Claims & Intake Workflow

What this group does

Claims & Intake Workflow is the front door of InsurOps — the three screens that take a raw notice of loss and turn it into a structured, risk-scored, fully-fledged claim file that every downstream group (Field & Estimate Operations, Recovery & Analytics) can build on.

The three screens hand off real data to each other — approving an FNOL intake creates a ClaimRecord; freezing or flagging a claim in the Claim Files Hub opens or updates a FraudAlertRecord in Fraud & Risk Scoring. Nothing here is simulated: every action writes to the shared, tenant-scoped data store the rest of InsurOps reads from.

1. Triage & Loss (FNOL)

Purpose: Log a First Notice of Loss (FNOL) with photo/video evidence, auto-score it for fraud risk and priority, and validate the policy before a claim file is ever opened.

Key features

• Evidence capture — photo/video upload placeholders tagged with AI auto-tags (e.g. "#BumperDamage") and EXIF GPS metadata; a location mismatch between the EXIF GPS and the reported loss location is flagged automatically.
• Fraud risk score (0–100) and priority (low/medium/high) are computed at intake and drive the queue's default sort order.
• Policy validation — active / lapsed / excluded, surfaced as a status badge before anyone spends time triaging a non-covered loss.

Integration triggers

2. Claim Files Hub

Purpose: The central repository for every active and closed claim — search, filter, and drill into any dossier's full lifecycle (adjuster → estimate → payout → subrogation) from one place.

Key features

• Full lifecycle status — draft, in_triage, adjuster_assigned, estimate_approved, closed, subrogation — each claim shows exactly where it sits in the pipeline.
• FNOL snapshot — the drawer denormalises the originating FNOL's reported location and evidence thumbnails so reviewers never need a second round-trip to Triage & Loss.
• Freeze / unfreeze — a manual override that halts payout processing on a claim pending investigation, independent of the automated fraud score.

Integration triggers

3. Fraud & Risk Scoring

Purpose: The rule/score-based engine that reviews flagged claims — whether escalated automatically by risk score or manually frozen from the Claim Files Hub — and decides whether to clear, keep investigating, or confirm fraud.

Key features

• Red-flag reasons — a running list per alert (e.g. "Policy bound 48 hours prior to loss", "Duplicate image hash across claims"), appended to rather than overwritten as new signals arrive.
• Investigation status — open, under_review, cleared, confirmed_fraud — drives the alert's badge colour and downstream KPI classification (InsurOps Analytics' Fraud Mitigation Index only counts confirmed_fraud/auto-frozen exposure).
• Exposure amount — the dollar figure at risk if the flagged claim pays out unchecked; sums into the dashboard's total-exposure widget.

Integration triggers

End-to-end data flow

Pages in this section

• Overview
• Operational Setup & Master Data
• Domain Roles & Capabilities
• Screen Workflows
• Field & Estimate Operations
• Recovery & Analytics