Health Insurance Claim Document Verification and Processing

Checks diagnoses against lab, radiology and procedure records and coding and payer rules before a claim is submitted, and automates claim processing, for example for national health insurance (JKN) claims.

OCR and document LLM

0named models

477candidates

3deployments

3in Indonesia

Named Models

The research names no model for this use case.

Where this comes from

Models the research names for this use case. Research, with sources on each model record.

Who Runs It

production, 3

RSUD Haji Provinsi Jawa Timur with ITS and Universitas AirlanggaCountry: IndonesiaAI MINA: OCR, NLU and LLM checking BPJS (JKN) claim documents against ICD and BPJS rules before submission; on-premise (model not named)Vendor: ITS and Universitas AirlanggaproductionDate29 Jul 2026Launched with phased rollout; review time per document from about 20 minutes to under 2 minutes (claim)Evidence: company statementConfidence: lowSource: its.ac.id

RSCM (RSUPN Dr. Cipto Mangunkusumo)Country: IndonesiaAI-automated BPJS claim submission (product not named)Vendor: not statedproductionDate2026In use; no figures stated. Page undated (after March 2026)Evidence: company statementConfidence: lowSource: govinsider.asia

Halodoc (PT Media Dokter Investama)Country: IndonesiaGenerative AI on Amazon Bedrock for health service payment claim processing (model not named)Vendor: AWS (Amazon Bedrock)productionDate4 Mar 2025Claim time from about 3 minutes to under 1.5 minutes; productivity up over 45 percent; processing cost down over 50 percent (company claims)Evidence: company statementConfidence: lowSource: infobanknews.com

Where this comes from

Documented uses by named organisations. The evidence column says who made the claim.

Candidate Models

SEA-HELM leaderboard, 58 models, SEA average

A general benchmark for this model class, not a test on this use case. SEA average and per-language (incl. Indonesian) scores for open-weight models. Higher is better. Showing 10 of 11.

Qwen3.6-35B-A3BAlibaba (Qwen) maintainer-run73.86

Qwen3.5-35B-A3BAlibaba (Qwen) maintainer-run73.55

gemma-3-27b-itGoogle maintainer-run64.54

Gemma-SEA-LION-v4-27B-ITAI Singapore maintainer-run64.35

gpt-oss-20bOpenAI maintainer-run60.64

Llama-3.3-70B-InstructMeta maintainer-run60.44

Qwen3-8BAlibaba (Qwen) maintainer-run60.33

GLM 4.7 FlashZ.ai (Zhipu) maintainer-run53.76

Gemma-3-4B-itGoogle maintainer-run47.84

Nemotron 3 Nano 30B-A3BNVIDIA maintainer-run46.89

050100

Nemotron-SEA-LION-v4.8-120B-A12BAI Singapore, LLMReleasedSep 2026open weightsIndonesian statedhas scoreslast 18 months

Nemotron-SEA-LION-v4.8-30B-A3BAI Singapore, LLMReleasedSep 2026open weightsIndonesian statedhas scoreslast 18 months

Qwen-SEA-LION-v4.5-27B-ITAI Singapore, LLMReleasedMay 2026open weightsIndonesian statedhas scoreslast 18 months

Qwen3.6-35B-A3BAlibaba (Qwen), LLMReleasedApr 2026open weightsruns on edgehas scoreslast 18 months

Nemotron 3 SuperNVIDIA, LLMReleased2026open weightsIndonesian statedhas scoreslast 18 months

Nemotron 3.5 Lightning 30B-A3BNVIDIA, LLMReleased2026open weightsIndonesian statedhas scoreslast 18 months

gpt-oss-120bOpenAI, LLMReleasedAug 2025open weightsIndonesian statedhas scoreslast 18 months

Granite 4.2 8BIBM, LLMReleasedSep 2026open weightshas scoreslast 18 months

Hy4-previewTencent, LLMReleasedAug 2026open weightshas scoreslast 18 months

GLM-5.3Z.ai (Zhipu), LLMReleasedAug 2026open weightshas scoreslast 18 months

Showing 10 of 477. All models of this class

Where this comes from

Derived, not researched: models in the directory whose class matches a class this use case uses, excluding family records and models shut down or deprecated. Ranked by how many fit facts they meet, then by release date. Each fit fact is read from the model record.

