Claim Adjudication Report

Claim Summary

Claim ID: CLM-2025-10234

Patient: Ravi Kumar

Diagnosis: Acute Appendicitis

Procedure: Appendectomy

Claim Amount: ₹45,000

Clinical Validation

✔ Diagnosis matches procedure
✔ Treatment protocol followed
❌ Length of stay exceeds STG guideline

Document Verification

✔ Discharge Summary Valid
✔ Invoice Verified
❌ QR Code Missing

Timeline Summary

Admission → Diagnosis → Procedure → Discharge

✔ Sequence Valid

Final Decision

CONDITIONAL

Confidence: 78%

Approval Details

Approved Amount: ₹38,000

Deductions: ₹7,000

Reason: Excess hospital stay

Fraud Analysis

65% Risk

AI Explanation

Claim partially valid
Medical necessity confirmed
Overstay beyond recommended duration