Score a new claim for severity and complexity, assemble the coverage position and the evidence behind it, and place it with an adjuster licensed and authorised for that claim — who decides.
Take the claim as first notified — policy, loss date, cause, parties, reported injuries and whatever came with it.
02
Read the policy as it stood on the loss date, endorsements included, and note what the notice left out.
Reason
03
Score severity and complexity from the loss facts, the exposure and what the file does not yet hold.
04
Assemble the coverage position — the grants, conditions, exclusions and endorsements that bear on this loss.
05
Flag the injury, representation, subrogation and reserve indicators that change how a claim should be handled.
Decide
06
Propose a segment and a track, and name the adjuster skill, licence and authority the claim needs.
07
Send anything the score cannot separate, or the file cannot support, to a claims lead to place by hand.
Out
08
Hand the adjuster the coverage position, the evidence cited, the open questions and the reserve indicators.
09
Retain the policy version read, the signals scored, the segment, the desk it reached and every re-route.
→Product statement
The agent scores, assembles and places. Coverage, quantum, the reserve and anything adverse to the claimant belong to a licensed adjuster with authority for that claim — on every tier and in every configuration.
Example workflow
One claim, end to end
AgentHuman
1Claim notifiedA newly opened claim from FNOL, broker, portal or phone, carrying whatever the notice actually held
2Policy read at the loss dateCover, endorsements, limits, sub-limits and excess as they stood when the loss happened, and whether it was in force
3Severity and complexity scoredLoss facts, exposure, injury and representation indicators, and everything the file is still missing
4Coverage position assembledThe grants, conditions and exclusions that bear on this loss, each cited to the wording it came from
No human action required
Stages 1 to 4 run without a person in the loop — the policy read, the scoring and the coverage position are finished before an adjuster opens the file. Nothing has been decided.
5DecisionSplits on whether the score and the file support a track
Score and file agree
Goes to the matched adjuster, undecided.
Score unclear, or the notice too thin
Goes to a claims lead to place by hand.
Licensed adjuster or claims lead
Reads the claim itself, sets the track and the reserve, and decides coverage. Anything adverse to the claimant is theirs alone.
Accept · Re-route · Investigate
Placed — handed back▼
6Adjuster assigned, file handed overTo a skill, licence and authority level that matches the segment, inside the clock that started at notice
7Outcome evaluatedSegment agreement, severity calibration, coverage-issue recall, re-routes and time to the right adjuster, by channel and cohort
Re-routes
Every claim a person moves to another track or desk is counted.
What should not run autonomously
Human approval stays in control
Outside the boundary — human approval required8 items
Deciding coverage, in whole or in part.
Applying an exclusion, condition or policy defence.
Setting, raising or releasing a case reserve.
Denying, closing or withdrawing from a claim.
Automation boundaryAgent acts unaided
✓Read the policy as it stood on the loss date.
✓Score severity and complexity, and show what the score rests on.
✓Assemble the coverage position and cite each term to its wording.
✓Name what the file is missing before an adjuster opens it.
Write actions run only inside the approval boundaries agreed during implementation. The agent scores a claim and places it; a licensed adjuster with authority for that claim decides coverage, quantum and reserve.
Calling a claim suspicious, or referring it to SIU.
Placing a claim beyond an adjuster's licence or authority.
Telling a claimant anything about cover, liability or value.
Changing the segments, the score or the routing rules.
Example output
One new claim, annotated
Everything the agent scores is attached to the notice line or the policy term it came from.
Triage output · single claimIllustrative example
Loss notified
Policy at loss date
Channel
Segment
Confidence
Coverage call
Rear-end collision
In force, endorsed
Broker, partial
Injury track, complex
88%
None — adjuster's
As receivedThe notice as it arrived and the policy as it stood on the loss date, endorsements and excess included.
Signals scoredInjury named at noticeMid-term endorsementThird party represented
Why this segmentInjury named at notice and a represented third party outrank the damage figure entirely.
ActionAcceptRe-routeInvestigate
What the score decidesWhich adjuster opens it, not what they decide. The coverage issues reach them open.
Value
Where AI adds value
The same four claims, placed at the point in the workflow where each one applies.
Where the value landsValue 01 – 04
Every new claimFrom FNOL and every channel
03Policy & segment
Score against the policy that was in force
Cover, endorsements, limits and excess as they stood on the loss date — read at triage time and stamped with the version, so the segment rests on the contract rather than on the notice alone.
01Approved path
Assemble the file before assignment
The policy read, the coverage position and the cited evidence are ready ahead of assignment, so the first hour of the claim is not spent finding out what is in it.
02Human review
Name the claim that cannot be placed
A claim the score cannot separate, or a notice too thin to place, reaches a claims lead instead of a track — and the clock keeps running, because triage does not pause the statutory timeframes.
04Build an evidence trail
Retain the policy version read, the signals the score used, the segment proposed, the desk it reached and every re-route a person made — on both paths.
Integrations
Typical integrations
Five system groups connect to the same agent. Which of them are in scope is decided in discovery.
Claims & policy adminGuidewire · Duck Creek · Sapiens Majesco · Claim and policy APIs
FNOL & evidence capturePhone and web FNOL · broker notice Photos, estimates and reports
Adjuster workforceSkill and licence registers · capacity Authority levels · work queues
Agent
Claims triage & adjudication support
Scores severity Assembles coverage Places the claim
The under-scoring clusters where the notice is thinnest
A score built on claim history, channel and geography decides who reaches an experienced adjuster within the hour and who waits a week. The mis-scoring sits in a few channels. Nestack reports performance by slice, not only in total.
