Article

An Explainable AI Engineering Framework for Claims-Only First-Stage Provider Audit Triage Using SHAP-Guided Hybrid Retrieval-Augmented Generation

2026-08-17

Abstract excerpt

This study proposes an explainable artificial intelligence (XAI) engineering workflow for provider-level healthcare claim audit prioritization using SHAP-guided hybrid retrieval-augmented generation (RAG). The framework integrates provider-level claim aggregation, tree-based risk screening, SHAP explanation, exploratory group-level SHAP clustering, policy concept retrieval, and constrained large language model aud...

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Literature Corpus work: 2dabdfae-c96b-5d2c-a0a7-7da814fe784e
DOI: 10.20944/preprints202608.1111.v1

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