Data Template: Claims Processing

This attribute describes a single step or task performed within the claims lifecycle, such as 'Claim Submitted', 'Initial Review Performed', or 'Payment Issued'. Each activity represents a distinct point in the process that has a start and potentially an end time.

Analyzing activities is the core of process mining. It allows for the visualization of the process map, identification of bottlenecks between steps, analysis of activity frequency, and understanding of process variations. The sequence of activities for a given Claim ID forms the basis of the process flow.

It defines the steps of the process, which is fundamental for creating the process map and identifying bottlenecks or inefficiencies.

Typically derived from event logs, status change records, or task completion tables within Sapiens ClaimsPro. May require mapping from status codes or transaction types.

The Claim ID is the fundamental case identifier that links all events and activities associated with a single insurance claim. It ensures that the entire journey of a claim, from initial submission to final closure, can be reconstructed and analyzed cohesively.

In process mining, every event log entry must be associated with a Claim ID. This allows the tool to trace the complete path of each claim, visualize process variants, calculate end-to-end cycle times, and identify bottlenecks or deviations from the standard workflow. Analyzing data through the lens of the Claim ID provides a complete picture of its journey.

It is essential for grouping all related activities into a single process instance, enabling end-to-end analysis of the claims lifecycle.

This is a primary key in the main claims transaction table within Sapiens ClaimsPro. Consult system documentation for the exact table and field name.

The Event Timestamp records the start time of each activity in the claims process. It provides the chronological context necessary to sequence events and calculate durations between them. This timestamp is the temporal backbone of the event log.

In process mining analysis, this attribute is critical for calculating all time-related metrics, including cycle times, waiting times, and activity durations. It enables the discovery of bottlenecks, the analysis of process performance over time, and the monitoring of SLA compliance by providing the factual basis for when things happened.

This timestamp is essential for ordering events chronologically and calculating all duration-based metrics, such as cycle time and bottlenecks.

Located in the event or transaction log tables alongside the activity or status change information in Sapiens ClaimsPro.

This attribute identifies the individual user or resource who performed an action on the claim. Tracking the assigned adjuster is key to understanding workload distribution, individual performance, and resource allocation.

In analysis, this allows for filtering the process map to see how different adjusters handle claims, comparing their performance, and identifying potential training opportunities. It is fundamental for building the 'Adjuster & Department Activity Load' dashboard and calculating the 'Adjuster Workload Balance' KPI.

Crucial for resource analysis, helping to identify workload imbalances, high-performing individuals, and training needs.

Found in user activity logs or transaction tables within Sapiens ClaimsPro, often linked to the user who created or last modified a record.

This attribute indicates the business unit or team, such as 'Initial Intake', 'Complex Claims', or 'SIU (Special Investigations Unit)', that is assigned to a claim or activity. It allows for analysis of the process from a departmental view.

Analyzing by department helps identify bottlenecks that are specific to certain teams, understand handoffs between departments, and evaluate departmental efficiency. It is essential for the 'Adjuster & Department Activity Load' dashboard and for higher-level organizational process analysis.

Enables analysis of process performance and handoffs between different teams, revealing organizational bottlenecks.

Often associated with the user's profile in the system or assigned directly to the claim object. Consult Sapiens ClaimsPro documentation.

Claim Severity is a rating assigned to a claim to indicate its estimated complexity, risk, or financial exposure. This rating often determines the level of scrutiny, the experience required of the adjuster, and the workflow it follows.

This attribute is critical for the 'Claim Severity Cycle Time Analysis' dashboard. It helps to understand if more complex claims are handled efficiently or if they disproportionately contribute to long cycle times. It provides a vital context for performance metrics, as a high-severity claim is expected to take longer than a low-severity one.

Provides crucial context for cycle time analysis, helping to explain why some claims take longer than others and whether complex cases are handled efficiently.

This may be a manually entered field or a derived score based on claim characteristics in Sapiens ClaimsPro.

Claim Type classifies claims based on the line of business or the nature of the loss. This is a fundamental segmentation attribute that often dictates which process workflow a claim will follow and which teams will be involved.

Analyzing the process by Claim Type is crucial for identifying variations in efficiency and procedure across different business lines. For example, the process for an auto claim may be highly automated and fast, while a commercial property claim may be complex and slow. This attribute is needed to calculate the 'Settlement Amount Consistency Index' KPI.

