Industry processes
Claims Validation (P&C)
Auto-validate coverage, policy match, document completeness.
- document intake
- walkthrough
- document intake
- field extraction
- review packet
How it works
Built walkthrough
Claims Validation (P&C) is modeled as a real run: process diagram, live path, review packet, and evidence trail.
Superprocess · Insurance
Claims Validation
Design
The process waits for missing evidence, separates coverage judgment from fraud risk, and routes each exception to the correct authority.
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What the diagram shows
A claim file is checked for completeness, coverage, dates, parties, duplicate history, policy criteria, and fraud signals; coverage ambiguity goes to an adjuster while fraud signals take a separate SIU route.
11
modeled steps
13
modeled routes
2
human gates
Run
This run follows a complete claim that pauses at the coverage branch for an exclusion interpretation before its status update.
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Register claim
00:00FNOL, policy, claimant, loss, and documents attached
Read evidence
00:18Dates, parties, damage, codes, and citations extracted
Validate
00:37Coverage, completeness, duplicate, eligibility, and fraud checks run
Route authority
00:54Coverage ambiguity reaches an adjuster; fraud signals reach SIU
Update claim
—Decision, next action, claimant status, and evidence recorded
Decision
The adjuster sees policy language, cited evidence, loss facts, prior claims, risk signals, and the exact coverage question.
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Decision required
Named authority · Coverage adjuster
Coverage
Active on loss date
Open question
Water-damage exclusion
Duplicate history
No matching claim
Recommendation
Approve subject to evidence
interpret ambiguity or exclusion
Evidence
The record keeps the original file, extracted facts, coverage criteria, risk checks, adjuster or SIU rationale, and claimant-visible status.
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Run record
Inputs, decisions, artifacts, and system writes stay together.
Claim registered
FNOL, policy, claimant, loss facts, and documents attached
Evidence extracted
Dates, parties, damage facts, codes, and source citations prepared
Validation routed
Coverage ambiguity separated from duplicate and fraud evaluation
Adjuster review requested
Coverage exclusion question routed to the adjuster with cited evidence
Claim updated
Decision, rationale, next action, and claimant status written back
First Notice of Loss (FNOL)
Intake triage, severity classification, next-step routing.
- classification
- classification
- routing
- quality sample
How it works
Today
Reviewers gather forms, policy, medical or claim evidence, status notes, and payer/customer context by hand.
With Superprocess
The case arrives with facts extracted, criteria checked, gaps identified, and the next decision clear.
01 · Read
Agents extract facts.
Agents extract dates, codes, coverage facts, missing evidence, and policy criteria with citations.
02 · Check
Process applies rules.
The process waits across document collection, payer responses, callbacks, and review queues.
03 · Review
People decide exceptions.
The reviewer handles coverage, clinical, or exception judgment with the evidence already assembled.
Fraud Investigation
Evidence correlation across policy, claims history, external sources.
- risk triage
- signal scoring
- risk route
- investigator packet
How it works
Today
Investigators open many false positives and reconstruct the story from transactions, names, accounts, and prior alerts.
With Superprocess
The queue separates likely clears from cases that need investigator judgment.
01 · Correlate
Agents build the risk story.
Agents build the alert story across transactions, entities, history, lists, and supporting evidence.
02 · Triage
Process applies policy.
The process applies thresholds, waits for missing evidence, and keeps case actions auditable.
03 · Decide
Reviewers handle material cases.
Investigators decide clear, escalate, file, or monitor from an explained packet.
Commercial Underwriting
Document extraction, risk modeling, policy comparison, human review on complex risks.
- risk triage
- signal scoring
- risk route
- investigator packet
How it works
Today
Insurance teams reviews broad signal streams and reconstructs the case manually before deciding what matters.
With Superprocess
Low-risk items clear faster; high-risk cases arrive as evidence-backed review packets.
01 · Correlate
Agents build the risk story.
Agents collect Policy admin, Claims system, and Document intake and explain the risk drivers.
02 · Triage
Process applies policy.
The process applies thresholds, pauses for missing evidence, and keeps decisions auditable.
03 · Decide
Reviewers handle material cases.
The reviewer decides clear, escalate, assign, or monitor from one packet.
Appeals Review
Policy re-examination, communication drafting, audit-trail ready for regulatory review.
- case resolution
- case intake
- evidence
- response
How it works
Today
Reviewers gather forms, policy, medical or claim evidence, status notes, and payer/customer context by hand.
With Superprocess
The case arrives with facts extracted, criteria checked, gaps identified, and the next decision clear.
01 · Read
Agents extract facts.
Agents extract dates, codes, coverage facts, missing evidence, and policy criteria with citations.
02 · Check
Process applies rules.
The process waits across document collection, payer responses, callbacks, and review queues.
03 · Review
People decide exceptions.
The reviewer handles coverage, clinical, or exception judgment with the evidence already assembled.
Reinsurance Settlements
Multi-party reconciliation, contract interpretation.
- reconciliation
- record match
- variance
- finance owner
How it works
Today
Insurance teams compares records across systems, explains mismatches, and chases owners before anything can close.
With Superprocess
Matched items move through; real variances become a clear resolution queue.
01 · Match
Agents reconcile the source records.
They compare Policy admin, Claims system, and Document intake and cite the exact records behind each match or variance.
02 · Hold
The process waits where finance work waits.
Missing files, approvals, payment holds, and close checkpoints stay durable instead of becoming inbox follow-up.
03 · Resolve
Owners clear only the exceptions.
The resolution packet includes reason, source evidence, suggested action, and writeback target.
Ready to scope one of these for your operation?
We shadow your ops, scope the process, blueprint it, pilot it, and ship it to production. Typically 6–12 weeks to first production value.