A health insurer can keep the policy, covered terms, policyholder, reported loss and benefit decision together. Claims staff record the loss and evidence against the policy; an authorized reviewer decides whether to approve, decline or request more evidence.
Claims in one list
Claims Decision Reviewer authorizes the benefit decision.
Every feature works on the same records. Pick one to see the screen your team works in.
Keep the issued policy, coverage terms, endorsements and receipt evidence together.
Policies
| Record number | Subject | Counterparty | Owner | Revision | Status | |
|---|---|---|---|---|---|---|
| PLC-45346 | Family health plan, Morgan household | Jonah Patel | Fatima Nasser | 280 | Under review | |
| PLC-35357 | Silver outpatient plan, Nia Brooks | Amara Diallo | Marcus Bell | 350 | Under review | |
| PLC-95355 | Employer medical plan, Alder Clinic | Samir Haddad | Anika Rao | 840 | Under review | |
| PLC-54240 | Senior care plan, Elias Torres | Lena Ward | Fatima Nasser | 230 | Under review | |
| PLC-20381 | Family health plan, Patel household | Jonah Patel | Marcus Bell | 250 | Under review |
Give policies a clear party, organization and staff owner before downstream review.
Policies
| Record number | Subject | Counterparty | Effective date | Status | |
|---|---|---|---|---|---|
| PLC-50776 | Family health plan, Morgan household | Samir Haddad | 24 Oct | Draft | |
| PLC-12033 | Silver outpatient plan, Nia Brooks | Jonah Patel | 28 Oct | Under review | |
| PLC-23104 | Employer medical plan, Alder Clinic | Mei Lin | 12 Oct | Issued | |
| PLC-59796 | Senior care plan, Elias Torres | Mei Lin | 02 Nov | Active | |
| PLC-57043 | Family health plan, Patel household | Elias Torres | 25 Oct | Expired |
Keep a submitted request, its evidence and the insurer's decision tied to one policy.
Approval conditions
| Parent | Organization | Member reference | Requested at | Requested benefit USD | Revision | |
|---|---|---|---|---|---|---|
| Comprehensive plan, Lin household | Willowbend Benefit Services | MBR-2026-4182 | 17 Oct | 400 | 390 | |
| Silver outpatient plan, Nia Brooks | Brookvale Benefit Cooperative | MBR-2026-5027 | 22 Oct | 930 | 890 | |
| Family health plan, Morgan household | Silverfern Assurance Partners | MBR-2026-1194 | 20 Oct | 710 | 560 | |
| Family health plan, Morgan household | Cedarfield Coverage Group | MBR-2026-7631 | 03 Nov | 310 | 280 | |
| Employer medical plan, Alder Clinic | Mariner Health Plans | MBR-2026-2846 | 01 Nov | 690 | 790 |
Follow a reported loss from intake evidence to an authorized benefit decision.
Claims
| Claim number | Policy | Claimed USD | Loss evidence | Status | |
|---|---|---|---|---|---|
| CLM-24155 | Employer medical plan, Alder Clinic | 120 | itemized-imaging-bill.pdf | Review | |
| CLM-68387 | Comprehensive plan, Lin household | 20 | emergency-discharge-summary.pdf | Review | |
| CLM-86450 | Senior care plan, Elias Torres | 60 | therapy-visit-notes.pdf | Review | |
| CLM-25748 | Family health plan, Patel household | 590 | specialist-referral.pdf | Review | |
| CLM-48845 | Family health plan, Morgan household | 80 | surgery-operative-report.pdf | Review |
Verify paid events against the approved benefit before a claim is settled.
Claim payments
| Claim | Decision | Amount USD | Paid at | Provider event ID | Verified | |
|---|---|---|---|---|---|---|
| Samir Haddad, urgent care | Specialist claim pending records | 90 | 28 Oct | EVT-2026-81742 | No | |
| Jonah Patel, specialist consultation | Emergency visit approved in full | 90 | 01 Nov | EVT-2026-81763 | No | |
| Jonah Patel, specialist consultation | Day surgery benefit partially approved | 900 | 23 Oct | EVT-2026-81804 | No | |
| Lena Ward, prescription benefit | Lab claim approved in network | 530 | 14 Oct | EVT-2026-81855 | No | |
| Mei Lin, day surgery | Lab claim approved in network | 810 | 29 Oct | EVT-2026-81913 | No |
Keep reviewer decisions, supporting files and operation outcomes close to the policy.