Allows for comparing processes across different business lines to identify best practices and specific bottlenecks for each claim category.

A standard field on the main claim record in Sapiens ClaimsPro. It's a core data element for any claims system.

The Event End Time marks the completion of an activity. While some events are instantaneous (StartTime equals EndTime), many activities have a duration. This timestamp, when available, allows for the precise measurement of how long each step took.

This attribute is used to calculate the 'active time' or 'processing time' of an activity, as opposed to the 'waiting time' between activities. This helps differentiate between time spent actively working on a claim versus time it spent idle in a queue. This is crucial for pinpointing specific activities that are time-consuming.

Enables the calculation of active processing time for individual activities, helping to distinguish between value-added time and waiting time.

May be available in the same transaction logs as the start time, or may need to be inferred from the start time of the subsequent event. Consult Sapiens ClaimsPro documentation.

This attribute captures the value of the claim settlement. It is a key outcome metric that reflects the financial impact of the claim and the decisions made during the process.

In process analysis, the Settlement Amount is used in the 'Claim Decision & Settlement Insights' dashboard to analyze how process variations or adjuster behavior might correlate with settlement outcomes. It is also a primary input for the 'Settlement Amount Consistency Index' KPI, helping to identify inconsistencies in settlement decisions for similar types of claims.

This is a key outcome metric. Analyzing it against process variants can reveal how process inefficiencies or deviations impact financial results.

Found in the financial or payment transaction tables associated with the claim in Sapiens ClaimsPro.

This attribute represents the overall status of the claim case at any given point in time. While activities are events, the status is the state of the claim resulting from those events. It provides a high-level summary of where the claim is in its lifecycle.

Analyzing claim status helps in understanding the inventory of open claims and their current stage. It's useful for operational dashboards and for calculating the 'Claim Status Transparency Score' KPI by tracking how frequently and meaningfully the status is updated throughout the process.

Provides a high-level view of a claim's current state, useful for tracking workload in progress and understanding case progression.

A primary field on the main claim record in Sapiens ClaimsPro, updated by various business transactions.

This attribute is set to 'true' when an activity or sequence of activities is repeated for the same claim. For example, if a claim moves from 'Initial Review' to 'Additional Information Requested' and then back to 'Initial Review', the second instance of the review would be flagged as rework.

Flagging rework is critical for quantifying process inefficiency. It powers the 'Claims Rework & Re-submission Trends' dashboard and the 'Claim Rework Loop Frequency' KPI. By isolating and analyzing rework loops, organizations can identify root causes, such as poor initial data quality or unclear guidelines, and take action to reduce wasted effort.

Helps quantify process inefficiency by explicitly flagging activities that are being repeated, enabling targeted improvement efforts.

This is not in the source system. It is calculated by the process mining tool by detecting repeated sequences of activities within a single case.

This attribute records the date and time of the most recent data pull from Sapiens ClaimsPro. It is essential for understanding the freshness of the data being analyzed and is typically uniform across all records in a single dataset.

In any analysis or dashboard, this timestamp provides crucial context about the data's currency. It helps users understand if they are viewing real-time information or a historical snapshot, which is vital for making timely operational decisions.

Provides context on data freshness, ensuring users know how current the analysis is.

This value is generated and stamped onto the dataset during the data extraction (ETL) process.

The Loss Date, also known as the Date of Loss, is the date of the actual event (e.g., car accident, property damage) for which the claim is being made. It is often the starting point of the entire claims journey from the customer's point of view.

This attribute is important for calculating reporting lag, which is the time between the Loss Date and the 'Claim Submitted' date. Analyzing this lag can provide insights into customer behavior and identify opportunities to encourage faster reporting, which often leads to better outcomes.

Defines the start of the claim event itself, allowing for analysis of reporting lag (time from loss to claim submission).

A core field on the main claim record, captured during the First Notice of Loss (FNOL).

The Policy Number links the claim to the specific insurance contract held by the claimant. This provides essential context about coverage, limits, and deductibles that influence claim handling and decisions.

While not always used directly in process flow analysis, it's a critical attribute for any deep-dive investigation. It allows analysts to connect claim data with policy data, enabling a more holistic view of the customer relationship and risk profile. It can also be used to aggregate claims by policy to identify problematic policies or trends.

