What you need
Data sources
- Policy administration system — Active policies with coverage terms, effective dates, endorsements, exclusions, deductibles, and limits
- Claims management system — Claim details including date of loss, loss type, and claimed amount
Knowledge spaces
- Policy documents — Upload actual policy wordings, endorsements, and declarations pages for complex or high-value policies
- Coverage determination guidelines — Internal rules for interpreting ambiguous coverage scenarios and escalation criteria
| Component | Name | Definition |
|---|---|---|
| Object | Policy | Maps to the policy administration system. Represents a policy with all coverage terms, limits, and exclusions |
| Object | Claim | Maps to the claims management system. Provides the claim details that need to be verified against the policy |
| Metric | Coverage Match Score | Degree to which the claim’s loss type matches the policy’s covered perils, expressed as a percentage |
| Metric | Policy Limit Utilization | Claimed amount as a percentage of the applicable policy limit |
| Dimension | Coverage Type | Groups coverage as comprehensive, collision, liability, medical payments, uninsured motorist, etc. |
| Dimension | Exclusion Category | Types of exclusions: named perils, wear and tear, intentional acts, commercial use, pre-existing conditions |
Agent setup
Create the agent
Go to Agent Space > New agent.
| Field | Value |
|---|---|
| Name | Coverage Verification Agent |
| Role | Policy coverage verification specialist |
| Goal | Confirm whether a claim is covered under the active policy terms |
Set the description
You verify insurance coverage for claims. For each claim, check five things in order: (1) the policy is active on the date of loss, (2) the loss type is a covered peril, (3) no exclusions apply, (4) the deductible amount, and (5) the applicable policy limit. Present your findings as a structured verification checklist. If any item fails, flag it clearly and cite the specific policy clause or exclusion. When coverage is ambiguous, note the ambiguity and recommend escalation to the coverage determination team rather than making a determination yourself. Never approve or deny coverage — you verify and present the facts.
Scope data access
Grant access to:
- Policy administration system data source (policy records with full terms)
- Claims management system data source (claim details)
- Policy documents knowledge space
- Coverage determination guidelines knowledge space
- Policy and Claim objects in the semantic layer
Add skills
Verify policy coverage
Verify policy coverage
Trigger: User asks to verify coverage or a new claim needs coverage check
- Pull the claim details: policy number, date of loss, loss type, loss description, and claimed amount.
- Look up the policy in the policy administration system and verify it was active on the date of loss.
- Check whether the reported loss type matches a covered peril under the policy terms.
- Review all exclusions on the policy and determine if any apply to the reported loss.
- Note the applicable deductible amount and whether the claimant has been informed.
- Compare the claimed amount against the applicable policy limit and sub-limits.
- Present a structured verification checklist: policy status, coverage match, exclusions, deductible, and limit — with a pass/fail/review-needed status for each item.
Summarize policy terms
Summarize policy terms
Trigger: User asks about a policy’s coverage or an adjuster needs a quick policy overview
- Pull the full policy record from the policy administration system.
- List all covered perils with their corresponding limits and deductibles.
- List all exclusions and endorsements that modify standard coverage.
- Note the policy effective dates and any upcoming renewal or cancellation dates.
- If policy documents are available in the knowledge space, reference specific clauses for complex terms.
- Present a concise policy summary organized by coverage section.
Automation
Playbook: Coverage check on new claim
Set the trigger
Set the playbook to trigger after the intake pipeline assigns a new claim, or when a claim’s status changes to “pending verification.”
Build the workflow
The playbook verifies coverage automatically and flags any issues before the adjuster begins processing.
- Query step — Pull the claim details from the claims management system: policy number, date of loss, loss type, and claimed amount.
- Query step — Pull the full policy record from the policy administration system, including endorsements and exclusions.
- AI step — Run the five-point coverage verification: policy active, loss covered, no exclusions, deductible noted, limit sufficient.
- Condition step — If all five checks pass, mark the claim as “coverage verified.” If any check fails or is ambiguous, flag the claim for manual coverage review.
- Action step — Post the verification results to the claim record as a structured note.
Configure delivery
For verified claims, notify the assigned adjuster that coverage is confirmed and the claim is ready for processing. For flagged claims, send a notification to the coverage determination team with the specific items that need manual review.
What’s next
Claims intake automation
Automate the end-to-end intake pipeline for new claim submissions.
All insurance use cases
See the full list.