Insurance claims process
From claim submission through fraud checks to payout.
Claims handling is the process every insurer documents and almost none documents accurately — the official version skips the loops, and the loops are where claims actually spend their time. This template draws the honest version: submission, a document-completeness gate that bounces incomplete claims back to the start, registration and handler assignment, coverage confirmation, a fraud-screening branch with referral to special investigation, damage assessment, threshold-based senior approval, and finally payout and closure.
Two rejection paths converge on the same letter — failed coverage and confirmed fraud — which is exactly how most claims systems behave and exactly the kind of detail that gets lost in slideware versions of this process.
When to use this template
- Process documentation — give claims handlers, auditors, and regulators a single agreed picture of how a claim moves from intake to payout.
- Operational bottleneck analysis — annotate the branches with volumes and cycle times; the document-request loop and the senior-approval queue are the usual suspects.
- System implementation projects — use the diagram as the shared spec between business stakeholders and the team configuring the claims platform, so every status and transition has a named owner.
How to adapt it
Map each node to a status in your claims system, then refine:
- Add straight-through processing — a fast path that skips manual assessment for low-value claims below a set amount.
- Split assessment into internal review vs. external adjuster branches if field inspections are part of your process.
- Insert customer communication touchpoints (acknowledgment, status updates, settlement offer) so the policyholder's experience is visible too.
The visual editor regenerates clean Mermaid code as you rearrange nodes, so the adapted process drops straight into your operations wiki or audit pack.
Mermaid code
Copy it anywhere Mermaid is supported — GitHub, Notion, or your docs.
flowchart TD
A[Claim submitted] --> B{Documents complete?}
B -->|No| C[Request missing documents]
C --> A
B -->|Yes| D[Register claim + assign handler]
D --> E{Coverage confirmed?}
E -->|No| F[Send rejection letter]
E -->|Yes| G{Fraud indicators?}
G -->|Yes| H[Refer to special investigation]
H --> I{Fraud confirmed?}
I -->|Yes| F
I -->|No| J[Assess damage amount]
G -->|No| J
J --> K{Above approval threshold?}
K -->|Yes| L[Senior approval]
K -->|No| M[Approve payout]
L --> M
M --> N[Pay claim + close file]
Frequently asked questions
- What are the main stages of an insurance claims process?
- Intake and document completeness checks, claim registration and handler assignment, coverage verification, fraud screening with possible referral to special investigation, damage assessment, an approval step that escalates above a monetary threshold, and finally payout and file closure. This template maps all seven stages including the rejection and rework loops between them.
- Why model the fraud check as a separate branch?
- Because it changes who handles the claim and how long it takes. Claims with fraud indicators detour to a special investigation unit, and only return to normal damage assessment if fraud is ruled out. Making this branch explicit helps teams measure how many claims take the slow path and whether the indicators are tuned correctly.
- How do I use this diagram in a process improvement or consulting project?
- Annotate each decision diamond with real volumes and cycle times from your claims system. The loops — incomplete documents bouncing back to submission, claims waiting on senior approval — are where elapsed time accumulates. A diagram with numbers on the branches turns a vague "claims are slow" complaint into a specific bottleneck to fix.
- Can I adapt this template for health, auto, or property claims?
- Yes — the skeleton is line-agnostic. Swap the damage assessment node for medical review, vehicle inspection, or property adjuster visit, and adjust the approval threshold to your authority matrix. Rename nodes in the visual editor and it regenerates clean Mermaid code you can drop into your process documentation.