Claims Validation
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.
Coverage and evidence reviewSuperprocess · Insurance
Claims Validation
Design
The process waits for missing evidence, separates coverage judgment from fraud risk, and routes each exception to the correct authority.
Scroll to follow every step → Swipe to follow every step →
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.
Scroll to follow every step → Swipe to follow every step →
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.
Scroll to follow every step → Swipe to follow every step →
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.
Scroll to follow every step → Swipe to follow every step →
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
Boardroom
For claims leadership, the value is faster straight-through validation without hiding coverage authority, fraud escalation, or leakage controls.
Operator
For adjusters, Superprocess turns a raw claim folder into a cited decision packet containing only the uncertain or material issues.
Builder
For builders, the model preserves missing-evidence waits, a coverage-to-adjuster branch, a separate fraud-to-SIU branch, status updates, and the claim history.
Systems touched
The process connects work, people, and records.
- claim checks
- 6
- decision paths
- 3
- authority routes
- 2
Want to walk through your version of this process?
We can map the current path, find the decision points, and show where agents should work under human and policy control.