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AI-Powered Health Insurance Adjudication · Explainable Pipeline
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TC001: Member submits two prescriptions for a consultation claim that requires a prescription and a hospital bill.
TC002: Member uploads a valid prescription but a blurry, unreadable photo of their pharmacy bill.
TC003: The prescription is for Rajesh Kumar but the hospital bill is for a different patient, Arjun Mehta.
TC004: Complete, valid consultation claim with correct documents, valid member, covered treatment, within all limits.
TC005: Member joined 2024-09-01. Claims for diabetes treatment on 2024-10-15, which is within the 90-day waiting period for diabetes.
TC006: Bill includes root canal treatment (covered) and teeth whitening (cosmetic, excluded). System must approve only the covered procedure.
TC007: MRI scan costing ₹15,000 submitted without pre-authorization. Policy requires pre-auth for MRI above ₹10,000.
TC008: Claimed amount of ₹7,500 exceeds the per-claim limit of ₹5,000.
TC009: Member EMP008 has already submitted 3 claims today before this one arrives. This is the 4th claim from the same member on the same day.
TC010: Valid claim at Apollo Hospitals, a network hospital. Network discount must be applied before co-pay.
TC011: One component of your system fails mid-processing (simulate with the flag below). The overall pipeline must continue, produce a decision, and make the failure visible in the output with an appropriately reduced confidence score.
TC012: Member claims for bariatric consultation and a diet program. Obesity treatment is explicitly excluded under the policy.
Claim Details
Member ID *
Policy ID *
Claim Category *
CONSULTATION
DIAGNOSTIC
PHARMACY
DENTAL
VISION
ALTERNATIVE MEDICINE
Treatment Date *
Claimed Amount (INR) *
Hospital Name
YTD Claims Amount (INR)
Simulate Component Failure (TC011)
Documents
+ Add Document
Doc 1
Document Type *
HOSPITAL BILL
PRESCRIPTION
LAB REPORT
DISCHARGE SUMMARY
DIAGNOSTIC REPORT
DENTAL XRAY
VISION TEST
File ID
Quality
— Not specified —
GOOD
READABLE
LOW
UNREADABLE
Patient Name on Doc
Document Content (JSON or free text)
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