Claim assessment and settlement

Step by step

1. Report loss Claims Examiner

   Claims Examiner records the loss date, report date, claimed amount and evidence on the policy.

   • Retain dates, amount and loss evidence
   • Updates Claims, Policies

2. Assess claim Claims Examiner

   The assessment action moves an eligible Reported claim to Assessment or records a reasoned refusal.

   • Move Reported to Assessment or record refusal
   • Updates Claims, Operation receipts

3. Decide benefit Authorized Underwriter

   Authorized Underwriter approves, declines or requests evidence and records the benefit amount and reason.

   • Retain authorized decision and reason
   • Updates Claim decisions, Claims
   ApprovalA person approves before the work moves on.

4. Settle claim Authorized Underwriter

   A verified provider payment against the approved decision supports the move to Settled.

   • Match verified payment and move Approved to Settled
   • Updates Claim payments, Claim decisions, Claims

5. Reconcile outcome Authorized Underwriter

   Authorized Underwriter checks the operation receipt and persisted payment effect.

   • Compare operation with persisted effect
   • Updates Operation receipts, Claim payments

Claims Examiner

Prepares and assesses the loss.

Authorized Underwriter

Decides the benefit and reconciles settlement.

Auditor

Reads the case and evidence.