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- Health Insurance Claims
- Who it's for
- Claims administration teams
Claims administration teams
A claims administration team often receives a reported loss before the final decision is clear. The useful handoff is a claim linked to its policy, with loss evidence and the dates needed to check effective coverage. The team can use the claim's status to distinguish new reports, assessment work and cases awaiting a decision. Claim Decisions then records the authorized outcome and approved benefit separately from the claimed amount.
How Health Insurance Claims is set up for you
Intake
Claims Intake Specialist records the report and checks that the policy reference matches the party provided by the claimant.
Assessment
Claims Assessor checks the relevant coverage line and supporting evidence, then prepares a case for review.
Decision
Claims Decision Reviewer records an approval, decline or evidence request with the reason and authorizing person.
Handoff to finance
Finance Reconciler reads the approved benefit and waits for verified provider events before settlement.
A claims administration team often receives a reported loss before the final decision is clear. The useful handoff is a claim linked to its policy, with loss evidence and the dates needed to check effective coverage. The team can use the claim's status to distinguish new reports, assessment work and cases awaiting a decision. Claim Decisions then records the authorized outcome and approved benefit separately from the claimed amount.
Choose a set of claims with different evidence outcomes. Include one that can be approved, one that needs more evidence and one whose loss date requires close coverage review. Enter the reported and loss dates separately. Link each claim to the actual policy and review coverage terms that apply on the loss date. The decision reviewer should see the same original claim and reason for any amount difference.
Test the review handoff with a claims staff account and a separate reviewer account. A prepared case must not become approved merely because the assessor changed a status. A payment event should be traceable to both the claim and the approving decision. If the decision changes, finance should recheck the eligible benefit before verifying anything further.
[See claims assessment](/health-insurance-claims/modules/claims-assessment) and [review the roles](/health-insurance-claims/roles).
Features to start with
Claims assessment
Follow a reported loss from intake evidence to an authorized benefit decision.
Policy and coverage
Keep the issued policy, coverage terms, endorsements and receipt evidence together.
Preauthorization review
Keep a submitted request, its evidence and the insurer's decision tied to one policy.
Roles on the team
- Claims Intake Specialist
- Records reported losses and supporting evidence for review.
- Claims Assessor
- Checks claim evidence against the policy and prepares a decision case.
- Claims Decision Reviewer
- Makes an independent benefit decision on a reviewed claim.
- Finance Reconciler
- Verifies payment and premium evidence and investigates operation exceptions.
- Admin
- Maintains staff identities and organization access.
Set up Health Insurance Claims your way.
Start free, then use Proto to change fields, steps and approvals before your team goes live.