Your claims operation,
run autonomously.
from $0.99 per closed claim From FNOL to settlement — coverage analysis, fraud detection, field coordination, settlement calculation — without an adjuster working the queue.
Claims processing is slow, inconsistent, and leaking revenue to fraud.
When a policyholder reports a loss, the claims adjuster must open the claim, verify coverage, and initiate investigation — simultaneously, across different systems, different teams, and different manual lookups. Coverage verification alone requires reading the policy, interpreting exclusions and endorsements, and mapping them to the specific circumstances of the reported loss. Most adjusters manage this across dozens of open claims.
Fraud detection compounds the bottleneck. Every claim carries some probability of fraud, but fraud scoring is typically a separate workflow triggered only after initial processing — meaning the investigation happens too late to prevent payment. The result: slow legitimate claims and fraudulent payments that were identifiable at intake but never caught.
Eight steps. No adjuster queue required.
Every step below is executed autonomously by the PLRX claims fleet. The PLRX Durable State Machine persists state through investigation timelines that span weeks — field inspection scheduling windows, medical record collection periods, SIU referral reviews, and multi-party negotiation cycles. A claim suspended pending a medical records subpoena resumes with full claim context when the records arrive.
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01FNOL Intake & Claim OpeningThe First Notice of Loss arrives via phone transcription, digital intake form, or structured API submission from the carrier's policyholder portal. The First Notice of Loss Specialist agent extracts all structured claim data — date of loss, loss location, reported circumstances, claimant identity, and policy number — and validates the submission against the policy record. A claim number is assigned and a PLRX Durable State Machine workflow starts immediately. The loss facts are logged verbatim. Mission state:
FNOL_RECEIVED. The carrier's acknowledgement obligation clock starts. -
02Coverage AnalysisThe Coverage Analyst agent retrieves the policy document and interprets coverage against the reported loss facts. Policy limits, deductibles, applicable endorsements, and exclusions are evaluated against the specific cause of loss and the claimant's circumstances. The ISO loss cause code is assigned. State-specific coverage requirements — mandatory personal injury protection, uninsured motorist provisions, or assignment of benefits restrictions — are applied based on the loss location. The coverage determination is documented in the claim file with specific policy language citations. If the loss is excluded, the Claims Examiner receives an immediate coverage denial recommendation with the supporting rationale.
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03ISO ClaimSearch & Prior Loss HistoryThe Fraud Analyst agent submits the claim to ISO ClaimSearch — the industry-wide prior claims database — to retrieve the claimant's complete loss history across all carriers. Prior claims involving the same property, the same vehicle, or overlapping injury circumstances are flagged. The agent also queries the carrier's internal claims database for prior interactions with the claimant, the repair facility, or the medical provider named in the FNOL. The prior history profile is factored into the initial fraud risk score, which determines the investigation track — standard, enhanced, or SIU referral.
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04Document CollectionThe Claims Examiner agent sends structured document requests to all relevant parties — the policyholder, the claimant's attorney if represented, the treating medical providers, and the property owner or repair contractor. For property claims: police report, photographs of damage, contractor repair estimates, and proof of ownership. For bodily injury claims: medical records, treatment bills, NCCI injury codes, lost wage documentation, and any recorded statements. As documents arrive, each is processed through the OCR pipeline, validated for completeness and consistency, and added to the claim file. The PLRX Durable State Machine suspends in
COLLECTING_DOCUMENTSwith configurable reminder intervals until all required documents are received. -
05Field Inspection & Damage EstimationFor property claims, the Field Coordinator agent engages an independent adjuster or inspection service from the carrier's approved panel, coordinates the inspection appointment, and tracks delivery of the inspection report. On receipt, the damage estimate — often in Xactimate or equivalent format — is validated against the reported loss circumstances: scope of damage consistent with reported cause of loss, line items within normal cost range for the loss location, and no items inconsistent with the policy's covered perils. Discrepancies between the estimate and the coverage scope are flagged to the Coverage Analyst for review before the reserve is updated.
