Claim settlement

Step by step

1. Read the decision Claims Specialist

   Claims Specialist checks the claim's approved status and the linked decision's reason and approved benefit amount.

   • Confirm benefit authority and amount
   • Updates Claims, Claim decisions

2. Capture payment evidence Claims Specialist

   Record the paid amount, date and provider event identifier on a payment linked to both the claim and decision.

   • Link event to claim and decision
   • Updates Claim payments, Claims, Claim decisions

3. Verify the event Claims Specialist

   Claims Specialist compares the provider event with the approved benefit and checks the payment's verification state. An unmatched amount remains for review.

   • Check amount USD, provider event ID and Verified
   • Updates Claim payments

4. Settle the claim Claims Specialist

   After payment evidence is confirmed, Claims Specialist moves the claim from Approved to Settled under the team's settlement rule.

   • Move Status from Approved to Settled
   • Updates Claims, Claim payments

5. Close the case Claims Specialist

   Claims Specialist closes the claim after outstanding questions and evidence are resolved. The decision and payment event remain linked for later explanation.

   • Move Status from Settled to Closed
   • Updates Claims, Claim decisions, Claim payments

Claims Specialist

Reconciles the payment and closes the case; Claims Authorizer resolves questions about the approved benefit; Admin handles access or provider-operation exceptions.