Insurance Claims Orchestration: From FNOL to Triage in 14 Days

You don’t need a moonshot model to modernize claims. In two weeks, you can stand up a safe, auditable FNOL→triage loop that routes by coverage and completeness, requests missing docs, and flags suspicious patterns for review.

Why this matters now

Most claims teams live with swivel-chair work: emails, portals, DMS, core systems. The result is slow first response, inconsistent decisions, and little visibility on why a claim moved. A deterministic orchestration layer fixes the basics first—consistent intake, rules, handoffs—then adds targeted AI only where it reduces toil (doc checks, classification, dedup). That order matters: governance and auditability come from the process, not the model.

What changes with orchestration

Think swimlanes. Intake normalizes FNOL (email, form) and attachments. Doc check validates required artifacts by claim type. Coverage rules run as versioned YAML, not tribal knowledge. Triage splits to approve/request info/SIU, with a human gate for escalations. Every step writes provenance (inputs, rule version, approver). When you later add models (doc classification, entity extraction, similarity across VINs/addresses), they slot into those steps without breaking audits.

Example / How-to (copy this plan)

Scope (week 1):

• Inputs: FNOL payload, policy record, attachments (PDF, photos).
• Outputs: triage bucket, email task, case note, audit trail.
• Rules (starter):
  • Coverage invalid or lapsed → request_info.
  • Deductible > claimed amount → review_denial (human confirm).
  • Stolen vehicle, no police report → SIU_flag.
  • Repeat VIN/claimant within 90 days → SIU_flag.

Human-in-the-loop:

• All SIU flags require supervisor approval.
• “Request info” emails are templated and tracked; one-click close when files arrive.

Phase 2 (week 2+):

• Add doc classification (claim type), entity extraction (plate, ID, address).
• Similarity checks across historical claims (possible rings).
• Scorecard view: first response time, % auto-triaged, rework rate, and justification compliance.

Templates (drop-in):

• Request info: “Thanks for your submission. To proceed we need: [list]. Upload securely via [link]. Case #[id].”
• SIU note: “Pattern: VIN seen N times/90d + missing police report. Rule v1.2.”

Next steps

• Stand up the deterministic loop; measure first-response time and % auto-triaged.
• Layer doc classification where reviewers spend the most minutes.
• Run a weekly rules review with SIU to prune false positives.
• Want the swimlane diagram + email pack? Download the blueprint or book a 30-min walkthrough.