Use Case

Industry: healthcare and pharma
Model classes: OCR and documentLLM
Benchmarks or datasets: not in the notes
Regulatory notes: Surat Edaran Menkominfo 9/2023 Etika Kecerdasan Artifisial, Kementerian Komunikasi dan Informatika (now Kementerian Komunikasi dan Digital)Health insurance claim document verification and processing is an AI-based service run by an electronic system operator, and the circular asks such operators to build and use AI on the values of inclusivity, transparency, humanity and security.
UU 27/2022 Pelindungan Data Pribadi, DPR and President of the Republic of Indonesia (administered by Kementerian Komunikasi dan Digital)Health insurance claim document verification and processing processes health and claims data of insured members, so the controller needs a lawful basis, must protect the data and must honour data subject rights.
UU 17/2023 Kesehatan, DPR and President of the Republic of Indonesia (administered by Kementerian Kesehatan)Health insurance claim document verification and processing handles health financing and claims linked to health services, which this law regulates under health funding and health information systems.

Where this comes from

From the industry tracks T08 to T10 of the research notes.

R&D Topics

Links to R&D topics are awaiting review.

Where this comes from

Which R&D topics would most change this use case. Drafted by Claude from the topic definitions and the use case; proposed until approved.

Incidents

Cigna Algorithm PXDX Allegedly Rejected Thousands of Patient Claims En Masse in Breach of California LawUnited States, 2023-07-24, financialCigna health insurer faces a class-action lawsuit for allegedly using the PXDX ("procedure-to-diagnosis") algorithm to automatically reject over 300,000 patient claims in violation of California law, prompting two members to file the lawsuit seeking damages and a jury trial.
Airbnb Host Reportedly Accused of Using Purportedly AI‑Altered Photos in False Damage ClaimUnited States, 2025-08-02, financialA London-based Airbnb guest was reportedly accused by a New York host of causing over £12,000 in damages.

Where this comes from

Documented failures, harms or misuse in this kind of use, Indonesia first, then the region, then well-known cases elsewhere (AI Incident Database, OECD AI incidents monitor, reputable news). Not a claim about any deployment listed here.

In Neighbouring Countries

Fullerton Healthmulti-country, production, 2026-01-06Hybrid OCR, logistic regression and Qwen 2.5-VL-7B vision-language model for claim document classification and field extraction; tens of thousands of claims weekly from Vietnam and Singapore

Where this comes from

Documented deployments of this use case in Malaysia, Singapore, Thailand, Vietnam and the Philippines, each with its source.

Opportunities

Opportunities are awaiting review.

Where this comes from

Gaps found by rule in what the directory holds for this use case. Each is a proposal for review.

Links

IndustryHealthcare40 use cases, 66 deployments

Use CaseHealth Insurance Claim Document Verification and ProcessingHealthcare

Modelsnone recorded

Who Runs ItRSUD Haji Provinsi Jawa Timur with ITS and Universitas AirlanggaIn production, 29 Jul 2026

RSCM (RSUPN Dr. Cipto Mangunkusumo)In production, 2026 Halodoc (PT Media Dokter Investama)In production, 4 Mar 2025

Graph

Deployments 3

Halodoc (PT Media Dokter Investama)Generative AI on Amazon Bedrock for health service payment claim processing (model not named), Indonesia RSCM (RSUPN Dr. Cipto Mangunkusumo)AI-automated BPJS claim submission (product not named), Indonesia RSUD Haji Provinsi Jawa Timur with ITS and Universitas AirlanggaAI MINA: OCR, NLU and LLM checking BPJS (JKN) claim documents against ICD and BPJS rules before submission; on-premise (model not named), Indonesia

Sources

its.ac.id/?p=66933 https://www.its.ac.id/?p=66933
govinsider.asia/indo-id/article/rscm-di-garis-depan-transform... https://govinsider.asia/indo-id/article/rscm-di-garis-depan-transformasi-layanan-kesehatan
infobanknews.com/simak-ini-hasil-nyata-penerapan-ai-di-bisnis-... https://infobanknews.com/simak-ini-hasil-nyata-penerapan-ai-di-bisnis-halodoc/

To cite this page: Project AURION, AI Use-Cases Research & Innovation, "Health Insurance Claim Document Verification and Processing", https://aurion.semai.id/usecases/hc-claim-document-verification/, records of October 2026.