Autonomous AI Agents for Every Step of the Claims Process
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Claim Resolution
Team Capacity
OpEx Savings
Autonomous AI Agents for Every Step of the Claims Process
Claim Resolution
Team Capacity
OpEx Savings
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What is Agentic Claims Automation?
Agentic claims automation uses AI agents to process insurance claims autonomously from FNOL to settlement while keeping you in control.
Traditional automation relied on point solutions that digitized fragments of the process. These tools always required manual review and never delivered true end-to-end automation.
Your team handled most complexity, exceptions, and judgment themselves, acting as the glue between disconnected systems. Claims moved through multiple hands (often repeatedly) because automation couldn’t run processes end-to-end autonomously.
Otera replaces that patchwork with Agentic operations that run on autopilot.
AI agents understand policy data, extract and validate documentation, detect exceptions, and trigger payments under built-in governance and full audit oversight. Claims can be managed end-to-end without human touch, with clear visibility and safe control at every step.
The Autonomy Advantage
Otera enables enterprises to finally shift from Human-first to Agentic-first operations for all the highly regulated, exception-heavy claims processes you can’t afford to get wrong.
Point Automation (<10% End-to-End Automation Rate)
- Multi-week turnaround during peak periods
- Backlogs piling up, poor CSAT
- Team size becomes a bottleneck
- No end-to-end oversight or control
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Agentic Automation with Otera (>90% End-to-End Automation Rate)
- <90s settlement
- No backlog, industry-leading CSAT
- +10x operational capacity
- Full end-to-end oversight
AUTONOMOUS AI AGENTS
Meet Otera’s Autonomous Decision Agents for Claims Automation
Otera’s AI agents are purpose-built to run insurance operations on autopilot while keeping you fully in control with compliance and explainability at their core:
What it does
This agent extracts and understands every claim input instantly across 100+ languages, including skewed images, low-quality scans, rotated pages, emails, and handwritten notes. It transforms messy, multi-source content into clean, standardized, machine-ready data to trigger downstream actions automatically.
How it works
- Uses proprietary multi-step vision and data representation methods to read structured and unstructured content
- Unifies all your data input across PDFs, forms, emails, attachments, and images
- Maps extracted fields to policy and customer records for contextual accuracy
- Produces standardized data objects ready for routing and reporting
Why it matters
Claims rarely begin with clean, structured input. This agent eliminates manual review of messy documents so that every claim enters the process with automation-ready data, pulled from any source simultaneously.
What it does
This agent instantly classifies and routes claims with autonomous awareness of urgency, customer wait time, sentiment, region, policy type, ongoing catastrophic events, and more.
How it works
- Detects type, severity, channel, policy attributes, sentiment, and other critical data points.
- Can prioritize re-submitted claims from waiting customers based on business rules.
- Can elevate cases linked to catastrophic events or emerging risk clusters, so that they get human-first handling
- Directs predictable cases into autonomous flows and escalates nuanced cases with precision
Why it matters
Intake is where cluttered backlogs are born. This agent replaces slow sorting queues with instant, context-aware routing that eliminates bottlenecks at any volume.
What it does
This agent converts policy wording, contracts and agreements into deterministic, self-enforcing rules. Then, it validates coverage instantly across all terms, limits, exclusions, endorsements, and conditional requirements, even for complex or multi-document policies.
How it works
- Converts policy documentation into rules and structures that can be incorporated into every workflow
- Detects mismatches, missing documentation, eligibility conflicts, and special clauses
- Evaluates nuanced conditions such as illness-linked travel disruptions and required proofs
- Resolves coverage questions instantly before adjudication begins
Why it matters
Manual coverage validation is the number one enemy of claims velocity. Shifting this step entirely to machines creates a leap to instant, superhuman-quality decisions that eliminate any possible leakage from interpretation errors.
What it does
This agent evaluates claim details and rules to determine the correct outcome autonomously. Then, it produces a fully traceable, audit-ready decision path for every case.
