From documents to decision, in under a minute.
Not a dashboard for adjusters — the adjuster itself. A configurable agent fleet takes a claim from raw documents to a fully adjudicated decision: extract, classify, assess medical necessity, screen for fraud, and decide. Every decision cites the policy, with a full audit trail.
CLM-2026-04891
Outpatient — Dental Filling
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Agent pipeline
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Languages
Inside the pipeline
One claim. Five agents. Every step accountable.
Each stage is a specialized agent with a single job — and each hands off a decision you can trace back to its evidence.
Document Extraction
OCR + NLP reads invoices, receipts, and reports in Thai, Vietnamese, Traditional Chinese, and English — with sub-field bounding boxes.
Classification
Auto-classifies each claim: inpatient, outpatient, dental, maternity, accident — and routes it accordingly.
Medical Necessity
Validates diagnosis and treatment against clinical pathways and 60,000+ medical reference records.
Benefit Assessment
Calculates the payable amount at policy level — sublimits, deductibles, co-pays, and coverage rules.
FWA Screening
Six-factor fraud, waste & abuse screening runs in parallel — every flag backed by evidence.
Adjudication
Auto-approves, flags, or escalates — with policy citations and a complete audit trail on every decision.
Cashless Claims
The guarantee-letter lifecycle, automated end to end.
For cashless (guarantee-of-payment) hospitalization, Papaya runs the whole letter workflow — from the initial guarantee on admission to the final letter at discharge — raising medical queries and deferment letters automatically when information is missing. Top-up guarantees and denial letters too.
Initial Guarantee Letter
On admission, Papaya reads the request, checks eligibility and benefits, estimates the guaranteed amount, and auto-issues the IGL to the hospital in minutes.
Medical Queries
When documentation or medical necessity is incomplete, it drafts a precise medical query back to the provider — asking only for what's actually missing.
Deferment Letters
If a decision must wait on information, a deferment letter is generated and tracked automatically — with the clock and follow-ups managed for you.
Final Guarantee Letter
At discharge, the final bill is assessed against the IGL and policy, and the FGL is auto-generated with the final approved amount and citations.
Why it holds up
Fast is easy. Fast and defensible is the hard part.
Automation only counts if you can stand behind every decision. Papaya cites the policy language it applied, shows the evidence it used, and escalates the genuine judgment calls to a human — so speed never costs you accountability.
Put your claims on autopilot.
See the full pipeline run on your own claim types — end to end, in under a minute.