Use Case · Insurance

Claims

A claims department is the section of an insurance company that manages the settling of claims. Essential to any insurer, this department evaluates whether losses are covered, determines payout amounts, investigates for fraud, and handles all aspects of claims processing.

Examiners, adjusters, trainers, supervisors, and managers all work together to guide policyholders through the claims process and ensure efficient, accurate outcomes.

What is a Claims Workflow?

DexFLOW manages paperless workflow tasks and processes, providing the ability to retrieve any document at any time. In a claims context this could be a claim request, policy information, risk history, past claims, or any other document required for that insured.

How It Works

Documents can be entered via email capture, fax, file pickup, normal mail scanning by EDS staff, or through the DexFLOW Office plugin from MS Office or Outlook. A parcel is created and indexed via OCR, barcode reading, or manually. Configured rules route the parcel to the correct adjuster for that region or district.

Use Case: New Claim Request

An insured has an accident and contacts their agent, who fills out the claim form and submits it by email, fax, mail, or web form. The email capture process ingests the email and attachments, transforms them into the preferred image format, and routes them automatically for indexing. The claim is then sent to the correct adjuster who investigates and processes it per company policies, then routes to payment or denial processes. Once complete, all documents are committed to storage.

The system can automatically hide, mask, or redact personally identifiable information (PII) based on user security rights.

Key Terminology

  • Parcel – holds one or many documents with indexing values throughout the workflow.
  • Commit – the final storage step, converting to the preferred file format.
  • OCR – reads documents into searchable metadata for automatic indexing.
  • Barcode – automatic document and parcel identification and indexing.
  • EDS – Electronic Document Services, managing electronic document records.

The Challenge

High volumes of incoming claims from multiple channels, complex routing to adjusters, fraud detection, and regulatory compliance.

The Solution

DexFLOW automates ingestion from all channels, indexes claim documents, routes to the correct adjuster, and tracks every step of the process.

Results

Faster claims processing, reduced manual handling, automatic PII protection, and full audit trail from receipt to payment.