Claims lifecycle · Stage 02 of 08 · Triage & assignment
AI claims triage software that scores severity, litigation and fraud together
Clean claims go straight through. Everything else reaches the right adjuster with the reasons attached.
In short
Hesper AI is an AI claims resolution platform for P&C carriers, TPAs, and MGAs. At triage, its agents read the whole first notice and every attachment, score severity, litigation, and fraud risk together with the evidence behind each score, route clean claims straight through, and assign the rest to the right adjuster by license, skill, and workload. Supervisors can override any routing.
Why do single-score triage models misroute claims?
Many claims operations run triage as separate systems: a severity model, a fraud score from another vendor, and a litigation flag that only fires once an attorney letter is coded. Each reads a handful of structured fields. A claim can look low-severity on paper while the notes mention an attorney, or look routine while the photos contradict the description.
When those signals live in different places, claims land on the wrong desk and get re-assigned later, and the most expensive claims are the ones that sit longest before an experienced adjuster sees them. Litigation is where misrouting costs most: the Insurance Research Council found litigation rates among auto injury claimants nearly doubled from 2017 to 2022, and represented claimants waited a median of nearly 440 days for closure.
What does Hesper score at triage?
- Severity: injuries, damage extent, coverage limits, and the facts in reports and photos, not just the loss code.
- Litigation risk: attorney representation, demand language, and other signals in correspondence and notes.
- Fraud risk: built-in fraud detection that checks for red flags and inconsistencies across the file. Suspicious claims go to an investigation-grade workup instead of a queue.
Each score comes with the reasons behind it, pointing to the document, photo, or note that drove it, so an adjuster can see why a claim was routed the way it was.
How do routing and assignment work?
Claims that meet your straight-through criteria resolve without a human touch, inside the authority limits you set. The rest are assigned by the rules that matter in practice: the adjuster's license for the loss state, their skill with the line and complexity, and their current workload.
You set the thresholds. Hesper applies them the same way on every claim, and supervisors can move any claim at any time.
How does triage connect to the rest of the claim?
Triage starts from the file built at first notice of loss. The same evidence carries forward: a fraud signal at triage becomes the starting point for investigation, and a liable third party noticed at triage is already on the list for subrogation and recovery.
Hesper connects to Guidewire, Duck Creek, Majesco, and other claims systems through its API. For the method behind triage models, see our claims triage automation guide, or all eight stages on the claims lifecycle overview.
What does Hesper do, and what does your team decide?
| Hesper's agents | Your team |
|---|---|
| Scores severity, litigation, and fraud risk with reasons | Sets the thresholds and straight-through criteria |
| Routes clean claims straight through within your authority limits | Owns authority limits and exceptions |
| Assigns by license, skill, and workload | Overrides any assignment |
| Sends suspicious claims to an investigation-grade workup | Decides on referral, denial, or payment |
What does the output look like?
- Loss
- Rear-end collision, claimant reports neck and back pain, ER visit
- Severity
- Moderate: soft-tissue injury with ongoing treatment noted
- Litigation risk
- Elevated: letter of representation received after first notice
- Fraud risk
- Low: statements, photos, and police report are consistent
- Routing
- Bodily injury desk; adjuster licensed in the loss state with capacity
Evidence cited
- Attorney letter in correspondence, not yet coded in the claim system
- Police report confirms the other driver's account
- Treatment records reference physical therapy referral
Recommended next action: Assign to an experienced BI adjuster, request medical authorizations, and diary the demand watch.
Frequently asked questions
What is AI claims triage?
AI claims triage reads a new claim and decides how it should be handled: how severe it is, whether it is likely to involve an attorney, whether anything looks suspicious, and who should work it. Hesper reads the full first notice and attachments rather than a few coded fields, and explains every score.
How is this different from a claim severity model?
A severity model predicts cost from structured data. Hesper scores severity, litigation, and fraud risk together from the whole file, including notes, photos, and correspondence, and then acts on the result by routing and assigning the claim.
Can we set our own straight-through rules?
Yes. You define which claims can resolve straight through and the authority limits that apply. Hesper applies your criteria consistently and records why each claim qualified or did not.
Does triage work for TPAs managing many client programs?
Yes. Assignment rules can reflect each client program's requirements, and every routing decision carries its reasons, which helps with client audits and SLA reporting.
How does Hesper integrate with Guidewire or Duck Creek?
Through an API connection to your claims system of record. Hesper can take a claim at first notice or pick one up mid-stream through that connection. No rip-and-replace.
Other stages of the claim
Book a demo of Hesper's triage agents
A 30-minute walkthrough on your claim types: how a new claim gets scored, explained, and assigned.
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