Claims Service — AI Integration
Status: populated Owner: TBD Last updated: 2026-04-18 Companion: SERVICE_OVERVIEW · Service Template · 02 DDD
Current Status
No AI features in v1. The claims-service does not integrate with any AI or ML model in its initial release.
Rationale
Claims processing is a financially and regulatorily sensitive domain. Incorrect AI-assisted decisions could result in:
- Fraudulent or erroneous claim submissions
- Incorrect denial or payment allocations
- Regulatory non-compliance (HIPAA, payer contracts)
All claim decisions in v1 are deterministic: coding validation via terminology-service, scrubbing via rules engine, and state transitions driven by explicit payer responses.
Future Backlog
The following AI capabilities are under consideration for future phases. None are committed.
| Feature | Phase | Description | Constraints |
|---|---|---|---|
| Denial Prediction | Future | ML model to predict denial likelihood before submission based on historical patterns | Must not auto-reject claims; HITL review required; model outputs advisory only |
| Coding Suggestion | Future | Suggest additional or corrected CPT/ICD-10 codes based on encounter notes | PHI cannot leave tenant boundary; on-premises or tenant-scoped model required; clinician approval mandatory |
| Duplicate Claim Detection | Future | Detect potentially duplicate claim submissions using similarity scoring | Rules-based approach preferred first; ML fallback only if rules insufficient |
| Prior Auth Decision Assistance | Future | Surface historical auth approval patterns to guide requests | Advisory only; no automated submission of auth requests |
Constraints (Applied to Any Future AI Work)
- No PHI transmitted to external AI APIs without explicit tenant consent and DPA.
- All AI-generated suggestions require human-in-the-loop confirmation before affecting claim state.
- AI model decisions must be auditable — inputs and outputs stored in audit log.
- Model performance (accuracy, recall, precision) must be monitored and dashboarded.
- Fallback to non-AI path must be available if model is unavailable or degraded.