Compliance-Aware AI Adjudication Using LLMs in Claims Engines (Delta Lake + LangChain)
DOI:
https://doi.org/10.63282/3050-9262.IJAIDSML-V5I2P105Keywords:
AI Adjudication, Claims Engine, CMS Compliance, Large Language Models, Delta Lake, LangChain, Healthcare Automation, NLP Compliance, Intelligent Processing, Dynamic Rule Interpretation, Generative AI, Medical Claims Workflow, Claims Processing Automation, Real-Time Compliance, Data Integrity, Healthcare AI, Regulatory Compliance SystemsAbstract
Together with the continually shifting regulatory environment, the growing complexity of healthcare claims processing creates an immediate demand for more sophisticated, more flexible claims adjudication solutions. Conventional rule-based engines can fail to guarantee current compliance with changing standards, notably those published by the Centers for Medicare & Medicaid Services (CMS). Using Large Language Models (LLMs), which can understand & apply CMS rules in almost actual time, our approach offers a compliance-aware adjudication framework. Our method minimizes human rule updates and more compliance issues by dynamically interpreting their regulatory changes and incorporating them into claims decision-making processes using the natural language comprehension capabilities of LLMs. Delta Lake is our basic layer for more scalable, consistent data storage and versioned data access, therefore ensuring traceability & openness at every stage of adjudication. Together with LangChain, which combines structured data operations with LLMs, this system offers a strong, verifiable, flexible adjudication engine. This case study shows how the system handled thousands of claims in a mid-sized healthcare payer environment while following the newest CMS rules with over 90% accuracy in automated more compliance evaluations. This reduced administrative load and error rates as well as gave regulatory teams an understanding of how decisions were derived. This paper shows how generative AI combined with modern data infrastructure may change claims adjudication, improve its responsiveness, more compliance, and also more efficiency in the fast changing regulatory environment
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