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Claim Workflow Rules
Claim workflow rules are the guidelines set up by the insurance company to process and evaluate insurance claims. They are used for consistent processing of the claims, improved customer satisfaction, robust compliance, and enhanced operational efficiency.
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Define the criteria for transitioning a claim record to the target stage. Claim workflow rules set the conditions for the root product that determine the claim’s progress. After you define stage definitions and configure stage transitions, create claim workflow rules to define the transition criteria for those stages.
These rules apply conditions and actions at different stages of a claim record and evaluate whether the claim can move to the target stage. Depending on the evaluation outcome, the claim record either advances to the target stage or remains in its current stage.
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There are two aspects of the claim workflow rules - design time and runtime.
- The design time is handled by the admin to set up the claim workflow rules.
- In the runtime, the workflow rules are executed when the Claim Adjuster updates the status of the claim.
Learn About Claim Workflow Rules Design Time
The design time phase is owned by the Administrator. The primary goal is to define the logic and associated actions that will be evaluated against a claim. This process involves several key components and services working in sequence.
- Foundational Setup (Prerequisites): Before a rule can be designed, two foundational
elements must be configured:
- Stage Management: Defines the various stage transitions a claim can move through, for example, from 'Open' to 'In Review'.
- Rule Library: Defines the Usage Type and its associated data context. A new usage type, Claim Workflow Rules, has been introduced to separate it from other rule types and ensure seamless integration with the Business Rules Engine (BRE).
- Rule Design (Rule Designer UI): Once the prerequisites are in place, the administrator uses the Rule Designer UI to configure the actual rule. This is where the core business logic is defined.
- Rule Transformation (Insurance Dynamic Rule Service): When the administrator saves the
rule in the designer, the Insurance Dynamic Rule Service (IDRS) is invoked. The primary
function of this service is to:
- Transform the Payload: It uses the insurance-specific payload generated by the Rule Designer UI.
- Translate for the Engine: It converts that payload into the format expected by the core Business Rules Engine (BRE), ensuring seamless evaluation at runtime.
- Action Orchestration (Dynamic Revenue Orchestrator): After the IDRS successfully transforms the rule, the actions configured in the rule are passed to the Dynamic Revenue Orchestrator (DRO).
Considerations for Using Claim Workflow Rules
- Use claim workflow rules to define conditions for a specific root product, rather than for an entire object type, such as Claim. While rules configured in Stage Management apply to transitions across all claims, claim workflow rules apply to a single root product.
- Keep in mind the distinction between Stage Management and claim workflow rules. Use Stage Management to define stage definitions and configure stage transitions. Use claim workflow rules to define criteria and actions for those stage transitions. Claim workflow rules offer greater flexibility and are best suited for stage transitions at the root product level.
- Set Up Claim Workflow Rules
Before creating claim workflow rules, set up stage management, configure rule library, and add the Claim Workflow Rules component to the Product details page. - Configure Sharing Rules for Customer Community Users
Sharing rules give customer community users access to records that are relevant for using claim workflow rules. - Create a Claim Workflow Rule
Define conditions for claim transitions and configure actions for both true and false evaluations. The claim progresses to the target stage if the defined rule criteria is satisfied. - Claim Workflow Rule Groups
Claim workflow rules are organized into groups based on object type and transition step. For example, Rule Group - Claim, Draft to Approved includes all rules that apply to the Draft to Approved stage transition for the Claim object. - Understand Claim Workflow Rules Runtime
The runtime phase is initiated automatically to evaluate a specific claim against the rules configured during design time.