Slice performance — reported separately, not only in aggregateIllustrative example
Slice
Failure rate
Lift
Lift vs. threshold
Status
Sparse first-notice files
6.1%
3.4×
Review
Phone-notified claims
4.7%
2.6×
Review
Injury reported at notice
3.2%
1.8×
Watch
Repeat routine motor claims
1.4%
0.8×
Normal
Bar: mis-scoring lift vs. routine motor baseline · scale 0–4.0× · tick marks the 2.0× review threshold2 of 4 slices over threshold
Evidence-linked improvement
Adjusters correct the score by moving the claim
When an adjuster moves a claim to another track, the score was wrong that morning. That belongs in the evaluation, not a handling note nobody reads.
Improvement cycle · five stagesSwitchback — the path turns at Improve and returns at Learn
01Detect
Segment agreement, coverage recall or re-route rate moves in one slice.
02Diagnose
Traced to the notice, the policy read, the scoring or a routing rule.
03Improve
The signal, threshold or routing rule is changed, re-signed by the claims officer and version-linked.
04Verify
Re-run against held-out claims, including every one an adjuster re-routed.
05Learn
The re-routed claim becomes a regression case with the missed signal marked.
Learn → DetectThe return edge. Every cycle also re-reads the segment mix by channel and cohort — a track that quietly stopped admitting one of them goes back to the claims officer who signed it.
Typical build scope
Twelve workstreams across six weeks
The build scope read against the delivery timeline. Week structure follows the six-week plan — discovery, policy reads and notice extraction, scoring and coverage assembly, evaluation, adjuster matching, then production validation and handover.
WorkstreamWeek 1Week 2Week 3Week 4Week 5Week 6
01Workflow discovery and automation-boundary definition.
02Segment, track and severity-band sign-off.
03Claims and policy-admin API assessment.
04Policy-at-loss-date and endorsement reads.
05First-notice extraction and missing-data detection.
06Severity and complexity scoring.
07Coverage-position assembly and citation.
08Reserve, injury and litigation indicator flags.
09Adjuster skill, licence and authority matching.
10Segment-agreement and disparity evaluation.
11Claims-system handover and re-route capture.
12Deployment, documentation and Agent Care handover.
12 workstreams · 6 weeks · bar shows the weeks a workstream is active — several run in parallelFinal scope and sequence confirmed in discovery
Engagement tiers
What each tier includes
Rows are the capabilities named in each tier's scope. Higher tiers include everything below them.
Capability✓ in scope · — not at this tierPilotOne line, shadow scoringProductionOne line, live routingAdvancedMulti-line / multi-entity
Introduced at Pilot
Severity and complexity scoring✓✓✓
Policy-at-loss-date reads✓✓✓
Coverage-position assembly✓✓✓
Shadow mode — scores, routes nothing✓✓✓
Baseline evaluation✓✓✓
Introduced at Production
Segment and track assignment—✓✓
Adjuster skill and licence matching—✓✓
Missing-evidence and reserve flags—✓✓
Disparity slicing by channel and cohort—✓✓
Introduced at Advanced
Litigation and referral-queue routing——✓
Multi-line and enterprise controls——✓
Build priceFrom $5,000From $8,000Custom quote
Final build priceConfirmed after discovery based on the lines and claim types in scope, the claims and workforce systems involved, notification channels, claim volume, the segments and authority rules agreed, and deployment requirements.
Separate from buildBuild pricing is separate from recurring Agent Care, which covers managed monitoring, evaluations, incidents and verified improvements after launch.
What we need from you
What you bring, and what we build with it
Each input maps to a piece of build scope and a week in the delivery timeline.
You bringWe build with it
01The lines, claim types and tracks you already run→Workflow discovery and automation-boundary definitionWeek 1
02How you segment claims today, and who set the bands→Segment, track and severity-band sign-offWeek 1
03Access to claims and policy admin, endorsements included→Policy-at-loss-date reads and coverage-position assemblyWeek 2
04Real first notices, including the thin ones→First-notice extraction and missing-data detectionWeek 3
05Your adjuster skills, licences and authority levels→Adjuster skill, licence and authority matchingWeek 4
06Claims an experienced adjuster re-segmented, and why→Evaluation suite, regression cases and failure-mode testingWeek 4
07Your written policy on who may decide coverage→Routing rules, the adjuster gate and the audit trailWeeks 5–6
Nothing else is requiredDeployment, documentation and Agent Care handover are ours.
Delivery timeline
Four phases across six weeks
Phases are drawn over the weeks they actually occupy. Nothing is routed live before week 6, and the scoring runs beside your existing triage until it is.
PhaseW1W2W3W4W5W6
DiscoveryW1
BuildW2 – W3
EvaluateW4 – W5
Pilot & LaunchW5 – W6
Week focusW1Lines, tracks, segments and who may decide coverageW2Policy-at-loss-date reads and endorsement handlingW3First-notice extraction, scoring and coverage assemblyW4Adjuster matching, evaluation suite and disparity slicesW5Scoring beside your own triage, and agreement measuredW6First live placements, re-route capture, then handover
Reading the bandBars span only the weeks their work is named in. The shadow run in week 5 is real — the agent scores and places nothing.
At the end of W6Claims have been placed live from agent scores, and every coverage decision in that period was a licensed adjuster's.
DurationSix-week plan shown · typical delivery 4–6 weeks depending on scope confirmed in discovery.
Next step · Insurance AI agent
Agree the segments before you let a model assign them.
Show us how a claim reaches an adjuster today, the tracks you run and the licence and authority behind each desk. We'll score a week of your real notices beside your own triage and show you every claim where the two disagree.
