Insurance Claims Processing Feature Spec Template

Run fraud detection in parallel with claims processing, not as a sequential gate. Process legitimate claims at full speed while fraud signals are being evaluated. Only pause the workflow when the fraud score exceeds a high threshold (e.g., 70+). For low and medium fraud scores, flag the claim for post-payment review. This approach means 90%+ of claims are processed without delay while still catching the highest-risk fraud. Accept that some low-level fraud will slip through. The cost of delaying every claim to catch every fraudulent one exceeds the fraud losses.

Start with 15-20% of claims eligible for straight-through processing. Mature insurtech operations achieve 40-60%. Begin with the simplest, most standardized claim types (glass replacement, minor property damage under a threshold) and expand criteria as you validate accuracy. Track the error rate on auto-adjudicated claims monthly. If the error rate exceeds 2%, tighten criteria before expanding further.

A car accident might generate an auto claim (vehicle damage), a health claim (injuries), and a liability claim (third-party damages). Create separate claims in each line of business but link them with a shared incident ID. Each claim follows its own adjudication workflow and SLAs. Assign a lead adjuster to coordinate cross-line communication. Show linked claims in the adjuster's dashboard so they have full context.

State insurance regulations dictate claims handling timelines (e.g., acknowledge within 15 days, pay within 30 days of agreement), communication requirements (written explanation of every denial), and data retention periods. HIPAA applies to health-related claims data. Fair claims settlement practices acts vary by state. Build configurable SLA timers per state and automate compliance deadline alerts. Have your compliance team review every workflow change before deployment.

Track five metrics: (1) Average cycle time from FNOL to payment. (2) Touch count, meaning the number of human interactions per claim. (3) Cost per claim (labor + vendor + system costs). (4) Straight-through processing rate (claims resolved without human intervention). (5) Customer satisfaction (NPS or CSAT survey post-claim). Benchmark against industry averages for your line of business and set quarterly improvement targets.