Long-horizon AI agents for medical stop-loss underwriting and claims.
Stop-loss cases cross broker, TPA, PBM, clinical, actuarial, contract, and payment systems. The Stop Loss Underwriting AI Agent carries each submission from intake and missing-data chase through claimant risk, pricing, and a written recommendation. The Stop Loss Claims AI Agent works each reimbursement request from TPA intake through contract interpretation, claim reconstruction, integrity checks, calculation, and resolution — evidence-linked, governed, and ready for the right human approval.
One long-horizon agent per stop loss function.
Each agent below owns every step of its function and runs uninterrupted for hours or days — inside your existing systems, until the work is finished and staged for human approval.
Stop Loss Underwriting AI Agent
One agent builds the canonical case from broker, TPA, pharmacy, census, plan, and loss-experience files. It chases gaps, identifies material and emerging claimants, estimates prospective cost, feeds the carrier's actuarial engine, checks terms against portfolio and authority rules, and produces an evidence-linked recommendation for approval — then supports negotiation and bind preparation.
Stop Loss Claims AI Agent
One agent examines each reimbursement request end to end. It ingests the submission from any TPA channel, interprets the stop-loss contract and plan document, verifies eligibility and contract basis, reconstructs the claim from source data, runs payment-integrity and coordination-of-benefits checks, calculates reimbursement with cited rationale, drafts correspondence, and routes the decision to the correct authority while continuing to chase missing evidence.
Workflows in stop loss.
Every step below belongs to one agent's single continuous run — one long-horizon agent per function, working uninterrupted until the work is finished.
Stop Loss Underwriting AI Agent workflows.
The underwriting agent turns fragmented group submissions into evidence-linked, decision-ready cases — every step below in one continuous run inside the carrier's existing underwriting and actuarial systems.
- 01Broker, TPA, PBM, census & plan-file intake
- 02Submission completeness review & autonomous data chase
- 03Census, enrollment & loss-experience normalization
- 04Material and emerging claimant identification
- 05Clinical and specialty-drug risk reconstruction
- 06Prospective claimant cost estimation
- 07Carrier actuarial engine inputs & pricing reconciliation
- 08Specific deductible, laser & contract-term evaluation
- 09Portfolio guideline and authority checks
- 10Written recommendation, negotiation & bind preparation
Stop Loss Claims AI Agent workflows.
The claims agent reconstructs, validates, and resolves stop-loss reimbursement requests with source-linked calculations and governed decision routing — one agent from intake through execution.
- 01TPA intake across email, portal, EDI & API
- 02Document classification, indexing & version control
- 03Stop-loss contract, plan document & endorsement interpretation
- 04Covered-person eligibility & contract-basis verification
- 05Claim-line reconstruction from TPA and source data
- 06Payment integrity, duplicate, COB & MSP checks
- 07Specific deductible and eligible reimbursement calculation
- 08Evidence-linked rationale, letters & decision package
- 09Authority-based approval and exception routing
- 10Missing-information chase, payment & settlement follow-through
How Layerup deploys here.
Operational details that matter when deploying long-horizon AI agents inside stop loss operations.
- 01Supports specific and aggregate medical stop-loss across new-business and renewal underwriting and reimbursement claims.
- 02Connects broker, TPA, PBM, clinical, actuarial, claims, policy, document, and finance systems without replacing the systems of record.
- 03Every material fact, calculation, contract interpretation, and recommendation links back to source evidence for review and audit.
- 04Approval and straight-through thresholds are configured to the carrier's authority matrix; exceptions route to the appropriate underwriter, examiner, medical director, or executive.
Explore other lines of business.
Layerup runs critical workflows across the insurance and financial services lines below.
Deploy long-horizon AI agents in your stop loss operation.
Start with one function's agent. Prove the operational lift. Then expand by line of business or by department.