Use casesFinancial institutions & fintech

  • Insurance

Private health insurance provision review

A contracted hospital asks for a provision while the patient waits, and the answer depends on the epicrisis, the policy's terms, and what was declared at underwriting.

With the systemEach request read, the policy, declarations, and history gathered, limits checked; the provision team decides.

Who decides
Provision officer

Contracted hospital · provision request · 4 November 2026

Epicrisis · general surgery

Patient, 46, presented with pain in the upper right abdomen after meals; complaints for about three months. Ultrasound shows multiple gallstones; elective laparoscopic cholecystectomy planned.

→ onset before the policy start, 01.09 · to the physician

Illustrative The document as it arrives. In red, what the system marks for your expert.

1. The work

Today

  1. ReadA contracted hospital sends a provision (pre-approval) request for an operation, a stay, or an expensive test: the request form with its diagnosis codes (ICD-10), the epicrisis, the physician's notes, and the test results; a provision officer reads each one, often while the patient is still at the hospital.
  2. GatherThey open the policy and its plan, the special conditions, the exclusions and extra conditions set at underwriting, the health declaration, earlier claims and provisions, and the hospital's network contract and tariff, screen by screen.
  3. CheckWaiting periods, the remaining annual limit, the participation share, and the tariff for the procedure are worked out by hand against the request.
  4. WriteAnything medical (whether the condition began before the policy, whether the procedure is needed) goes to the provision physician with a note written by hand.
  5. DecideThe provision officer, or the physician where medical judgment is needed, approves the provision, asks the hospital for documents, or limits or declines it, and answers the hospital.

With the system

  1. ReadThe SLM reads the request, the epicrisis, the notes, and the results, scans included, and returns the diagnosis, the procedure, the stay, the onset the documents state, and any earlier history they mention, each with its line cited.SLM
  2. GatherThe agent runs the checks in parallel, read-only: policy and plan, special conditions, underwriting exclusions, the health declaration, earlier claims and provisions, and the hospital's contract and tariff, each fact cited.Agentic AI
  3. CheckYour written rules, run as code, compute the waiting periods, the remaining limit, the participation share, and the tariff for the procedure.Your rule
  4. WriteThe SLM writes the coverage note in your format: each point with its policy clause or medical document, the questions for the physician, and the documents to ask for; it never writes a decision.SLM
  5. DecideThe provision officer decides, as before, and the provision physician answers every medical question; any decline, partial approval, or exclusion is always a person's.Person decides

What lands on the desk

The provision officer gets the request already read, the policy, the declaration, and the history gathered, the periods and limits computed by your own rules, and one medical question put plainly for the physician. The file never approves or declines; the answer to the hospital is the team's.

FIG. 1 · Provision fileIllustrative
Provision request · contracted hospital · inpatient · 04.11.2026Laparoscopic gallbladder removal, one night

SLM · what the documents say

  • DiagnosisGallbladder stones without inflammation, ICD-10 K80.2request form
  • OnsetPain after meals for about three monthsepicrisis
  • ImagingMultiple stones on ultrasoundradiology report
  • PlanPlanned laparoscopic cholecystectomy, one nightrequest form

Agent · policy file

  • metPolicy in force since 01.09.2026, inpatient cover in the planpolicy
  • metNo exclusion or extra condition set at underwritingunderwriting file
  • No digestive history declaredhealth declaration
  • metNo earlier claim or provision for this complaintclaims history

Code · periods and limits

  • metNo waiting period listed for this procedurespecial conditions
  • metAnnual inpatient limit available
  • metRequested fee within the hospital's tariffnetwork contract

SLM · coverage note

Covered by the plan on its face. The epicrisis dates the complaint to about three months ago, before the policy began on 01.09.2026. Question for the provision physician: did the condition exist before the start date? Documents to ask for: any earlier visit records.

  • SLM
  • Agent
  • Code

Written limitThe system never declines, partly approves, or excludes; those are the provision officer's or the physician's.

DecidesProvision officer

2. The system

For your technical team — skip it if you like.

How it works

In

  • Provision request and ICD-10 codes
  • Epicrisis and physician's notes
  • Test results and scanned reports

  1. SLM · reasons

    Medical request reader

    SLM fine-tuned on your requests and medical documents

    Reads

    • Everything under In

    Out

    • Diagnosis, procedure, and stay
    • Onset and history the documents state
    • Each point with its line cited

  2. Agent · acts

    Policy file agent

    Parallel checks; read-only

    Reads

    • The read request
    • Policy, plan, and special conditions

    Out

    • Cover and exclusions for this insured
    • Health declaration and underwriting notes
    • Earlier claims and provisions
    • The hospital's contract and tariff

  3. Code · calculates

    Waiting period and limit checks

    Your written rules, run as code; no model

    Reads

    • Policy start and waiting periods
    • Limits used, participation share, tariff

    Out

    • Waiting period met or not
    • Remaining limit
    • Tariff and participation share

  4. SLM · reasons

    Coverage note writer

    SLM, in your coverage-note format

    Reads

    • The checks and their sources
    • Your policy wording

    Out

    • Each point with its clause or document
    • Questions for the physician
    • Documents to ask for

  5. Decision

    Provision officer and physician

    Reads

    • The coverage note and the documents

    Out

    • The officer decides the provision
    • The physician answers medical questions
    • Any decline, limit, or exclusion is theirs
How the agent's work is arrangedParallel

Parallel

The facts behind one request sit in independent systems and every request needs all of them, so the checks run side by side and merge into one file while the patient waits.

