Health Insurance Claim Process flowchart template
Editable health insurance claim workflow with swimlanes for Member, Healthcare Provider, Claims Operations, two decision gates, correction and review loops, and a documented handoff to the next insurance operation.
What the health insurance claim process flowchart process is
This claims template follows a specific operating record from submit provider or member claim to reconcile payment and close claim. The Member, Healthcare Provider, Claims Operations, Approver, Finance 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.
The first gate asks whether administrative data complete. An incomplete case goes through request corrected claim or documentation and returns to validation. The later gate asks whether adjudication ready for approval; a failed review goes through refer exception or coding discrepancy before the decision is reconsidered. Record the reason at each branch so the next team can reconstruct the outcome.
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
- Submission and Validation: capture service, member and provider identifiers and check eligibility and claim data
- A correction loop from administrative data complete? to request corrected claim or documentation
- Adjudication: apply plan terms and benefit rules and calculate covered amount and member share
- An exception route through refer exception or coding discrepancy
- Closure through approve payment or communicate denial and reconcile payment and close claim
When to use this template
- You need to assign ownership across Member, Healthcare Provider, Claims Operations for claims 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 capture service, member and provider identifiers, calculate covered amount and member share and approve payment or communicate denial. Keep a separate lane for any independent decision owner.
Define the intake check
Specify the information and evidence needed before the Administrative data complete? gate can pass. Put the owner of request corrected claim or documentation on the return loop.
Set the decision authority
Document who may decide adjudication ready for approval? and what sends a case through refer exception or coding discrepancy. Use your own product terms and authority matrix.
Confirm the handoff
Check the output of approve payment or communicate denial against what the receiving team needs to complete reconcile payment and close claim.
Frequently asked questions
What does this health insurance claim template show?
It shows submit provider or member claim, intake and validation, an information correction loop, assessment, an exception review loop, and reconcile payment and close claim. 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
- Health insurance administration