Claims assessment

Claims assessment begins with a claim number, policy, loss date, report date, claimed amount and loss evidence. Claims Intake Specialist records what was reported. Claims Assessor checks the policy, effective coverage and evidence, then prepares the case for decision. Claims Decision Reviewer records an authorized decision with a reason and approved benefit amount. The reported amount and approved benefit remain separate values; the latter is the limit used when payment is checked.

The claim status shows whether work is reported, in assessment, in review, approved, declined, settled or closed. Review is a real handoff: the assessor should not change a case to approved solely because an amount appears plausible. The decision record captures the authorizing person and decision date. A request for more evidence keeps the review accountable without pretending the claim has been approved or declined.

• Take the report. Capture the loss and report dates, claimed amount and evidence against the correct policy.
• Assess the case. Compare the loss date with effective policy terms and note what evidence is still needed.
• Decide the benefit. Record the authorized decision, reason and approved benefit before finance considers settlement.

Agree what counts as a complete loss report and who may amend it after assessment begins. The insurer should state how exclusions, deductibles and limits affect the authorized benefit and when a case moves to review. Define who can make the benefit decision, how that person is distinguished from the preparer, and what evidence must accompany a decline or request for more information.

Choose a stable claim-number source and keep the policy reference during import. A claim may be reported later than the loss date; the team needs both dates for coverage and intake review. Do not use the policyholder’s name as a substitute for the policy link. It can change, while the policy and its coverage revision remain the decision context.

A member reports a loss with a claimed amount of $800. Claims Intake Specialist finds the issued policy and records the loss evidence. Claims Assessor checks the applicable coverage line, deductible and effective dates. The assessor moves the claim into review only after the evidence is ready. Claims Decision Reviewer approves a $600 benefit and records why the difference applies. Finance Reconciler later checks verified payments against the $600 decision, rather than the $800 request.

Rehearse a second case with missing evidence. The reviewer requests evidence and records the reason; the claim should remain open for follow-up. Also test a loss date outside the relevant coverage range. The outcome must be an explicit authorized decision with a reason, not a silent deletion of the report.

• Claims requiring assessment — Find reports and in-progress assessment work.
• Claims awaiting benefit decision — Review cases handed to the decision owner.
• Claims decision board — Follow the case by status without mixing payment dates into the decision view.

Follow a reported claim and inspect benefit settlement.