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User Guide — Claim Processing Services

Overview

Claim Processing Services is an intelligent claims management platform that handles four types of insurance claims: Health, Motor, Property, and Travel. The platform provides AI-powered fraud detection, automated document extraction, and real-time claim tracking.

Getting Started

Accessing the Platform

Open the platform URL in your web browser:

Production: https://.cloudfront.net

You'll see the landing page with three persona cards. Click the one that matches your role.

User Roles

Role Description Access
Policyholder Insurance customer filing claims File claims, track status, upload documents
Claims Adjudicator Internal staff reviewing claims Review queue, approve/reject, view fraud scores
Admin System administrator User management, analytics dashboard, rules configuration

Policyholder Guide

1. Register an Account

  1. Click Register on the login page
  2. Fill in:
    • User ID (your chosen username)
    • Email address
    • Password (minimum 8 characters)
    • Full name
    • Phone number (optional)
  3. Click Create Account
  4. You'll be logged in automatically

2. File a New Claim

  1. From the dashboard, click File New Claim

  2. Select Claim Type:

    • 🏥 Health — Hospitalization, OPD, wellness claims
    • 🚗 Motor — Accident, theft, vehicle damage
    • 🏠 Property — Fire, flood, burglary, natural disaster
    • ✈️ Travel — Trip cancellation, medical emergency, baggage loss

  3. Fill Claim Details (varies by type):

    Health Motor Property Travel
    Hospital name Vehicle details Property address Trip details
    Diagnosis Incident type Damage type Incident type
    Treatment dates Incident location Incident date Incident location
    Bill amount Damage description Estimated loss Claim amount

  4. Upload Documents:

    • Medical bills, discharge summaries (Health)
    • FIR copy, damage photos, repair estimates (Motor)
    • Damage photos, police report, valuation (Property)
    • Boarding passes, receipts, airline correspondence (Travel)

    Documents are automatically scanned using OCR — extracted data will auto-populate relevant fields.

  5. Review & Submit:

    • Review all entered information
    • Click Submit Claim
    • The system performs fraud analysis and rules evaluation
    • You'll receive a claim reference number (e.g., CLM-20250525-ABCD1234)

3. Track Your Claims

  1. Navigate to My Claims from the sidebar

  2. View all your claims with current status:

    • 📝 Draft — Saved but not submitted
    • 📤 Submitted — Sent for processing
    • 🔍 Under Review — Being reviewed by an adjudicator
    • ✅ Approved — Claim approved, settlement pending
    • ❌ Rejected — Claim denied (reason provided)
    • 💰 Settlement — Payment being processed
    • ✔️ Closed — Fully resolved

  3. Click any claim to see full details and status timeline

4. Notifications

You'll receive notifications via:

  • Email — For all status changes
  • SMS — For important updates (approval, rejection)

Manage preferences in Profile → Notification Settings.

Claims Adjudicator Guide

1. Review Queue

  1. Log in with your adjudicator credentials
  2. The dashboard shows your pending review queue
  3. Claims are sorted by submission date (oldest first)
  4. High fraud-risk claims appear at the top with a warning indicator

2. Reviewing a Claim

  1. Click a claim from the queue
  2. You'll see:
    • Claim details — Type, amount, description, documents
    • Fraud Risk Score — AI-generated score (0-100):
      • 🟢 0-30: Low risk
      • 🟡 31-69: Medium risk — verify documentation
      • 🔴 70-100: High risk — thorough review recommended
    • Fraud Explanation — AI reasoning for the score
    • Extracted Document Data — OCR results from uploaded documents
    • Status Timeline — Full history of the claim

3. Approving a Claim

  1. After review, click Approve Claim
  2. Enter the settlement amount (may differ from claimed amount)
  3. Add optional notes
  4. Click Confirm Approval
  5. The policyholder is notified automatically

4. Rejecting a Claim

  1. Click Reject Claim
  2. Enter a rejection reason (required, minimum 10 characters)
  3. Click Confirm Rejection
  4. The policyholder is notified with the reason

5. Auto-Approved Claims

Some claims are automatically approved by the rules engine:

  • Low fraud score (< 30)
  • Amount below auto-approve threshold
  • All policy criteria met

These appear in the Auto-Approved section for your awareness.

