ChecklistGuro Claims Investigation Process
Streamline your entire claims lifecycle with our automated Claims Investigation Process. Eliminate manual bottlenecks, ensure regulatory compliance, and accelerate decision-making with a structured workflow designed to track evidence, manage adjuster assignments, and deliver seamless end-to-end case management.
Inicio
Inicio del flujo de trabajo/proceso.
1. Retrieve Claim Details
Fetch the initial claim entry and all associated incident reports from the Claims Data Model.
2. Fetch Policyholder Profile
Retrieve user data and policy coverage details for the person filing the claim.
3. Calculate Estimated Liability Score
Run a formula based on incident severity, evidence strength, and policy terms to determine initial liability probability.
4. Assign Investigator
Create a task for the Claims Department to assign a specialized investigator to the case.
5. Create Investigation Log
Generate a new entry in the Investigation Log data model to track all findings related to this specific claim ID.
6. Evidence Collection Task
Create a task for the investigator to gather photos, witness statements, and police reports.
7. Update Claim Status to 'In Investigation'
Update the status field in the original Claim Entry to reflect the current stage of the process.
8. Retrieve Evidence Attachments
Fetch all uploaded files and documentation linked to the claim entry.
9. Sum Total Reported Damages
Aggregate all line-item repair estimates and medical bills to find the total estimated loss.
10. Calculate Deductible Impact
Subtract the policyholder's deductible from the total estimated loss to determine the net payable amount.
11. Fraud Detection Review
Create a task for the Fraud Unit if the calculated liability score exceeds a specific threshold.
12. Log Investigation Findings
Update the Investigation Log entry with the final conclusions and summary of the investigation.
13. Update Claim Value
Update the 'Final Estimated Loss' field in the Claim entry with the aggregated damage total.
14. Notify Policyholder of Decision
Send an automated email to the policyholder informing them if the claim has been approved, denied, or requires more info.
15. Urgent Update Alert
Send an SMS to the assigned investigator when a high-priority evidence piece is uploaded.
16. Final Settlement Approval
Create a task for the Claims Manager to review and digitally sign off on the final payout amount.
17. Finalize Claim Status
Update the Claim entry status to 'Closed' or 'Settled'.
18. Generate Payment Instruction
Create an entry in the Finance/Disbursement data model to trigger the actual fund transfer.
19. Monthly Claims Audit Report
Generate a monthly performance report summarizing investigation turnaround times and loss ratios.
20. Cleanup Draft Entries
Delete any temporary or duplicate investigation drafts created during the process to maintain data hygiene.
Fin
Fin del flujo de trabajo/proceso.
Inicio del flujo de trabajo/proceso.
Fetch the initial claim entry and all associated incident reports from the Claims Data Model.
Retrieve user data and policy coverage details for the person filing the claim.
Run a formula based on incident severity, evidence strength, and policy terms to determine initial liability probability.
Create a task for the Claims Department to assign a specialized investigator to the case.
Generate a new entry in the Investigation Log data model to track all findings related to this specific claim ID.
Create a task for the investigator to gather photos, witness statements, and police reports.
Update the status field in the original Claim Entry to reflect the current stage of the process.
Fetch all uploaded files and documentation linked to the claim entry.
Aggregate all line-item repair estimates and medical bills to find the total estimated loss.
Subtract the policyholder's deductible from the total estimated loss to determine the net payable amount.
Create a task for the Fraud Unit if the calculated liability score exceeds a specific threshold.
Update the Investigation Log entry with the final conclusions and summary of the investigation.
Update the 'Final Estimated Loss' field in the Claim entry with the aggregated damage total.
Send an automated email to the policyholder informing them if the claim has been approved, denied, or requires more info.
Send an SMS to the assigned investigator when a high-priority evidence piece is uploaded.
Create a task for the Claims Manager to review and digitally sign off on the final payout amount.
Update the Claim entry status to 'Closed' or 'Settled'.
Create an entry in the Finance/Disbursement data model to trigger the actual fund transfer.
Generate a monthly performance report summarizing investigation turnaround times and loss ratios.
Delete any temporary or duplicate investigation drafts created during the process to maintain data hygiene.
Fin del flujo de trabajo/proceso.
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