What is Claims Processing and How it Works - ByteScout

What is Claims Processing and How it Works

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If you have an insurance policy, you likely felt home with the insurer’s great reputation or their policy quotes that spelled out everything you needed for your insurance.  The insurer may also have promised a fast settlement during claims processing.

No one in their right mind would wish to have their car involved in an accident or be bogged down by huge healthcare bills. But if these unfortunate events occur, it is important to know about the insurance claim process.

Read on to find out what it is and how it works.

  1. What is claims processing?
  2. How does claims processing work?
  3. Stages of an insurance claims process
  4. Note

What is claims processing?

Claims processing involves the actions an insurer takes to respond to and process a claim it receives from an insured party. A claim is that payment an insurer makes to an insured party with respect to paid premiums.

Note that when processing a claim, the insurer undertakes several actions before reaching a conclusion. The company will review, investigate, and as part of their obligation, act on the claimant’s filing according to what is set out in the insurance contract.

How does claims processing work?

What happens to a claim once an insured party submits it? Is there something one can do to speed up the event? What could make an insurer deny my application and fail to honor the claim? These are some of the questions one might grapple with as they await a response from an insurer.

One of the main functions of insurance companies is to make settlement of claims easy for claimants. But it doesn’t mean that any claim would be automatically processed and paid.

Acting on a claim involves various adjudication steps and require confirmation of several factors, including:

  • Is the claim related to a specific event as noted in the insurance contract?
  • if the policy is in effect
  • the policyholder must have paid the required premiums
  • Has the insured event happened?
  • insurer’s obligations under the contract

Once a party files a claim, an individual who works as a claims processor takes up the process. Through their insurance information analyses, they can adjudicate to have it adjusted, processed, or denied.

An insurer has the authority to reject claims that it deems invalid if for instance there are elements of forgery. The company will also deny the request if the claim is not in tandem with the terms of the insurance policy.

Stages of an insurance claims process

Different claims processors will look at requests differently, but will usually follow similar steps as far as processing is concerned.

1. Understand your responsibility

Typically, you need to understand your obligation first before approaching your broker. For instance, you will need to know what your insurance policy covers and whether you have paid all your premiums (up to date). You also need to know what timelines apply to the policy as some can be extremely short.

Then you need to have all the relevant documents, including those that provide evidence of accident/damage to the car or home. Here is where those accident pictures are vital. If it’s health-related, your hospital should provide these details.

2. Contact your broker

Ensure you contact your broker or agent as soon as possible, most probably as that means you are likely to stay within the stipulated time frame. Here you should have the procedure on with an adjuster taking up the process once your insurance agent has all the documents needed.

3. Investigation, review, and evaluation

Once you file a claim, an adjuster will investigate, review, and evaluate it based on the policy, loss or damage and/or records from a healthcare provider. This stage also involves identifying liable parties and what deductibles are applicable.

In this adjudication process, insurance companies verify claims and proceed to determine payment. If it’s for health insurance, the insurer will explain benefits and offer to settle the claim.

4. Claims settlement

The settlement is the last step in the claims process and involves settling on an amount to be paid to the insured or a healthcare provider. How long it takes to make payments depends but should be relatively faster once the company commits to pay.


Claims processing starts when you file a request with the insurance provider – either through an insurance agent or medical biller. It is a procedure and the insurance company has to check and counter check the claim request for authenticity.

Remember that honesty is paramount. Any sort of insurance fraud will not only render the claim or policy invalid but also put you in danger of prosecution.