Claims Fraud Investigation Process flowchart template
Editable claims fraud investigation workflow with swimlanes for Claims Handler, Fraud / Special Investigation, Approver, two decision gates, correction and review loops, and a documented handoff to the next insurance operation.
What the claims fraud investigation process flowchart process is
This fraud template follows a specific operating record from flag claim for review to return outcome to claims handler. The Claims Handler, Fraud / Special Investigation, Approver, Legal / Compliance lanes show who gathers information, who evaluates it, and who owns the final handoff. Adapt the roles and documents to your product and distribution model.
A screen without sufficient grounds returns the claim to ordinary handling with a recorded rationale. A justified referral opens a proportionate investigation. Missing evidence loops back to review; findings are documented and returned to the claims decision owner, with escalation where the internal procedure calls for it.
This is an operational starting point. Coverage terms, authority limits, notices and required records vary by insurer, product and jurisdiction; the diagram does not establish regulatory compliance or decide an individual customer's entitlement.
What this flowchart covers
In this template
- Screen and Referral: record objective indicators and preserve file and screen against documented referral criteria
- A documented screen that returns a case without sufficient grounds to ordinary claims handling
- Investigation: assign investigator and plan proportionate checks and collect and review permitted evidence
- An exception route through seek missing evidence or specialist review
- Closure through record findings and authorized decision and return outcome to claims handler
When to use this template
- You need to assign ownership across Claims Handler, Fraud / Special Investigation, Approver for fraud work
- Cases regularly pause for missing information or unclear authority and need a visible return path
- You are updating a procedure and want staff to compare actual handoffs with the documented path
How it works
Map the actors
Replace the example lanes with the actual teams that perform record objective indicators and preserve file, collect and review permitted evidence and record findings and authorized decision. Keep a separate lane for any independent decision owner.
Define the intake check
Define the objective indicators and referral criteria used for this product. Record why a case is referred or returned to ordinary handling.
Set the decision authority
Document who may decide investigation complete? and what sends a case through seek missing evidence or specialist review. Use your own product terms and authority matrix.
Confirm the handoff
Check the output of record findings and authorized decision against what the receiving team needs to complete return outcome to claims handler.
Frequently asked questions
What does this claims fraud investigation template show?
It shows flag claim for review, intake and validation, an information correction loop, assessment, an exception review loop, and return outcome to claims handler. The lanes identify the teams responsible for each handoff.
Can I use this flowchart for every insurance product?
Use it as an editable starting point. Replace the example evidence, decision criteria, authorities and communications with those for the product, insurer and jurisdiction involved.
Does this template establish legal or regulatory compliance?
No. It illustrates an operational workflow and contains no universal deadline, threshold or mandatory regulatory procedure. Have the relevant specialists check local obligations before adopting it.
Part of
- Insurance
- Fraud review