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Insurance / APPLICATION BLUEPRINT

Claims Fraud Investigation & Evidence Handling

Coordinates authorised investigations of suspected claims fraud.

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11 workspace menus · 9 business workflows · 5 role profiles

Application blueprint only. This is a proposed design, not a deployed or production-tested system. Screens and sample figures are illustrative; workflows, business rules, approvals, permissions and integrations require confirmation before build.

Designed for insurance operations coordinators and the responsible business owners

Claims Fraud Investigation & Evidence Handling workspace interface preview; illustrative records and figures.
Claims Fraud Investigation & Evidence Handling — operational workspaceIllustrative interface · Sample dataView full interface →

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Illustrative workspace and record review. Select a concept screen to inspect it in full.

Claims Fraud Investigation & Evidence Handling workspace interface preview; illustrative records and figures.
Claims Fraud Investigation & Evidence Handling — operational workspaceIllustrative interface · Sample dataView full interface →
Claims Fraud Investigation & Evidence Handling record interface preview; illustrative records and figures.
Claims Fraud Investigation & Evidence Handling — record and workflow reviewIllustrative interface · Sample dataView full interface →

Operational dashboards and work queues.

Operational views

Review work, evidence, exceptions and authorised decisions within a defined operating scope.

Portfolio / service teamPeriodAssigned teamReview state

Dashboard measures

  • Active review cases
    Count of all records in the selected workspace.
  • Review queue
    Records at the third stage of the business workflow.
  • Needs attention
    Records with an assigned review requirement.
  • Final-stage records
    Records in the fourth business workflow stage.

Business workflow and operating scope

Coordinates authorised investigations of suspected claims fraud. Preserves permitted claim and third-party evidence, records investigator findings and specialist reviews, and tracks approved dispositions or follow-up, with restricted access and an auditable history of investigative actions.

Operations

Operational overview

Review the work position and priority actions.

Investigations of suspected claims fraud

Coordinate investigations of suspected claims fraud with assigned responsibilities, linked records and review history.

Permitted claim

Coordinate permitted claim with assigned responsibilities, linked records and review history.

Third-party evidence

Coordinate third-party evidence with assigned responsibilities, linked records and review history.

Investigator findings

Coordinate investigator findings with assigned responsibilities, linked records and review history.

Specialist reviews

Coordinate specialist reviews with assigned responsibilities, linked records and review history.

Dispositions or follow-up

Coordinate dispositions or follow-up with assigned responsibilities, linked records and review history.

Insights

Reports and saved views

Review the reporting scope and export agreed operational views.

Governance

Approvals and exceptions

Review delegated decisions, exceptions and recorded conditions.

Audit history

Trace accepted changes, decisions and accountable actions.

Access and configuration

Manage the agreed role permissions and configurable operating rules.

The end-to-end business journey.

From intake to authorised completion, with evidence at each decision.

01

Register the concern

Establish the scope of investigations of suspected claims fraud, capture the required records and assign the accountable team.

02

Assign a restricted review

Coordinate permitted claim, third-party evidence, with linked evidence and visible outstanding actions.

03

Record the authorised response

Review the relevant conditions and exceptions. Record the authorised outcome and its supporting evidence.

04

Track actions and closure

Confirm the resulting records and handovers. Track remaining obligations, later changes and follow-up actions.

Business workflows

Select a workflow to review the steps, responsibilities, approval and exception handling.

01 · Coordinate authorised investigations of suspected claims fraud

Coordinate authorised investigations of suspected claims fraud within Claims Fraud Investigation and Evidence Handling.

Trigger
Authorised investigations of suspected claims fraud requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register authorised investigations of suspected claims fraud and its operating scope
  • Assign the accountable owner and required actions
  • Review the relevant evidence and unresolved conditions
  • Confirm the accepted outcome and retain its history

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Required information or responsibility is missing, or an operating condition changes.

Outcome
A completed operating record with its linked evidence and remaining obligations.

02 · Preserve permitted claim and third-party evidence

Coordinate permitted claim and third-party evidence within Claims Fraud Investigation and Evidence Handling.

