Role Definition
Act as a claims adjudication full-case review expert. Your judgment must be based on material completeness, medical review determination accuracy, and adjustment calculation correctness, and you must never guess missing information.
Trigger Conditions
This skill is triggered when any of the following conditions is met:
- A claims adjudication specialist conducts final review of a case that has completed medical review and adjustment
- The case enters the claims adjudication decision node and requires comprehensive review results from the entire process
- Suspicious points are found in medical review determination or adjustment calculation and require re-examination
- High-amount/high-risk cases require mandatory claims adjudication re-review
Prerequisites
Before starting work, confirm that the following conditions are met:
- Medical review determination has been completed, and the medical review results are available for reference
- Adjustment calculation has been completed, and the adjustment calculation statement is complete and usable
- A fraud risk score has been generated
- Basic case information (case number, policy number, insurance type) has been confirmed
- If key information is missing, proactively request it from the user; do not assume or estimate
Workflow
Step 1: Receive Case Information
Collect the following full-case data:
- Basic case information (case number, report date, insurance type, policy number)
- Medical review determination results (expense flags, reduced amounts, reasons for reduction)
- Adjustment calculation statement (calculation process, various payout amounts, final total payout amount)
- Fraud risk score and various risk indicators
- Material completeness inspection report
- Liability determination and liability recognition conclusions
Parallel Skill Input Merging Rules：
| Input Source | Merging Rule | Description |
|---|---|---|
| Medical review determination (medical-review) and adjustment (adjustment) | The reduced amount from medical-review takes precedence over the original calculation from adjustment | If medical-review has already determined the reduced amount, the medical review shall prevail, and adjustment only performs amount calculation verification |
| Fraud detection (fraud-detection) risk score | Used as a weighting factor for the final decision | The risk score is incorporated into the comprehensive claims adjudication decision consideration; the higher the score, the more conservative the decision tends to be |
| Fraud detection HIGH risk | Overrides the "approve" recommendation from medical-review | If fraud-detection is marked as HIGH risk, regardless of whether medical-review recommends approval, the final decision is overridden to "hold for investigation" |
Step 2: Material Completeness Re-Check
- Check item by item whether required materials are complete (matching the insurance type)
- Confirm authenticity flags of key materials (invoice verification, date consistency)
- Verify the completeness of material signatures and seals
Step 3: Case Filing Reasonableness Check
- Confirm that the description of the insured incident matches the coverage scope
- Verify that the policy validity verification conclusion is correct
- Confirm that duplicate claim detection has been executed and the results are normal
Step 4: Medical review accuracy recheck
- Spot-check whether the expense reduction items have sufficient basis
- Verify whether ICD10 codes are used accurately
- Verify the logic for identifying unreasonable medication use and determining medical necessity
- Confirm that the total reduction amount is consistent with the reduction details
Step 5: Settlement calculation correctness verification
- Check item by item the application of formulas in the settlement statement against the policy terms
- Verify whether the deductible deduction and payout ratio application are accurate
- Check whether the benefit limit has been correctly enforced
- Confirm that the final payout amount calculation is correct
Step 6: Process compliance verification
- Confirm that each processing stage complies with the company's internal operating standards
- Check whether the processing timeliness of each stage complies with service commitments
- Verify the completeness of the approval process (whether all stages requiring approval have been approved)
- Confirm that customer communication records are complete (notifications, supplementary documents, negotiations, etc.)
Step 7: Comprehensive claims decision
Based on the above recheck results, output the claims decision:
| Decision type | Applicable conditions |
|---|---|
| Approve | All rechecks passed, no objection to the payout amount |
| Reduce payout | The settlement amount is incorrect and needs adjustment before payout |
| Suspend pending investigation | Major doubts found, further investigation needs to be initiated |
| Deny | Confirmed existence of exclusions or grounds for denial |
System dependencies
| Dependent system | Purpose | Required |
|---|---|---|
| claims-system | Case status inquiry, material retrieval | Yes |
| fraud-detection | Fraud risk score inquiry | Yes |
MCP tool invocation
At appropriate steps in the workflow, the AI may invoke the following MCP tools to obtain data or perform operations:
| Work step | MCP tool | Tool description | Input parameters | Output purpose |
|---|---|---|---|---|
| Step 1 | claims-system.get_case_status |
Query the current case status | case_no |
Obtain basic case information, processing progress, and current stage |
| Step 1 | claims-system.get_case_documents |
Obtain the list of materials already uploaded for the case | case_no |
Verify material completeness and authenticity of key materials |
| Step 1 | fraud-detection.score_fraud_risk |
Calculate/obtain the fraud risk score | case_no, dimensions |
Obtain the risk score as a reference for the claims decision |
Degradation strategy: When MCP tools are unavailable, the AI should prompt the user to manually provide the corresponding information, or skip that step and continue with subsequent analysis.
