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91 lines
3.1 KiB
91 lines
3.1 KiB
from swarms import Agent
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from swarms.structs.multi_agent_debates import PeerReviewProcess
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# Initialize the insurance claim reviewers and author
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claims_adjuster = Agent(
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agent_name="Claims-Adjuster",
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agent_description="Senior claims adjuster with expertise in complex medical claims",
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system_prompt="""You are a senior claims adjuster specializing in:
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- Complex medical claims evaluation
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- Policy coverage analysis
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- Claims documentation review
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- Fraud detection
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- Regulatory compliance
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Review claims thoroughly and provide detailed assessments based on policy terms and medical necessity.""",
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model_name="claude-3-sonnet-20240229",
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)
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medical_director = Agent(
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agent_name="Medical-Director",
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agent_description="Insurance medical director for clinical review",
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system_prompt="""You are an insurance medical director expert in:
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- Clinical necessity evaluation
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- Treatment protocol assessment
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- Medical cost analysis
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- Quality of care review
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Evaluate medical aspects of claims and ensure appropriate healthcare delivery.""",
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model_name="claude-3-sonnet-20240229",
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)
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legal_specialist = Agent(
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agent_name="Legal-Specialist",
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agent_description="Insurance legal specialist for compliance review",
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system_prompt="""You are an insurance legal specialist focusing on:
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- Regulatory compliance
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- Policy interpretation
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- Legal risk assessment
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- Documentation requirements
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Review claims for legal compliance and policy adherence.""",
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model_name="claude-3-sonnet-20240229",
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)
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claims_processor = Agent(
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agent_name="Claims-Processor",
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agent_description="Claims processor who submitted the initial claim",
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system_prompt="""You are a claims processor responsible for:
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- Initial claim submission
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- Documentation gathering
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- Policy verification
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- Benefit calculation
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Present claims clearly and respond to reviewer feedback.""",
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model_name="claude-3-sonnet-20240229",
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)
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# Initialize the peer review process
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review_process = PeerReviewProcess(
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reviewers=[claims_adjuster, medical_director, legal_specialist],
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author=claims_processor,
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review_rounds=2,
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output_type="str-all-except-first",
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)
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# Complex claim case for review
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claim_case = """
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High-Value Claim Review Required:
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Patient underwent emergency TAVR (Transcatheter Aortic Valve Replacement) at out-of-network facility
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while traveling. Claim value: $285,000
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Key Elements for Review:
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1. Emergency nature verification
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2. Out-of-network coverage applicability
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3. Procedure medical necessity
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4. Pricing comparison with in-network facilities
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5. Patient's policy coverage limits
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6. Network adequacy requirements
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7. State regulatory compliance
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Additional Context:
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- Patient has comprehensive coverage with out-of-network benefits
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- Procedure was performed without prior authorization
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- Local in-network facilities were 200+ miles away
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- Patient was stabilized but required urgent intervention within 24 hours
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"""
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# Execute the review process
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review_output = review_process.run(claim_case)
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print(review_output)
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