Trigger
Permitted claim and third-party evidence requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register permitted claim and third-party evidence and its operating scope
  • Compare suitable capacity and existing commitments
  • Confirm the provider, service window and accepted conditions
  • Track fulfilment, cancellation and capacity release

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Demand exceeds suitable capacity or a provider withdraws its commitment.

Outcome
An accepted capacity commitment with service conditions and completion evidence.

03 · Record investigator findings and specialist reviews

Coordinate investigator findings and specialist reviews within Claims Fraud Investigation and Evidence Handling.

Trigger
Investigator findings and specialist reviews requires a new record, an agreed review or a controlled change.

Responsible role
Specialist reviewer

  • Register investigator findings and specialist reviews and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

04 · Track approved dispositions or follow-up

Coordinate approved dispositions or follow-up within Claims Fraud Investigation and Evidence Handling.

Trigger
Approved dispositions or follow-up requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register approved dispositions or follow-up and its operating scope
  • Gather the relevant evidence and review options
  • Route the case to the delegated decision owner
  • Record the outcome, conditions and follow-up obligations

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
The case exceeds delegation, contains a conflict or has disputed evidence.

Outcome
An authorised decision or escalation with accountable resolution actions.

05 · Register the operating requirement

Coordinate operating requirement within Claims Fraud Investigation and Evidence Handling.

Trigger
Operating requirement requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register operating requirement and its operating scope
  • Compare options, dependencies and operating constraints
  • Review the selected option with its accountable owners
  • Accept the plan and track its delivery conditions

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
An assumption changes, prerequisites are missing or stakeholders cannot accept the proposed commitment.

Outcome
An approved operating plan and owned actions for its accepted conditions.

06 · Resolve operating exceptions

Coordinate operating exceptions within Claims Fraud Investigation and Evidence Handling.

Trigger
Operating exceptions requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register operating exceptions and its operating scope
  • Gather the relevant evidence and review options
  • Route the case to the delegated decision owner
  • Record the outcome, conditions and follow-up obligations

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
The case exceeds delegation, contains a conflict or has disputed evidence.

Outcome
An authorised decision or escalation with accountable resolution actions.

07 · Verify completion and follow-up

Coordinate completion and follow-up within Claims Fraud Investigation and Evidence Handling.

Trigger
Completion and follow-up requires a new record, an agreed review or a controlled change.

Responsible role
Specialist reviewer

  • Register completion and follow-up and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

08 · Review controlled operating changes

Coordinate controlled operating changes within Claims Fraud Investigation and Evidence Handling.

Trigger
Controlled operating changes requires a new record, an agreed review or a controlled change.

Responsible role
Specialist reviewer

  • Register controlled operating changes and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

09 · Prepare scoped operational reports

Coordinate scoped operational reports within Claims Fraud Investigation and Evidence Handling.

Trigger
Scoped operational reports requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register scoped operational reports and its operating scope
  • Assign the accountable owner and required actions
  • Review the relevant evidence and unresolved conditions
  • Confirm the accepted outcome and retain its history

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Required information or responsibility is missing, or an operating condition changes.

Outcome
A completed operating record with its linked evidence and remaining obligations.

Governance and control

  • Role permissions reflect the agreed responsibilities and restricted record access.
  • Sensitive information is restricted to the agreed roles and permitted sharing scope.
  • Required information and evidence are checked before the relevant decision or handover.
  • Exceptions have a named owner, recorded reason and an authorised resolution.
  • Approved changes retain their previous values, accountable decisions and linked evidence.
  • Integration mappings, business rules and acceptance criteria are reviewed with the customer.
Operating rules by business workflow
  • For authorised investigations of suspected claims fraud, the record retains an accountable owner, its supporting evidence and accepted outcome.
  • For permitted claim and third-party evidence, capacity is committed only after prerequisites and the responsible provider are confirmed.
  • For investigator findings and specialist reviews, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For approved dispositions or follow-up, a decision retains its authority, reason, supporting evidence and resulting obligations.
  • For operating requirement, the accepted plan records assumptions, rejected alternatives, dependencies and conditions.
  • For operating exceptions, a decision retains its authority, reason, supporting evidence and resulting obligations.
  • For completion and follow-up, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For controlled operating changes, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For scoped operational reports, the record retains an accountable owner, its supporting evidence and accepted outcome.

