Claims and settlement

A claim starts with a policy, claim number, loss date, report date, claimed amount and loss evidence. The assessment action works on a Reported claim. It moves an eligible claim to Assessment with an operation receipt or records a reasoned refusal. A claim decision separately states whether to approve, decline or request evidence, with the reason, authorized person, decision date and approved benefit amount.

A verified provider payment links both the claim and the approved decision. The settlement action marks the claim Settled and records an operation receipt. This sequence lets the team explain why a claim was paid and which external payment event supports the outcome. The approved benefit and verified amount can be compared from the linked records rather than inferred from a claim status alone.

• Loss report. Dates, amount and evidence place the reported event against its policy.
• Decision. The authorized result and reason explain the benefit judgment.
• Payment. The provider event and verification state connect the decision to settlement.

Agree who can prepare the claim record, who makes the benefit decision and which provider event establishes payment. Review a coverage line with a realistic exclusion and effective period so the assessor can compare the reported loss to the policy terms. Choose a claim with clear evidence and a separate reviewer. Decide who investigates a failed operation receipt, and have the reviewer inspect the persisted result before retrying. Keep the authority to decide a benefit distinct from the work of gathering loss evidence.

Start with a Reported claim attached to an issued policy. Confirm the loss date and coverage terms before assessment. Inspect the assessment receipt and its reason if the action refuses to proceed. For an eligible claim, record the authorized decision and approved benefit. Match a verified provider payment to that decision and claim, then check that settlement moved the claim to Settled and left a receipt. If a payment event is repeated, compare its event ID with the existing record before concluding a new payment occurred. The Auditor can trace the claim, decision, payment and operation result as one case.

• Claims by loss date — Review reported losses and their changing assessment states.
• Operations and results — Follow the recorded effect when an action needs reconciliation.

Use claim assessment and settlement to rehearse a covered and a refused case. See reports for claim and payment questions.