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06Fraud Analysis & SIU RoutingWith the full document package assembled, the Fraud Analyst agent performs a comprehensive fraud analysis — combining the ISO prior loss history, the internal claims history, anomaly signals in the damage estimate, geographic and temporal clustering patterns, medical billing anomalies, and the consistency of the claimant's recorded statement with the physical evidence. Claims scoring above a defined risk threshold are referred to the Special Investigations Unit via a structured A2A task with full supporting documentation. The mission suspends in
SIU_REVIEWuntil the SIU disposition is returned. Claims below the threshold proceed directly to settlement calculation. -
07Settlement Calculation & NegotiationThe Settlement Specialist agent calculates the settlement amount against the policy limits, applicable deductible, coverage determination, and validated damage or injury valuation. For bodily injury claims, the calculation incorporates special damages — documented medical bills and lost wages — and a structured general damages estimate based on injury severity, treatment duration, and NCCI injury classification. State-specific settlement regulations are applied — interest accrual requirements, proof-of-loss statement contents, and mandatory settlement timeframes. The settlement offer is communicated to the claimant or their representative. Counter-offers received via structured response are evaluated and resolved within defined authority bands.
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08Claim ClosedThe PLRX Durable State Machine transitions to
CLAIM_CLOSED. The settlement payment is initiated. The complete claim file — FNOL, coverage determination, all received documents, fraud analysis, inspection report, settlement calculation, all agent decisions, and all AI prompts — is captured in the WORM audit log. The file is immediately available for regulatory examination, litigation discovery, or internal audit. The carrier is billed for one settled claim outcome.
Six specialists.
One claim lifecycle.
Each agent maps to a real claims function. The Claims Examiner owns the full claim lifecycle and is accountable for the claim file from FNOL to closure. The First Notice of Loss Specialist handles structured intake and acknowledgement obligations. The Coverage Analyst interprets the policy. The Fraud Analyst runs the risk and SIU workflow. The Field Coordinator manages inspections. The Settlement Specialist calculates and negotiates the settlement.
ISO ClaimSearch query, coverage analysis, and prior loss history checks all run in parallel immediately after FNOL — compressing the investigation timeline significantly. The Claims Examiner does not wait for coverage to be confirmed before initiating document collection — both run concurrently, with coverage feeding into the document scope when the determination is complete.
Fraud signals caught
before settlement.
The Fraud Analyst agent does not replace the SIU. It ensures the SIU sees every claim that warrants investigation — and only those claims. Today, rules-based scoring systems flag a fixed percentage of claims for review regardless of actual risk. Analysts spend time on low-risk referrals that should never have been escalated, while high-risk claims that scored just below the threshold proceed to payment unchallenged.
PLRX fraud analysis aggregates signals across multiple dimensions — prior claim history from ISO ClaimSearch, internal carrier history, medical billing patterns, geographic and temporal clustering, damage estimate anomalies, and statement consistency — and scores each claim against a composite risk model. High-risk claims receive a structured SIU referral package that documents every contributing signal. The SIU analyst receives context, not just a flag.
Prior loss clustering
Multiple claims within a short period, same property address, or overlapping injury circumstances — detected via ISO ClaimSearch cross-carrier history.
Medical billing anomalies
Treatment bills inconsistent with reported injury severity, unbundled billing for services typically billed together, or treatment duration exceeding NCCI injury classification norms.
Damage estimate irregularities
Repair line items inconsistent with the reported cause of loss, costs above regional benchmarks, or scope that exceeds what the reported incident could plausibly cause.
Statement inconsistencies
Recorded statement facts inconsistent with physical evidence, police report timeline, or medical records — detected via structured comparison by the Fraud Analyst agent using Claude Sonnet / Opus.
Network connections
Repair facility, medical provider, or attorney appearing in multiple high-value claims filed by different policyholders — cross-claim network analysis run by the Fraud Analyst at intake.
A claim that never gets lost.
Insurance claims span weeks to months — document collection windows, SIU investigation timelines, independent inspection scheduling, and multi-party settlement negotiations. Each is a durable workflow state that holds full claim context through every suspension. A claim placed in SIU review on day five resumes with the complete investigation file — FNOL facts, coverage determination, all documents, all fraud signals — when the SIU returns its disposition.
Your claims operation, running autonomously.
Connect the PLRX claims fleet to your FNOL intake and watch a claim move from first notice to settlement — with fraud signals caught, coverage confirmed, and the exam file assembled — without an adjuster working the queue.
Request a demo and we will walk you through a live claim from FNOL to closure.