How the models are trained and tested

Your expert writes the test first. A step the test does not need is skipped, and we say why.

Show the training steps

Small language model (SLM)

  1. Test set

    200–400 past provision requests with your provision team's notes and your physicians' assessments, graded by your senior provision physicians for reading accuracy, citations, and the questions a physician needs.

  2. Dataset

    Past requests, epicrises, coverage notes, and decisions, with names and identity numbers masked in training copies; health data never leaves your servers.

  3. Continued pre-training (CPT)If needed

    Only if the base model fails the test on Turkish clinical language and abbreviations.

  4. Supervised fine-tuning (SFT)

    On reading your hospitals' request forms and medical documents, and on your coverage-note format.

  5. Reinforcement learning (RL)Skipped

    Skipped: reading and citing are taught by fine-tuning, and no further reward is needed.

  6. Retrieval

    Retrieval supplies each plan's general and special conditions, the network contracts, and the tariffs as they stand today; limits and periods come from the code checks, never from the model.

  7. Monitoring

    The provision team reviews every note; a point a physician corrects joins the next test.

Where the agentic system stops

The provision officer decides each request; where medical judgment is needed, the provision physician does.

Show its tools, limits, and record
Tools and access
Reads the policy administration system, the underwriting file and health declaration, claims and provision history, and the network contracts and tariffs, only for the insured named in the request; read-only; writes only the provision file.
May not
Approve, decline, or partly approve a provision, apply an exclusion or an extra condition, set an amount, change a policy, answer the hospital or contact the insured, read another insured's health data, or grant itself any access.
Who decides and the written limit
Provision officerThe provision officer decides each request; where medical judgment is needed, the provision physician does. Any decline, partial approval, exclusion, or extra condition is always a person's. The system never declines or limits a provision, never sets an amount, never answers the hospital, and never contacts the insured.
Stops when
A medical question (a condition that may predate the policy, a procedure that may be cosmetic, documents that disagree), a missing document, an emergency marked on the request, or a document it cannot read with confidence: the file goes to the provision officer at once, marked, and medical questions to the physician.
Record
Every document and system read, each check and the rule version behind it, the coverage note, who opened the health data and when, and who decided.

How agentic systems stay inside limits

3. Value and conditions

Where the time goes, and what your institution will measure.

Where the value comes from

  1. Answers reach the hospital while the patient is still there.
  2. Physicians' time spent on medical questions only.
  3. Coverage notes that cite the same clauses for the same case.

What your institution measures

  • Time from request to answer
  • Requests answered without a second round for documents
  • Provisions changed later at claim
  • Physician time per request
  • Hospital complaints about waiting

Measured in the Decision Blueprint

Today's time from request to answer and physician time per request, from your provision system, set the baseline; your institution sets the target.

Conditions

The rules, the data, and the known error, with its guard.

  • Waiting periods and the conditions they apply to must be stated in the contract, and a waiting period applies only in the first insurance period of each cover (Özel Sağlık Sigortaları Yönetmeliği art. 6, as amended by SEDDK, Resmî Gazete 20 October 2025, no. 33053, in force 1 January 2026); the code reads each policy's own list.
  • For existing or risky conditions the insurer may set an extra premium, a limit, or a participation share, or leave them outside cover (art. 7(6)), and may ask written questions about health history (art. 5(3)); these are set at underwriting by your team. Whether a condition began before the policy is a medical question, and only a physician answers it.
  • Health data is special-category personal data, processed only under the conditions the law lists and with the adequate measures the Board sets (KVKK art. 6); the regulation keeps each insured's health information individually and under KVKK (art. 16). The system runs on your servers, reads only the insured named in the request, and logs every opening.
  • No machine-learning model is needed: which requests go to a physician is your written routing rule, and the agent applies it.

Start here

We take a month of provision requests with your provision team, time each step from request to answer, collect your coverage-note format and routing rules, and test the reader on your own hospitals' documents before anything is built.

Who builds it Every engagement is led by an engineer who has built machine-learning models that real decisions run on since 2012, and language models and agentic systems in production since 2024. About eqlx

Request a Decision BlueprintWhat the Decision Blueprint covers

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A short description of the work is enough; no confidential records.

  1. You send a short descriptionNo confidential records, credentials, or production data
  2. The engineer checks whether it fits, and what it would needA model, a small language model, an agent, or none
  3. A proposed first step, or an honest “not a fit”A technical conversation with the engineer
Start with a Decision BlueprintTalk to the engineer

https://eqlx.ai/use-cases/health-provision · Printed copy; the website is the current version.