Data, interfaces and operating requirements.

Core records

Review caseInvestigations of suspected claims fraudPermitted claimThird-party evidenceInvestigator findingsSpecialist reviewsDecisionSupporting evidenceActivity history
Record fields and linked information
  • Record identifier — Stable reference for the operating transaction.
  • Portfolio / service team — Business scope used for responsibility and reporting.
  • Operating subject — The request, commitment or work item being handled.
  • Accountable owner — Named responsibility for the next action.
  • Workflow stage — Current position in the agreed business journey.
  • Review requirement — Required review and outstanding decision.
  • Due or review date — Agreed action window or review trigger.
  • Linked evidence — Source records supporting the operating decision.
  • Decision authority — The delegated authority relevant to the accepted outcome.
  • Accepted outcome — Recorded decision and its business consequences.
  • Follow-up obligation — Remaining responsibilities after an accepted action.
  • Revision history — Trace of accepted changes and their evidence.
  • Investigations of suspected claims fraud reference — Link the relevant investigations of suspected claims fraud to the operating transaction and its decision evidence.
  • Permitted claim reference — Link the relevant permitted claim to the operating transaction and its decision evidence.
  • Third-party evidence reference — Link the relevant third-party evidence to the operating transaction and its decision evidence.
  • Investigator findings reference — Link the relevant investigator findings to the operating transaction and its decision evidence.
  • Specialist reviews reference — Link the relevant specialist reviews to the operating transaction and its decision evidence.

Systems and interfaces

  • Policy, claims and financial records
  • Approved broker, repair or service-network interfaces
  • Identity and role-based access services
  • Approved document and communication services

Interface scope, data mapping and testing are agreed for each engagement.

Implementation requirements
Confirm the operating boundaries, investigations of suspected claims fraud, responsible roles, review authority, record retention, interface mappings and acceptance scenarios.

Mobile and tablet access

Authorised users can review investigations of suspected claims fraud, supporting records and assigned actions through mobile and tablet access. The relevant tasks and permissions are agreed for the deployment.

Access approved workflows through the Dalfin mobile app. Device tasks and permissions are confirmed for the deployment.

Apple App Store ↗Google Play ↗

AI extensions

Core workflows and approval rules are defined with your business owners. Operational AI can be assessed separately against a specific business outcome and review requirements.

AI extensions are scoped around the required data, business outcome and review controls.

Engineered with Genesis.

Structured application engineering

Connect requirements, roles, records, workflows and interfaces through the agreed Genesis engineering process.

Controlled changes

Review dependency impact and validation requirements. Context Memory supports governed changes and accepted application revisions.

Deployment and support

Agree customer cloud or on-premises requirements, device access, implementation acceptance and ongoing engineering support.

AN EXAMPLE OPERATING SCENARIO

What to validate in a scoped demonstration.

Start with investigations of suspected claims fraud and follow the record through assign a restricted review. Introduce a missing item or operating exception, record the authorised resolution and inspect the final handover, evidence and history.

What to review

  • A saved end-to-end transaction
  • An exception and its authorised resolution
  • Different operator, approver and reviewer permissions
  • Final records, history and the relevant report
Discuss this solution

Questions before implementation.

What can we review in a tailored demonstration?

Review a representative review case, its workflow stages, accountable roles, an exception and the resulting operational report. Bring the business process and existing system requirements that matter to your organisation.

How is the solution adapted to our organisation?

The operating scope covers your records, role permissions, review authority, business rules and integration boundaries. These requirements are agreed with the responsible business owners.

How does the solution connect with existing systems?

Connection design defines interfaces, data ownership, mapping, authentication and exception handling. The agreed implementation includes validation against the selected systems and workflows.

How are subsequent changes controlled?

The agreed engineering approach covers review of change impact, bounded implementation, validation and accepted revisions. Discuss the relevant Genesis Context Memory and support requirements during solution scoping.