Insurance Claims Workflow Templates
Download 6 ready-to-use claims workflow templates by line of business. Fully customizable templates based on industry best practices, complete with decision trees, escalation rules, and SLA benchmarks.
Pre-Built Workflows for Every Line of Business
These templates are based on industry best practices from hundreds of insurance carriers. Each template includes the complete workflow with stages, decision points, routing rules, SLA targets, and escalation procedures. Customize them to match your specific requirements.
Property Claims Workflow
Built for high-volume property claims with CAT surge capacity.
Optimized for residential and commercial property damage from fire, water, wind, and other perils. Includes automated triage based on loss amount and complexity, parallel assignment of adjusters and vendors, estimate validation rules, reserve management checkpoints, and subrogation tracking. Designed to scale during catastrophe events with surge routing and batch processing capabilities.
Auto Claims Workflow
Optimized for high-frequency, low-severity claims.
Handles collision, comprehensive, and liability auto claims with automated severity scoring, photo estimation integration, rental car authorization, total loss determination, and salvage coordination. Includes fast-track processing for minor claims under threshold amounts, multi-party collision handling with liability apportionment, and medical payment coordination for BI claims.
Health Claims Workflow
HIPAA-compliant with coordination of benefits and duplicate detection.
Designed for medical, dental, and pharmacy claims with automated eligibility verification, CPT/ICD code validation, fee schedule application, coordination of benefits with other payers, and duplicate claim detection. Includes prior authorization tracking, medical necessity review routing, explanation of benefits generation, and appeal workflow with clinical review escalation.
Casualty Claims Workflow
Long-tail management with litigation support.
Handles general liability, professional liability, workers compensation, and other casualty lines with extended lifecycle management. Includes witness statement tracking, expert assignment and coordination, legal counsel integration, reserve adequacy monitoring with actuarial review triggers, settlement authority workflows, and multi-year claim tracking with periodic review requirements.
Commercial Lines Workflow
Multi-line coordination for complex accounts.
End-to-end workflow for commercial policies covering multiple lines (property, GL, auto, umbrella, WC) with coordinated underwriting, multi-location risk assessment, premium allocation across coverage parts, endorsement processing, and renewal management. Includes large loss notification, aggregate tracking, retrospective rating calculations, and account-level claim trend analysis.
Catastrophe Claims Workflow
Surge capacity and rapid deployment.
Specialized workflow for hurricane, wildfire, flood, and other catastrophic events affecting multiple policyholders simultaneously. Features emergency contact protocols, geographic batch assignment, mobile field adjuster support, temporary living expense acceleration, emergency advance payment authorization, vendor network activation, and event-specific aggregate tracking. Designed for 10x volume surges with automated routing and prioritization.
Complete Workflow Documentation
Each template includes everything you need to implement the workflow in your organization or automation platform.
Stage Definitions & Sequence
Detailed description of each workflow stage including objectives, typical duration, required inputs, expected outputs, and success criteria. Includes the complete sequence flow with parallel and conditional paths.
Decision Trees & Routing Logic
Visual decision trees showing how claims are routed based on complexity, severity, coverage type, and other factors. Includes automation vs. manual review thresholds and escalation triggers.
Role Assignments & Responsibilities
Complete RACI matrix showing who is Responsible, Accountable, Consulted, and Informed at each stage. Includes typical role assignments (adjuster, supervisor, vendor, legal, etc.) and handoff protocols.
SLA Targets & Escalation Rules
Industry benchmark SLA targets for each stage with escalation procedures when deadlines are missed. Includes notification rules, supervisor escalation triggers, and exception handling protocols.
Required Documentation & Data
Checklist of required documents and data fields at each stage. Includes standard forms, photographs, reports, statements, and system integrations needed to complete the workflow.
Compliance & Audit Requirements
Regulatory requirements and audit trail needs specific to each line of business. Includes mandatory documentation, notification timeframes, customer communication requirements, and decision rationale capture.
How to Use These Templates
Follow this proven approach to adapt these templates to your organization and automation platform.
Map Your Current State
Document your existing workflow for the claim type you're automating. Interview the team members who actually do the work—not just managers. Identify pain points, bottlenecks, exceptions, and workarounds.
Compare your current workflow to the template. What stages are similar? What's different? What steps can you eliminate? What's missing that should be added?
Customize the Template
Adapt the template to your specific needs. Add stages for your unique requirements. Modify routing rules to match your business rules. Adjust SLA targets to your organizational standards. Incorporate state-specific regulatory requirements.
Keep it simple initially—you can add complexity later. Start with the happy path (straightforward claims) and add exception handling as you gain experience.
Configure in Your Platform
Build the workflow in your automation platform using the template as your blueprint. Configure document extraction for required forms, set up routing rules and assignments, establish SLA monitoring and alerts, and integrate with your core systems.
If you're using Regure, these workflows are pre-configured and ready to customize. Learn about Regure's workflow engine.
Test & Refine
Run test claims through the workflow with real documents. Verify that routing logic works correctly, SLA tracking is accurate, required data is captured, and integrations function properly. Get feedback from actual users.
Expect to iterate 3-5 times before going live. This is normal. Small refinements during testing prevent big problems in production.
How Workflows Connect Across Your Organization
Claims workflows don't exist in isolation. They connect to underwriting, policy administration, finance, customer service, and compliance. Here's how these templates integrate with your broader operations.
Policy & Coverage Verification
All claim workflows begin with policy validation: active coverage, effective dates, coverage limits, deductibles, and exclusions. Integration with your policy admin system is critical.
The templates include standard integration points for policy data retrieval, automatic coverage determination, and real-time policy status checking. Missing or incorrect policy data is the #1 cause of claims delays.
Vendor & Network Management
Most workflows require external vendors: appraisers, contractors, medical providers, attorneys, investigators. The templates include vendor assignment protocols, communication requirements, and performance tracking.
Integration with vendor management systems enables automatic assignment based on geography, specialty, availability, and performance ratings. Vendor SLA monitoring is built into the workflow stages.
Financial Systems & Reserve Management
Each workflow includes reserve setting, adjustment, and payment authorization checkpoints. These connect to your accounting system for payment processing and reserve reporting.
The templates specify when reserves should be set, who has authority to adjust them, and what triggers financial system updates. Proper reserve management is essential for accurate loss ratios and regulatory reporting.
Customer Communication & Experience
Modern claims workflows include proactive customer communication at every stage. The templates specify when and how to communicate: status updates, document requests, payment notifications, and closing summaries.
Integration with communication platforms (email, SMS, customer portal) ensures consistent, timely updates that improve customer satisfaction and reduce inbound inquiries.
Compliance & Regulatory Reporting
Every stage captures the data and documentation required for regulatory compliance. The templates include audit trail requirements, mandatory notifications, and decision rationale capture.
Integration with compliance monitoring systems enables real-time SLA tracking, exception flagging, and regulatory report generation. Learn about audit trail requirements.
Analytics & Continuous Improvement
Workflow data drives operational insights: bottleneck identification, resource allocation, training needs, and process optimization opportunities. The templates include standard metrics and KPIs.
Integration with analytics platforms enables real-time dashboards, trend analysis, and predictive modeling for workload planning and performance management.
Get All 6 Workflow Templates in Editable Formats
Download includes all templates in multiple formats (PDF, Excel, Visio) with decision trees, escalation rules, and SLA benchmarks. Plus implementation guide and customization checklist.
See Regure process your actual claims documents
Book a 20-minute demo with your real workflows and documents. We'll show you exactly how Regure handles your specific operation.