Operation receipts
| Parent | Operation key | Action | Expected revision | Result state | Failure reason | |
|---|---|---|---|---|---|---|
| Essential care plan, Amara Diallo | claim-review-2026-0412 | Verify member eligibility | 820 | Failed | Provider banking details unverified | |
| Silver outpatient plan, Nia Brooks | preauth-check-2026-1178 | Approve outpatient benefit | 70 | Needs review | Member coverage expired before visit | |
| Employer medical plan, Cedar Works | benefit-pay-2026-0381 | Request clinical records | 250 | Failed | Duplicate payment event detected | |
| Employer medical plan, Alder Clinic | eligibility-2026-0864 | Issue benefit payment | 760 | Needs review | Clinical attachment unreadable | |
| Senior care plan, Elias Torres | claim-reopen-2026-0109 | Reopen claim review | 220 | Failed | Benefit schedule version unavailable |
Reported claim to verified settlement ships ready to use. One step needs a named approval before the work moves on: Decide benefit (Claims Decision Reviewer).
Record the loss, reported amount and evidence against the policy.
Compare the loss date with effective coverage and prepare the case for review.
Record an authorized benefit decision and reason.
Check each paid provider event against the approved benefit.
Confirm paid evidence before marking the claim settled.
Compare receipts with the saved policy and claim effects.
Open any claim to see its claim payments, the roles that work on it, its process stages and its approvals on one page.
Loss at, Reported at and Claimed USD.
Each line is linked to this claim.
Claims Intake Specialist, Claims Assessor and Claims Decision Reviewer, each with their own permissions.
Report claim and Assess evidence, with the role that acts.
Decide benefit, with who decides.
Reported
| Claim | Decision | Amount USD |
|---|---|---|
| Samir Haddad, urgent care | Specialist claim pending records | 90 |
| Jonah Patel, specialist consultation | Emergency visit approved in full | 90 |
| Jonah Patel, specialist consultation | Day surgery benefit partially approved | 900 |
Signed in as Claims Decision Reviewer
| Decision | Approver | |
|---|---|---|
| Decide benefitRecord an authorized benefit decision and reason. | Claims Decision Reviewer | |
| Approve Claims | Claims Decision Reviewer | |
| Approve Preauthorizations | Preauthorization Reviewer |
Everyone opens Health Insurance Claims to the work that is theirs. Pick a role to see what it starts with.
Records reported losses and supporting evidence for review.
This is the first screen this role sees.
Claims · Claims Intake Specialist
Checks claim evidence against the policy and prepares a decision case.
This is the first screen this role sees.
Claims · Claims Assessor
Makes an independent benefit decision on a reviewed claim.
This is the first screen this role sees.
Claims · Claims Decision Reviewer
Maintains policyholder, coverage and policy records before review.
This is the first screen this role sees.
Preauthorizations · Policy Operations Specialist
| Parent | Organization | Member reference | Requested at | Requested benefit USD | Revision | |
|---|---|---|---|---|---|---|
| Comprehensive plan, Lin household | Willowbend Benefit Services | MBR-2026-4182 | 17 Oct | 400 | 390 | |
| Silver outpatient plan, Nia Brooks | Brookvale Benefit Cooperative | MBR-2026-5027 | 22 Oct | 930 | 890 | |
| Family health plan, Morgan household | Silverfern Assurance Partners | MBR-2026-1194 | 20 Oct | 710 | 560 | |
| Family health plan, Morgan household | Cedarfield Coverage Group | MBR-2026-7631 | 03 Nov | 310 | 280 | |
| Employer medical plan, Alder Clinic | Mariner Health Plans | MBR-2026-2846 | 01 Nov | 690 | 790 |
Reviews submitted requests and records the insurer-confirmed outcome.
This is the first screen this role sees.
