and code validation at the source

Adjudication

✕ Fraud checks depend on whichever adjuster catches it

✓ Rule-based fraud review on every validated claim before assignment

Audit trail

✕ Reconstructed after the fact from email threads and exports

✓ Immutable, timestamped, source-tagged at every step

Cash flow visibility

✕ “Where is this claim?” answered four different ways

✓ Live ontology showing every claim's stage and its impact on payouts

Deployment

✕ Months of integration before go-live

✓ Live in 48 hours, on top of your stack

Contract

✕ Multi-year contracts and vendor lock-in

✓ Month-to-month, cancel anytime

Intake

Without ✕ EDI, email, fax, and scans landing in four systems

With Truzer ✓ Every channel unified into one pipeline at ingest

Data extraction

Without ✕ Manual re-keying from PDFs, photos, and medical records

With Truzer ✓ AI OCR with policy, amount, and code validation at the source

Adjudication

Without ✕ Fraud checks depend on whichever adjuster catches it

With Truzer ✓ Rule-based fraud review on every validated claim before assignment

Audit trail

Without ✕ Reconstructed after the fact from email threads and exports

With Truzer ✓ Immutable, timestamped, source-tagged at every step

Cash flow visibility

Without ✕ “Where is this claim?” answered four different ways

With Truzer ✓ Live ontology showing every claim's stage and its impact on payouts

Deployment

Without ✕ Months of integration before go-live

With Truzer ✓ Live in 48 hours, on top of your stack

Contract

Without ✕ Multi-year contracts and vendor lock-in

With Truzer ✓ Month-to-month, cancel anytime

Pick a side.

48 hours from now, your claims pipeline is either still leaking or it's live.

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Connect Everything

Your TMS, ERP, telematics, IoT, EDI. All of it. Truzer aggregates the complex and maps it into a single unified ontology. No rip-and-replace. No 18-month implementation. Your systems keep running.

See Everything

Right away you’re immersed into a complete visual experience. Seeing everything in real time. Your whole operation, stupidly visible. Not yesterday’s report. Not a dashboard silo. The truth, live, now.

Know Everything

The ontology doesn’t just show your data. It maps how every asset, route, team, customer, and regulation connects to each other. When one thing changes, you already know what it affects. All truth. No fiction.

Act on Everything

AI agents monitor your operation 24/7. They flag exceptions, lock down compliance violations, send proactive customer updates, and surface revenue opportunities. Grounded in your ontology. Not hallucinated from generic training data.

DEEP DIVE

What Is a Digital Twin?

Dashboards show you yesterday. A digital twin shows you the live state of your business, in one place, ready to decide what happens next.

Q What types of input channels does the Truzer AI Agent support for claims intake?

The system supports both structured and unstructured input channels, including EDI submissions (primarily EDI 837 and other X12 formats) and email attachments.

Q Which kinds of documents and data formats can the system process and extract information from?

It can process a wide range of unstructured documents such as PDF claim forms, medical records, invoices, accident photos, and other supporting documents.

Q What are the key operational benefits provided by the Pipeline Dashboard in terms of visibility and efficiency?

The ontology gives you one place to see every claim, every stage, and every SLA clock. Bottlenecks surface before they cost you. Audit trails build themselves. Your team stops re-keying and starts adjudicating. The pipeline scales without adding headcount.

Q How long does Truzer take to deploy for a TPA or carrier?

Truzer is deployed in 48 hours. Your connectors to EDI portals, email inboxes, and claims systems are configured, your ontology is populated with your existing claim data, and your team is live on the control tower.

Q Is Truzer HIPAA compliant, and how is PHI protected?

Data security comes first. Not eventually. Not if you pay more. Truzer runs inside your environment with AES-256 encryption at rest, TLS 1.3 in transit, and scoped tokens for every connector. Your data never leaves the vault.

Q How does Truzer handle fraud detection during adjudication?

The Adjudication stage runs rule-based reviews and fraud checks on every validated claim before adjuster assignment. Flagged claims are routed to senior adjusters with the full audit trail attached, so every decision is grounded in the source document, not a summary

Q Can Truzer work alongside Guidewire, Duck Creek, or our existing claims system?

Yes. Truzer connects to the claims systems you already run. The ontology unifies the data those systems hold in silos and gives your team a single control tower across all of them. No rip-and-replace.

Q Does Truzer work for TPAs managing claims on behalf of multiple carriers?

Yes. TPAs are a core buyer for this page. The ontology handles multi-carrier claim intake, keeps each carrier's data segmented, and gives your carrier partners their own view into the pipeline. One control tower, clean separation.

Q What happens to claims leakage when Truzer is deployed?

Leakage shrinks because errors get caught at intake, not at adjudication. AI validation flags policy, amount, and code mismatches the moment a claim enters the pipeline, before cash moves out the door.

Q Can Truzer process medical records, accident photos, and handwritten notes?

Yes. The OCR layer handles PDFs, scanned medical records, accident photos, invoices, and handwritten supporting documents. Every extraction is logged with its source document in the audit trail.

Q How does Truzer handle EDI 837 transactions specifically?

EDI 837 is a primary intake channel. Truzer ingests X12 837 files the moment they land in the portal, parses every loop and segment, and validates the data against policy before it hits adjudication

Q What does claims pipeline visibility look like for our executives?

A single control tower. Executives see every claim's stage, SLA status, and cash-flow impact in real time. No status meeting. No spreadsheet export. The answer to “where is this claim?” is the same for everyone.

next step

SEE IT LIVE

Stop Letting Fragmented Claims Drain Your Cash Flow.

Truzer unifies every claim channel into one live ontology in 48 hours. EDI, email, PDF, photo. All truth. No fiction.