Glossary
Claims Adjudication
Claims adjudication is the structured evaluation of coverage, liability, damages, and policy limits to determine what the carrier will pay, reserve, or deny—always subject to licensed adjuster authorization.
What are the stages of claims adjudication?
Adjudication spans investigation, policy analysis, damage valuation, coverage determination, and settlement execution. Each stage requires traceable evidence, clause citations, and reserve math aligned to NAIC expectations. AI assistants accelerate synthesis but cannot replace licensed determinations on coverage or liability.
How should policy analysis be documented?
Best practice structures responses as Evidence, Policy Clause, Analysis, and Conclusion. ClaimGPT's query_policy_system and orchestrate_claim_workspace tools return machine-readable coverage objects that adjusters can cite in files and correspondence drafts.
Where does human-in-the-loop fit?
Binding reserves, status transitions, outbound communications, and denial recommendations require explicit adjuster authorization in regulated environments. ECO-AI flags these actions and appends review language rather than executing them autonomously.
Frequently Asked Questions
- How does ClaimGPT help with Claims Adjudication?
- ECO-AI invokes governed MCP tools for triage, policy lookup, fraud analytics, document extraction, and draft communications inside ChatGPT.
- Do AI recommendations replace licensed adjusters?
- No. Binding reserves, status updates, and outbound communications require explicit adjuster authorization.
- Where can I connect ClaimGPT?
- Visit /developer for ChatGPT MCP setup or /enterprise for architecture review with your integration team.