claims-processor

What this skill does

# Claims Processor Workflow Design

Design the complete claims workflow from First Notice of Loss through settlement or denial, including intake, triage, assignment, investigation tracking, reserve setting, settlement authorization, and denial handling.

## Scope Confirmation

Confirm which claims workflow components are in scope:

- [ ] FNOL intake (phone script, web form, email parsing)
- [ ] Initial triage and coverage verification
- [ ] Assignment routing to adjuster, TPA, or vendor
- [ ] Investigation task tracking and document collection
- [ ] Reserve setting and authority levels
- [ ] Settlement authorization and payment
- [ ] Denial workflow and adverse action notices
- [ ] Status updates to insured and agent

Lines of business in scope: [Personal auto / Commercial auto / Property / GL / Workers comp / Professional liability]

---

## Component 1: First Notice of Loss (FNOL) Intake

**Intake channel design:**

| Channel | Implementation | Required Data Captured | Routing |
|---------|---------------|----------------------|---------|
| Phone | Script for CSR; data entered in claims system during call | All required fields | Immediate triage after call |
| Web form | Self-service form on agency/carrier portal | All required fields + file upload | Auto-triage on submission |
| Email | Parsed from incoming email (keyword detection + AI extraction) | Partial fields — follow-up required | Flagged queue for CSR completion |
| Mobile app | If applicable — same as web form | All required fields + photo upload | Auto-triage on submission |

**Required fields by LOB:**

**Auto (personal and commercial):**
- Date, time, and location of loss
- Description of what happened (free text)
- Other parties involved (name, contact, carrier, policy #, vehicle info)
- Police report number (if applicable)
- Vehicle information (year, make, model, VIN, damage description)
- Injuries: names, contact information, description
- Witnesses: names and contact information
- Photos uploaded (encouraged, not required at FNOL)

**Property:**
- Date and time loss discovered
- Type of loss (fire, water, wind, theft, vandalism, other)
- Location of damaged property
- Description of damage (free text)
- Temporary repairs needed immediately (document any emergency repairs)
- Public adjuster engaged? (Y/N — affects handling)
- Mortgage company / lienholder information

**GL / Professional Liability:**
- Date of incident / date claim received (claims-made distinction)
- Claimant name and contact
- Description of alleged wrongful act or injury
- Legal representation engaged by claimant? (Y/N — escalate immediately if yes)
- Prior notice of this claim? (Y/N — document for coverage determination)

**Workers Compensation:**
- Date and time of injury
- Employee name, ID, job title
- Description of injury and how it occurred
- Body part(s) injured
- Medical treatment received (yes/no, where, treating physician)
- Witness names
- Return to work expected? (Y/N)

---

## Component 2: Initial Triage

**Coverage verification (immediate — before assigning adjuster):**

1. Policy lookup by insured name, policy number, or VIN/property address
2. Confirm policy was active on the date of loss (not lapsed or cancelled)
3. Confirm LOB and perils — does the described loss fall within covered causes of loss?
4. Confirm deductible amount and any applicable sublimits
5. Flag if any coverage conditions are in question (e.g., vacancy exclusion for property, business use exclusion for personal auto)
6. Confirm reporting timely — no prompt notice issues

**Coverage determination outcomes:**

| Outcome | Action |
|---------|--------|
| Coverage confirmed | Proceed to assignment |
| Coverage in question — condition | Assign with coverage reservation letter triggered |
| Potentially no coverage | Route to senior adjuster or coverage counsel review before accepting |
| Duplicate claim (already reported) | Merge with existing claim file |
| Policy not found | Request policy information from insured; manual lookup |

**Claim type classification and priority scoring:**

| Priority | Criteria | Target Assignment SLA |
|---------|---------|----------------------|
| Critical | Fatality, catastrophic injury, significant property loss > $[X], litigation | Immediate — senior adjuster within 2 hours |
| High | Injury claim, commercial loss > $[X], multi-vehicle | Same business day |
| Standard | Property damage only, personal lines under $[X] | Within 1 business day |
| Low | Glass, roadside, minor property under $[X] | Within 2 business days |

---

## Component 3: Assignment Routing

**Adjuster/TPA routing rules:**

| Claim Type | Routing Condition | Destination |
|-----------|------------------|------------|
| Personal auto — glass only | State supports vendor direct | Auto-route to glass vendor network |
| Personal auto — property damage < $[X] | In-house adjuster available | In-house adjuster queue |
| Personal auto — injury (any) | Any BI involved | Senior adjuster or specialized BI team |
| Commercial property > $[X] | Over threshold | TPA or independent adjuster |
| Workers comp | Any WC claim | WC TPA (if using) or dedicated WC adjuster |
| Litigation | Any legal representation confirmed | Defense counsel notification + senior adjuster |
| Catastrophe event | CAT code activated | CAT team / storm adjuster roster |

**Workload balancing:**

- Display current open claim count per adjuster
- Route to adjuster with lowest open count within appropriate specialty
- Override: supervisor can manually reassign
- Escalation: if no appropriate adjuster available within SLA, notify supervisor

**Assignment notification:**

Upon assignment, send to adjuster:
- Claim summary (FNOL data)
- Policyholder contact information
- Policy coverage summary
- Priority level and contact-by deadline
- Document collection checklist for this claim type

Send to insured:
- Acknowledgment of claim receipt (required within state DOI time frame — typically 10 business days)
- Assigned adjuster name and contact information
- What to expect next
- How to submit additional documents

---

## Component 4: Investigation Tracking

**Task management by claim type:**

**Auto property damage:**
- [ ] Insured contacted (within [N] days per state DOI requirement)
- [ ] Damage inspection scheduled (in-person or photo estimate)
- [ ] Repair estimate received
- [ ] Total loss vs. repairable determination
- [ ] If total loss: ACV calculated, title obtained
- [ ] Other party demand received and responded to
- [ ] Payment authorized

**Property:**
- [ ] Insured contacted
- [ ] Field adjuster dispatched (if >$[X] or complex)
- [ ] Cause of loss investigation complete
- [ ] Scope of damage documented
- [ ] Contractor estimates received (minimum [N] estimates per policy or state requirement)
- [ ] Mortgage company notified if applicable
- [ ] Contents inventory received and reviewed
- [ ] ALE (additional living expense) documentation if displaced

**Document collection checklist (tracked per claim):**

| Document | Required For | Status | Due Date | Received Date |
|---------|------------|--------|---------|--------------|
| Police/incident report | Auto with other party; theft | | | |
| Medical records authorization | Any injury claim | | | |
| Medical bills and records | BI claims | | | |
| Repair estimates | Property damage | | | |
| Contractor invoices | Property paid claims | | | |
| Recorded statement | Complex or disputed claims | | | |
| Signed proof of loss | Property > $[X] (check policy) | | | |

**SLA monitoring:**

| Requirement | SLA | Monitoring |
|------------|-----|-----------|
| Acknowledgment to insured | 10 business days of claim receipt (most states) | Auto-alert at day 7 |
| Coverage acceptance or denial | 45 days (most states; varies) | Auto-alert at day 35 |
| Payment after coverage accepted | 15 business days of proof of loss (varies) | Auto-alert at day 10 |
| Response to insured inquiries | 10 business days | Auto-alert on pending inqui