/fraud/assessmentsRetrieve fraud scoring, anomaly detection, and risk analysis results for processed claims. The fraud engine analyzes patterns, provider behavior, pricing anomalies, and duplicate submissions.
Overall fraud risk (0.0–1.0)
Historical provider behavior
Member utilization analysis
Deviation from expected range
curl -X GET http://localhost:8000/api/v1/fraud/assessments \
-H "Authorization: Bearer YOUR_TOKEN"
# Get assessment for a specific claim
curl -X GET http://localhost:8000/api/v1/fraud/assessments?claim_id=CLM-2026-1001 \
-H "Authorization: Bearer YOUR_TOKEN"| Risk Level | Score Range | Action |
|---|---|---|
| LOW | 0.00 – 0.30 | Auto-approve (if other checks pass) |
| MEDIUM | 0.31 – 0.65 | Flag for secondary review |
| HIGH | 0.66 – 1.00 | Block or escalate to investigation |
duplicate_claimhighIdentical or near-identical claim submitted multiple times
pricing_spikemediumClaimed amount significantly exceeds historical provider averages
procedure_mismatchmediumProcedure code doesn't align with diagnosis codes
provider_velocityhighUnusual spike in claims volume from provider
member_frequencylowMember claim frequency exceeds typical patterns