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flowchart·ISO 5807:1985·insurance, operations·complexity 3/3·since v0.1.1

Insurance claim adjudication

ISO-style flowchart for a claims team triaging coverage, fraud risk, document completeness, manual review, and payment or denial outcomes.

For the claims operations lead

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Flowchart Flowchart with 14 nodes and 18 edges. start → intake intake → docs docs → request: No No request → docs: Resubmitted Resubmitted docs → coverage: Yes Yes coverage → deny1: No No deny1 → close coverage → fraud: Yes Yes fraud → review: Yes Yes review → liability fraud → liability: No No liability → denial: No No denial → close liability → estimate: Yes Yes estimate → approve approve → estimate: Needs changes Needs changes approve → pay: Approved Approved pay → close Claim submitted Claim submitted Capture FNOL data Capture FNOL data Documents complete? Documents complete? Request missing documents Request missing documents Policy active on loss date? Policy active on loss date? Issue coverage denial Issue coverage denial Fraud score high? Fraud score high? Manual SIU review Manual SIU review Liability accepted? Liability accepted? Send denial letter Send denial letter Calculate covered amount Calculate covered amount Adjuster approval? Adjuster approval? Payment ledger Payment ledger Close claim Close claim
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Scenario

Claim adjudication is not a straight line. The same claim can bounce for missing documents, route to special investigation, return for estimate changes, or close through denial. A flowchart is appropriate here because the core question is operational routing, not ownership lanes or event semantics.

Annotation key

Flowchart syntax →