Healthcare scenario: Speed claims processing
Available with: Microsoft 365 Copilot and Copilot Studio Scenario level:
KPIs impacted
Claims processing time
Value benefit
Cost savings
Using Copilot to speed claims processing
1. Get incoming claims context
Use a Copilot agent to cross-check provider details noted on pended claims against internal system records.
Copilot Studio Agent
Benefit: Saves time for claims adjudicator in understanding claims details.
2. Generate reports
Generate a report on pended claims with missing fields, discrepancies with provider match, flagged fields, along with the name of the submitting provider for each pended claim.
Copilot Studio Agent
Benefit: Assists claims team in understanding claims details by providing relevant insights.
3. Draft letters
For pended claims with missing fields, flagged fields, or that contain discrepancies with provider matching, use the agent to draft a letter requesting additional and/or updated information from providers.
Copilot Studio Agent
Benefit: Speeds up the claims review process by providing concise, relevant information.
4. Update provider information
If the Claims team receives updated provider information, use a Copilot agent to update the provider management system.
Copilot Studio Agent
Benefit: Automating updates increases accuracy and reduce the time required for claims processing.
5. Prepare for re-adjudication
Once the claim is submitted for re-adjudication, use the Copilot agent to search and retrieve relevant policy documents to the assist re-adjudication team with decision making.
Copilot Studio Agent
Benefit: Provides quick access to policy documents, aiding in accurate and timely claim adjudication.
1Access Copilot at copilot.microsoft.com or the Microsoft Copilot mobile app and set toggle to “Web”.
2Access Business Chat at copilot.microsoft.com or the Microsoft Copilot mobile app and set toggle to “Web”.
3Copilot agents allow Microsoft 365 Copilot to access your organization-specific apps. In the past, this would have required an API call to get data from a system of record. The content in this example scenario is for demonstration purposes only. You should evaluate how Copilot aligns with your organization’s business processes, regulatory requirements, and responsible AI principles.
The content in this example scenario is for demonstration purposes only. You should evaluate how Copilot aligns with your organization’s business processes, regulatory requirements, and responsible AI principles.
