ClaimWise AI

ClaimWise AI is an AI-powered insurance claims investigation solution using UiPath Maestro Case, machine learning, and explainable AI to support faster, human-reviewed claim decisions.

Comment

ClaimWise AI

Inspiration

Insurance claims processing is often time-consuming, costly, and susceptible to fraud. Claims professionals must balance rapid customer service with thorough investigations, while increasing claim volumes continue to add operational pressure.

We wanted to demonstrate how AI and enterprise orchestration can work together to streamline this process without removing human oversight. ClaimWise AI was inspired by the opportunity to build an intelligent, explainable, and trustworthy claims investigation solution using the UiPath Platform.

What it does

ClaimWise AI is an AI-powered insurance claims investigation and case management solution that combines UiPath Maestro Case, API Workflows, and machine learning to assist insurers throughout the claims lifecycle.

Each claim progresses through four stages:

  1. Intake – Collects claim information.
  2. Investigation – Invokes an AI service to classify the claim, assess fraud risk, and generate explainable recommendations.
  3. Human Review – Presents AI findings to an insurance adjuster for review and decision-making.
  4. Settlement – Finalizes the claim after human approval.

The AI supports adjusters by:

  • Classifying claim types using NLP.
  • Predicting fraud risk using machine learning.
  • Identifying the key factors influencing each prediction.
  • Providing explainable recommendations that improve transparency and consistency.

Rather than replacing human expertise, ClaimWise AI augments decision-making by enabling faster investigations while ensuring settlement decisions remain under human control.

How we built it

The solution combines enterprise automation with machine learning to deliver an end-to-end intelligent claims investigation workflow.

UiPath Components

  • UiPath Maestro Case
  • UiPath API Workflows
  • UiPath Automation Cloud

AI & Backend

  • Python
  • FastAPI
  • Scikit-learn
  • XGBoost
  • SHAP

The AI service uses:

  • TF-IDF + Logistic Regression for claim type classification.
  • XGBoost for fraud risk prediction.
  • SHAP for explainable AI.
  • Insurance-specific feature engineering to improve prediction quality.

The models are deployed as a FastAPI service on Hugging Face Spaces. UiPath API Workflows securely invoke the AI service, while Maestro Case orchestrates the complete business process from intake through settlement.

Challenges we ran into

Building an enterprise-ready solution required integrating multiple technologies into a unified workflow while maintaining reliability and transparency.

Key challenges included:

  • Designing a realistic insurance case lifecycle using UiPath Maestro Case.
  • Integrating an external FastAPI service through UiPath API Workflows.
  • Mapping structured workflow inputs and outputs between UiPath and the AI service.
  • Deploying and managing machine learning models for production inference.
  • Ensuring AI recommendations remained explainable and suitable for human decision support.

Accomplishments that we're proud of

  • Built an end-to-end AI-powered insurance claims investigation workflow.
  • Successfully integrated UiPath Maestro Case with an externally deployed FastAPI AI service.
  • Developed machine learning models for claim classification and fraud risk prediction.
  • Added explainable AI using SHAP to improve transparency and trust.
  • Implemented a human-in-the-loop workflow that balances automation with governance.
  • Delivered a working prototype running on UiPath Automation Cloud.

What we learned

This project reinforced that successful enterprise AI requires more than accurate models—it also requires orchestration, governance, explainability, and human oversight.

Throughout development, we gained practical experience in:

  • Enterprise workflow orchestration using UiPath Maestro Case.
  • Integrating external AI services through API Workflows.
  • Deploying production-ready FastAPI applications.
  • Designing explainable machine learning systems.
  • Building scalable architectures that combine automation and artificial intelligence.

What's next for ClaimWise AI

Future enhancements will further strengthen ClaimWise AI as an enterprise-ready insurance claims investigation platform. Planned capabilities include:

  • Intelligent document processing using OCR and AI.
  • Automated verification of supporting claim documents.
  • Integration with policy administration, CRM, and core insurance systems.
  • Continuous model improvement using adjuster feedback.
  • Real-time fraud monitoring and analytics dashboards.
  • Multimodal AI for analyzing claim documents and supporting images.
  • Enhanced workflow automation and enterprise governance features.

While ClaimWise AI is purpose-built for insurance claims, its modular architecture can also be adapted to other case-driven industries that require structured investigations, document review, and human-in-the-loop decision-making.

What's next for ClaimWise AI

The architecture behind ClaimWise AI is designed to be modular and extensible. While this prototype focuses on insurance claims, the same AI-driven case management approach can be adapted to a wide range of industries that rely on structured investigations, document review, and human decision-making.

Potential applications include:

  • Banking & Financial Services – Loan applications, fraud investigations, and dispute resolution.
  • Healthcare – Patient referrals, prior authorization, and clinical case management.
  • Government & Public Sector – Citizen service requests, benefit eligibility reviews, and permit processing.
  • Legal Services – Case intake, document analysis, and litigation support.
  • Human Resources – Employee onboarding, compliance investigations, and workplace case management.
  • Supply Chain & Logistics – Shipment claims, exception handling, and vendor dispute resolution.

Our long-term vision is to evolve ClaimWise AI into a production-ready enterprise platform that helps insurers investigate claims faster, reduce fraud, improve operational efficiency, and deliver transparent, explainable, and human-centered decision support at scale, while providing a flexible foundation that can be extended to other enterprise case management scenarios.

Built With

Share this project:

Updates