1. States
List the meaningful claim states from first notice through closure, reopening, payment, denial, litigation, recovery, or other end states.
2. Entry criteria
Define what information or evidence is required to move a claim into each state.
3. Decision owner
Identify which role or system can make each decision and where approvals or separation of duties apply.
4. Automation candidates
Identify validations, routing, reminders, document requests, calculations, or low-risk decisions that may be automated.
5. Exception paths
Document missing information, coverage ambiguity, fraud indicators, high severity, complaints, litigation, or other cases that need special routing.
6. Audit trail
Specify timestamps, reason codes, documents, overrides, approvals, communications, and user/system actions needed for reconstruction.
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