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- Health Insurance Claims
- Process
- Claim to verified settlement
Claim to verified settlement
The claims team keeps the original report, assessed evidence, authorized benefit and verified payment trail connected. The claim's approved state is a decision outcome. Settlement comes later, after finance has confirmed actual payment events against that benefit.
Step by step
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Report claim Claims Intake Specialist
Claims Intake Specialist records the loss against the policy with its dates, amount and evidence.
- Preserves loss date, reported amount and policy
- Updates Claims, Policies
-
Assess evidence Claims Assessor
Claims Assessor checks effective coverage and moves the case into review when ready.
- Presents applicable terms and evidence
- Updates Claims, Policy coverages, Record attachments
-
Decide benefit Claims Decision Reviewer
Claims Decision Reviewer approves, declines or requests evidence and records the reason and authorized amount.
- Preserves decision, reason and approved benefit
- Updates Claims, Claim decisions
ApprovalA person approves before the work moves on. -
Verify payment Finance Reconciler
Finance Reconciler links each paid provider event to the claim and approved decision.
- Verifies provider event and remaining benefit
- Updates Claim payments, Claim decisions, Claims
-
Settle claim Finance Reconciler
Finance Reconciler confirms paid evidence and the cumulative amount before settlement.
- Records settlement after paid evidence
- Updates Claims, Claim payments, Operation receipts
Who does what
Roles and permissions- Claims Intake Specialist
- Records the report.
- Claims Assessor
- Prepares review.
- Claims Decision Reviewer
- Decides the benefit.
- Finance Reconciler
- Verifies payments and settlement.
Set up Health Insurance Claims your way.
Start free, then use Proto to change fields, steps and approvals before your team goes live.