Links the claim to the insurance contract, enabling deeper analysis by connecting process data with policy details like coverage and limits.

A standard field on the main claim record in Sapiens ClaimsPro, linking it to the policy administration system.

Processing Time measures the time elapsed between the start of one activity and the start of the next. It represents the total cycle time of a step, which includes both the active work time and any idle or wait time before the next step begins.

This is one of the most fundamental metrics in process mining, used to power bottleneck analysis. By visualizing the average processing time on the arcs between activities in the process map, analysts can immediately identify where claims are getting stuck. It is essential for dashboards like 'Claims Activity Bottleneck Analysis'.

This metric is the foundation of bottleneck analysis, highlighting the stages where claims spend the most time waiting.

This is a calculated metric, derived during process mining analysis by taking the difference between the 'EventTimestamp' of consecutive activities for each 'ClaimId'.

When a claim decision is 'Denied', this attribute provides the underlying justification. It could be a standardized code or a free-text description explaining why the claim was not covered, such as 'Policy Exclusion', 'Lack of Evidence', or 'Fraud Suspected'.

This information is invaluable for the 'Claim Decision & Settlement Insights' dashboard. Analyzing rejection reasons can uncover patterns, such as a high number of denials due to incomplete information, which could point to problems in the data collection phase. It helps in root cause analysis for claim denials.

Provides critical context for denied claims, enabling root cause analysis to reduce denial rates and improve submission quality.

Associated with the 'Claim Denied' or 'Claim Decision Made' activities, likely stored in a status or reason code field in Sapiens ClaimsPro.

The Resolution Target Date is a deadline set for claim closure, often determined by factors like claim type, jurisdiction, or policy terms. It serves as a benchmark for measuring performance and adherence to service level agreements.

This date is fundamental for the 'Claim Resolution SLA Compliance' dashboard and the 'On-Time Claim Resolution Rate' KPI. By comparing the actual 'Claim Closed' date with this target, the system can automatically classify claims as 'On-Time' or 'Late', providing a clear view of SLA performance.

It is the benchmark for measuring SLA compliance, enabling the calculation of on-time resolution rates and identifying claims at risk of delay.

This date may be stored on the main claim record or in a related SLA management module within Sapiens ClaimsPro.

This attribute is derived by comparing the timestamp of the 'Claim Closed' activity with the 'ResolutionTargetDate'. It categorizes claims into states like 'On-Time' or 'Late', providing a clear and immediate indicator of SLA performance.

This calculated field is the backbone of the 'Claim Resolution SLA Compliance' dashboard. It simplifies analysis by allowing users to instantly filter for all late claims and investigate the common process paths or bottlenecks that led to the delay. It directly supports the 'On-Time Claim Resolution Rate' KPI.

Directly measures SLA compliance, making it easy to filter for and analyze claims that were resolved late.

This attribute is not in the source system. It is calculated during data transformation by comparing the 'EventTimestamp' of the 'Claim Closed' activity to the 'ResolutionTargetDate'.

This attribute provides context about the origin of the process data. While it might be a constant value like 'Sapiens ClaimsPro' for this specific dataset, it is crucial in environments where data is merged from multiple systems.

For analysis, it helps in data governance, troubleshooting, and ensuring that insights are correctly attributed to the source system. It is a key field for maintaining data lineage and understanding the technological context of the process.

Ensures data lineage and traceability, which is critical when data from multiple systems is combined or for auditing purposes.

This is typically a static value added during the data extraction, transformation, and loading (ETL) process to label the origin of the records.

This attribute identifies the intake channel for a new claim. Different channels can have a significant impact on initial data quality, which in turn affects the entire process downstream.

Analyzing the process by Submission Channel helps answer questions about efficiency and quality. For example, the 'Claims Submission Channel Efficiency' dashboard can reveal if claims submitted via an online portal have faster cycle times and lower rework rates compared to those submitted by mail. This insight can guide investments in channel optimization and digital transformation.

Helps identify which intake channels lead to the most efficient processing, highlighting opportunities for automation and improved customer experience.

Typically captured at the first point of contact and stored as a field on the main claim record in Sapiens ClaimsPro.