Insurance Claim Fraud Detection

osop_version: "1.0"
id: "claim-fraud-flag"
name: "Insurance Claim Fraud Detection"
description: "AI pattern-matches incoming claims against known fraud indicators."

nodes:
  - id: "claims_stream"
    type: "event"
    name: "Claims Intake Stream"
    description: "New claims submitted via portal, agent, or adjuster."

  - id: "pattern_match"
    type: "agent"
    subtype: "llm"
    name: "AI Fraud Pattern Matching"
    description: "Cross-reference claim details with historical fraud patterns and red flags."
    security:
      risk_level: "medium"

  - id: "fraud_score"
    type: "system"
    name: "Fraud Probability Score"
    description: "Score 0-100 based on pattern match confidence."

  - id: "investigator_review"
    type: "human"
    subtype: "review"
    name: "Claims Investigator Review"
    description: "SIU investigator reviews flagged claim, requests documentation."
    security:
      approval_gate: true

  - id: "disposition"
    type: "system"
    name: "Claim Disposition"
    description: "Approve, deny, or escalate to law enforcement."

edges:
  - from: "claims_stream"
    to: "pattern_match"
    mode: "sequential"
  - from: "pattern_match"
    to: "fraud_score"
    mode: "sequential"
  - from: "fraud_score"
    to: "disposition"
    mode: "conditional"
    when: "fraud_score.value < 20"
    label: "Auto-approve low-risk claims"
  - from: "fraud_score"
    to: "investigator_review"
    mode: "conditional"
    when: "fraud_score.value >= 20"
  - from: "investigator_review"
    to: "disposition"
    mode: "sequential"