Preauthorizations · Preauthorization Reviewer
| Parent | Organization | Member reference | Requested at | Requested benefit USD | Revision | |
|---|---|---|---|---|---|---|
| Comprehensive plan, Lin household | Willowbend Benefit Services | MBR-2026-4182 | 17 Oct | 400 | 390 | |
| Silver outpatient plan, Nia Brooks | Brookvale Benefit Cooperative | MBR-2026-5027 | 22 Oct | 930 | 890 | |
| Family health plan, Morgan household | Silverfern Assurance Partners | MBR-2026-1194 | 20 Oct | 710 | 560 | |
| Family health plan, Morgan household | Cedarfield Coverage Group | MBR-2026-7631 | 03 Nov | 310 | 280 | |
| Employer medical plan, Alder Clinic | Mariner Health Plans | MBR-2026-2846 | 01 Nov | 690 | 790 |
Verifies payment and premium evidence and investigates operation exceptions.
This is the first screen this role sees.
Claims · Finance Reconciler
Maintains staff identities and organization access.
Read claim stages, benefit decisions, verified payments and operation exceptions.
This quarter
How far records got this quarter
| Stage | Reached | Step | |
|---|---|---|---|
| Reported | 48 | ||
| Assessment | 9 | 19% | |
| Review | 2 | 22% | |
| Approved | 1 | 50% |
Sample totals per stage
Which reports still need assessment or a benefit decision?
How do authorized benefits compare with the amounts claimed?
Which approved benefits have paid evidence attached?
Which submitted requests reached a recorded decision?
Show coverage lines, limits, deductibles and effective ranges beneath each policy.
Compare received amounts and verification states by policy and provider event.
Which actions have an unresolved effect or failure reason?
List reviewer, decision, source revision and reason against each parent policy.
See how Health Insurance Claims fits your kind of team.
Each stage of reported claim to verified settlement names the role that acts and the status it records, so a change is never anonymous.
Each stage, the role that acts and the status it records
Prepare policy, claim and payment evidence for the people who decide.
Set up connections through ERP.AI and Proto workflows, with every change logged.
Every record lives in a table you can see, extend and export. Add fields or whole tables in Proto.
Browse all 15 tablesStart with one team and one process, then add the rest once the basics are running.
Name the people who prepare policies and claims, the independent reviewers, and the source of insurer and payment confirmation.
Match organization and policyholder codes, policy numbers, claim numbers, effective dates and provider event identifiers to their source systems.
Use one issued policy with coverage lines, one submitted preauthorization and one reported claim.
Try a stale revision, a self-review, a duplicate provider event, an excessive payment and a mismatched operation receipt.
Compare imported records and paid totals with their sources, then obtain the responsible domain owners’ acceptance.
$0per user
The base account and everyday work in the ERP.AI app are free, for every user.
| Usage | Per $1 |
|---|---|
| Record reads (list, filter, get) | 20,000 |
| Search or aggregate queries | 4,000 |
| Record writes | 4,000 |
| Imported or synced records | 200,000 |
| Workflow runs | 2,000 |
| AI agent runs | 2,000 |
| Scheduled jobs or webhooks | 20,000 |
| File uploads (MB) | 2,000 |
| CSV or PDF exports | 100 |
Click Get started, then use Proto to configure Health Insurance Claims for your business. Pilot one issued policy, one submitted preauthorization and one reported claim with a verified payment event.
Each claim references a policy. The assessor reads the effective coverage lines and endorsement history against the loss date before preparing the decision.
Claims Decision Reviewer records the decision, reason, authorizing person and approved benefit. Finance uses that approved amount when checking payments.
The reviewer records a request for evidence and its reason. The case remains available for the next assessment and decision.
A preauthorization records an insurer-confirmed request outcome. A paid claim needs a claim decision and verified payment evidence.
Each payment event links to the claim and approved decision. Finance checks the remaining eligible benefit before verifying another event.
Keep the provider event identifier stable. A repeated event should resolve to its existing payment record during reconciliation.
Access should follow the staff member's organization and assigned responsibility. Test direct record access and internal attachment visibility before rollout.
Manual work and machine work follow the published pricing policy. Scope any migration and external connection during implementation.
Start free, then use Proto to change fields, steps and approvals before your team goes live.