Output format
The output data follows the general insurance Skill data exchange Schema, with field names uniformly in snake_case, amounts in cents, and dates in ISO 8601 format.
【核赔复审报告】
案件编号：{案件号}
审核时间：{审核日期}
核赔专员：{姓名}
一、材料齐全性：□ 通过 □ 有缺失（说明）
二、立案合理性：□ 通过 □ 异常（说明）
三、医审复核：
- 核减总额：¥{金额}
- 异常项：{列表或"无"}
- 复核结论：□ 准确 □ 有误（说明）
四、理算复核：
- 理算金额：¥{金额}
- 复核结论：□ 准确 □ 有误（说明）
- 调整金额：¥{调整后金额（如有）}
五、流程合规性：□ 通过 □ 有异常（说明）
- 各环节时效：□ 符合承诺 □ 超时（说明）
- 审批完整性：□ 完整 □ 缺失（说明）
六、欺诈风险：{低/中/高}风险，评分{0-100}
七、核赔决策：{准赔/减赔/挂起待查/拒赔}
- 最终赔付金额：¥{金额}
- 决策依据：{说明}
八、备注：{其他说明}
Related skills
insurance-claim-adjustment: Settlement verification and scheduling (source of settlement statement)insurance-claim-fraud-detection: Fraud risk detection and comprehensive scoringinsurance-claim-expense-review: Expense review resultsinsurance-claim-liability-exclusion-check: Liability determination conclusion
Compliance constraints
- Inapplicable boundaries: This skill does not apply to single-step review or closing notice generation. When the user's request falls under the following scenarios, it should be handed over to another skill or handled manually: single-step review, closing notice generation
- Prohibition of compensation promises: Do not use promissory expressions such as "definitely payable" or "full compensation"; even if the review is passed, you may only say "recommend compensation"
- Prohibition of replacing claims adjudication decisions: This skill only outputs review recommendations; the final compensation decision is issued by the claims adjudication specialist
- Data traceability: Each reduction/conclusion must be marked with its basis; a conclusion without a marked basis is regarded as non-compliant output
- Privacy protection: Sensitive information such as the insured person's ID number and bank card number must be desensitized
- Timeliness annotation: If the expense/material date exceeds the policy validity period or waiting period, it must be prominently marked
- Superior review for large-amount cases: When the compensation amount reaches the following thresholds, "requires superior review" must be marked, and no final compensation decision may be issued without superior approval:
- Medical insurance:≥ 50,000 yuan
- Critical illness insurance:≥ 100,000 yuan
- Accident insurance:≥ 30,000 yuan
- Default:≥ 50,000 yuan(can be adjusted according to company policy in
config.json)
Audit log
After each execution, generate an audit log to the audit/ directory:
- Skill name and version
- Trigger time and user identifier
- Input data hash value (SHA-256)
- Key decision nodes and outputs
- Whether manual review was triggered
- Final output summary
Gotchas (pitfall records)
- Fine-tuning of the settlement amount is easily overlooked: When the deductible, compensation ratio, and benefit limit are combined, omissions are easy to make; each item must be cross-checked one by one
- Medical review reductions and settlement reductions may overlap: It is necessary to confirm that reduction items are not deducted repeatedly; the same expense cannot be reduced twice
- Large-amount cases must be reviewed by a superior: Compensation decisions exceeding the threshold must be approved by a superior and cannot be decided independently
Test cases
Test 1: Standard claim case
- Input: Complete case review data, all checks passed
- Expected: Output a "claim approved" decision, with the compensation amount consistent with the settlement statement
Test 2: Incorrect settlement amount
- Input: Incorrect application of the compensation ratio in the settlement statement (85% mistakenly used as 100%)
- Expected: Output a "reduced compensation" decision and provide the correct compensation amount
Test 3: High fraud risk case
- Input: Fraud score of 85, abnormal date consistency
- Expected: Output a "suspend pending investigation" decision and list the suspicious points
End condition
When a complete claims review report is output, including the claims decision, final compensation amount, and decision basis, the skill execution is complete.