Automate Document Verifications with Document AI
DocumentAI analyzes uploaded document evidence for family members to accurately verify eligibility while cutting manual workload by more than 90%.
Challenge
Government health insurance marketplaces require individuals — including federal/state employees and retirees — to verify the eligibility of family members before coverage can be added. These verification checks are essential to prevent fraud, waste, and abuse, such as adding non-eligible dependents to obtain Government sponsored / subsidized coverage.
To validate eligibility, enrollment systems must collect and review a wide variety of documents, which differ by family member type and often vary across states. Examples include:
Marriage certificates, tax returns, residency proof, bank statements, birth certificates, paternity affidavits, adoption decrees, custody orders, foster certification, medical certificates.
While portals allow individuals to upload photos or PDFs, reviewing these documents manually is slow, expensive, and error-prone. Each request may include several documents, and large marketplaces must process tens of thousands during open season or qualifying life events.
This creates:
- Large backlogs for eligibility teams
- Delays of weeks before dependents are approved
- Poor customer experience as families wait for coverage
- Operational cost pressure from growing review volumes
- Risk of inconsistent decisions during peak periods
Government programs need a modern, scalable way to verify documents quickly and accurately—without sacrificing integrity or compliance.
Solution
DocumentAI automates verification of dependent eligibility documents using advanced AI vision models and predefined rule sets tailored to each document type and family relationship.
1. Comprehensive Document Library
All accepted documents—across all family categories—are defined in the DocumentAI system, including state-specific variations. This enables the system to understand the full range of acceptable evidence.
2. Real-Time Document Recognition
As individuals upload documents, DocumentAI:
• Detects the document type
• Extracts key fields (names, dates, relationships)
• Checks authenticity markers (issuer, seals, formatting)
• Confirms whether required information is present
• Verifies that the document and request match (e.g., spouse’s name aligns across documents)
These assessments take seconds, not weeks.
3. Automated Eligibility Decisioning
DocumentAI applies configurable rules for each family type:
Example: Spouse
• Under 12 months married → marriage certificate
• Over 12 months married → marriage certificate + common residency or financial interdependency
Example: Child Under 26
One of:
• Birth certificate
• Tax return
• Consular birth report
• Paternity order
• Court or administrative order
DocumentAI checks whether the uploaded set meets the required combination. Approved documents flow through automated workflows to: approve the dependent immediately, or request additional evidence if something is missing, or route to manual review only when necessary (less than 10% of cases require manual review).
4. Integration with Enrollment & EDI Systems
Once an approval decision is made, the system can:
• Automatically generate EDI 834 transactions to carriers
• Update enrollment records
• Trigger notifications to individuals confirming approval or denial
• Track audit trails for compliance and quality assurance
This creates a seamless, end-to-end verification process.
Results
For Government Sponsors (and taxpayers)
• >90% automated document verification in real-time
• Massive reduction in manual review workload
• Shorter processing time—from weeks to seconds
• Lower operational costs
• Greater consistency and auditability of eligibility decisions
• Strengthened fraud, waste, and abuse controls
For Individuals & Families
• Immediate approvals for most dependent requests
• No waiting in backlog queues
• Transparent, modern upload experience
• Faster access to health coverage for spouses, children, and dependents
For Carriers
• Cleaner, more accurate enrollment records
• Fewer retroactive adjustments or terminations
• Improved member onboarding experience
Let us help you automate document verifications with DocumentAI.