How it works
- Compares claimed amounts to policy thresholds and historical patterns
- Detects documentation gaps and inconsistencies to flag anomalous claims
- Calculates payable amounts using deterministic logic
- Produces line-by-line, explainable reasoning
Why it matters
Adjudication is rule-heavy and inconsistent across adjusters. With this agent, every claim outcome is instant and precise.
What it does
This agent operates continuously in the background to surface anomalies and behavioral irregularities, even before human reviewers detect them.
How it works
- Flags duplicate submissions, emerging fraud clusters, suspicious suppliers
- Correlates signals across policies and historical activity
- Highlights the risk indicators that matter, with no false positives
Why it matters
Fraud detection can’t become autonomous at the expense of losing precision. This agent complements your existing fraud solution, using ground-truth data and plain-language instructions to spot patterns, so fraud cases surface instantly, while legitimate claims flow through without friction.
What it does
Research shows that humans often make different decisions on identical cases, even when nothing has changed. This agent makes all settlement decisions and executes all communication with customers and brokers autonomously and consistently.
How it works
- Drafts customer updates and settlement letters
- Initiates payment workflows with audit-ready logs
- Syncs across CRMs and finance/claims systems
- Maintains real-time timelines and SLAs
Why it matters
Settlement is the most important moment in insurance, and it can make a massive difference in customer sentiment. This agent ensures every customer receives clear, consistent, empathetic communication that’s backed by perfectly executed settlement actions.
Adaptable Across All Claim Types
Otera's agentic framework is designed for versatility, handling the unique complexities of any claims vertical with precision and speed.
Commercial Claims
Coordinate multi-party submissions and coverage decisions across complex commercial claim structures.
Employee Benefits Claims
Execute eligibility checks and benefit decisions across employer-sponsored plans, including health and mobility.
Pet Claims
Autonomously validate coverage and settle veterinary claims and payouts for exception-heavy cases.
Device Protection Claims
Handle diagnostics, coverage enforcement, replacements, and payouts for devices such as phones and laptops.
Liability Claims
Assess fault and validate/execute coverage across straightforward and disputed liability cases.
Auto Claims
Support damage, liability, and multi-party scenarios with consistent assessments and governed settlements.
Life Claims
Ensure accurate policy and beneficiary validation from first notification through final settlement.
Health Claims
Process medical invoices and benefit logic across standard treatments, including complex billing and rule-heavy cases.
Travel Claims
Run eligibility checks/validations, and reimbursements across diverse travel scenarios and policies.
Property Claims
From localized damage to catastrophe-driven volumes, execute property claims with stable, end-to-end control.
Home Claims
Automate document intake, evaluations, and customer communication for both routine incidents and major losses.
Velocity for your Automation team, Governance for your Claims team
For your Automation team: Build fast without bottlenecks
A unified platform to design, govern, and scale autonomous workflows with full visibility. Guardrails are defined once and applied everywhere:
With Otera
- Instant turnaround
- Handles any unstructured data
- Deploys fast across use cases
- 90%+ automation rate for E2E flows
Before Otera
- Multi-week cycles
- Data chaos, manual stitching
- Slow, brittle automations
- Human-dependent steps everywhere
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Go live in
Autonomous Ops
Cycle Time
Team Capacity
For your Claims team: Run autonomous claims with built-in governance
A faster, more consistent claims process that improves cycle times/CSAT and reduces leakage while freeing your team for complex cases.
With Otera
- One governed, auditable agentic platform
- Market-leading CSAT levels
- Integrates with existing systems
- Zero-leakage decision execution
Before Otera
- Tool sprawl, no governance
- Low customer satisfaction
- No audit-ready oversight
- High leakage
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Go live in
Autonomous Ops
Cycle Time
Team Capacity
The Autonomous movement has already begun
The world’s most regulated industries already use Otera for proven 90%+ end-to-end automation on mission-critical operations:
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100+ PREBUILT AGENTS
100+ Prebuilt Agents for Insurance
Deploy instantly across intake, validation, settlement, and customer communication workflows.
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Connect your existing infrastructure
Pioneering secure Agentic Automation
Trusted by leading Fortune 500 companies, Otera delivers best-in-class cyber security, data privacy and user trust with extensive encryption and infrastructure protection.