Admin Guide

1. User Management

Navigate to Admin → Users:

  • View all users — See all registered users with roles and status
  • Change role — Promote a user to Adjudicator or Admin
  • Deactivate user — Disable an account (cannot deactivate the last admin)
  • Filter — By role (Policyholder, Adjudicator, Admin) or status (Active, Inactive)

2. Analytics Dashboard

Navigate to Admin → Analytics:

The QuickSight-powered dashboard shows:

  • Claims Volume — Total claims by type and time period
  • Processing Times — Average time from submission to resolution
  • Approval Rate — Percentage of claims approved vs rejected
  • Fraud Detection — Fraud score distribution and flagged claims
  • Operational Health — Service performance metrics

Use filters to drill down by:

  • Date range (start date / end date)
  • Claim type (Health, Motor, Property, Travel)
  • Status

3. Claim Lifecycle Simulation

On the Admin Dashboard, click "🎬 Simulate Claim Lifecycle" to:

  • Automatically create a random claim
  • Submit it for review
  • Approve or reject it (70/30 probability)
  • Process settlement and close

This is useful for populating the system with realistic data for demos.

4. Service Health Monitoring

The Admin Dashboard shows real-time health of all 7 microservices:

  • Health checks run every 60 seconds
  • Green dot = healthy, Red dot = unhealthy
  • Response time in milliseconds per service
  • Active user count

5. CloudWatch Observability

Dashboard: https://console.aws.amazon.com/cloudwatch/home?region=us-east-1#dashboards:name=ClaimFlow-Operations

42 Alarms monitoring:

  • ECS CPU/Memory per service (threshold: 80%)
  • DynamoDB throttling per table
  • ALB latency and error rates
  • CloudFront error rates
  • NAT Gateway traffic

3. Rules Configuration

Assessment rules control automated claim decisions:

Rule Parameter Description
auto_approve_threshold Claims below this amount can be auto-approved
coverage_limit Maximum claimable amount per policy type
fraud_score_threshold Score above this triggers manual review (default: 70)

To manage rules:

  1. Navigate to Admin → Rules (via API)
  2. Create rules per claim type
  3. Rules are evaluated automatically during claim submission

Claim Lifecycle Flow

Policyholder                    System                      Adjudicator
     |                            |                              |
     |--- File Claim (Draft) ---->|                              |
     |                            |                              |
     |--- Submit Claim ---------->|                              |
     |                            |--- Fraud Detection (AI) ---->|
     |                            |--- Rules Evaluation -------->|
     |                            |                              |
     |                            |--- Auto-Approve? ----------->|
     |                            |        YES → Approved        |
     |                            |        NO → Under Review --->|
     |                            |                              |
     |                            |                    Review --->|
     |                            |                              |
     |<-- Notification -----------|<--- Approve/Reject ----------|
     |                            |                              |
     |--- View Status ----------->|                              |
     |                            |                              |

Supported Document Types

Format Max Size OCR Support
PDF 10 MB ✅
JPEG/JPG 5 MB ✅
PNG 5 MB ✅
TIFF 10 MB ✅

Documents are processed by Amazon Textract (text extraction) and Amazon Comprehend (entity recognition) to auto-populate claim fields.

FAQ

Q: How long does claim processing take? A: Simple claims with low fraud risk can be auto-approved within seconds. Claims requiring manual review typically take 1-2 business days.

Q: What if my claim is rejected? A: You'll receive a notification with the rejection reason. Review the reason and contact support if you believe it was incorrect.

Q: Can I edit a submitted claim? A: No. Only claims in Draft status can be edited. Once submitted, the claim enters the review pipeline.

Q: How is the fraud score calculated? A: Amazon Bedrock (Claude Sonnet 4.5) analyzes claim patterns, document consistency, historical data, and anomaly indicators to generate a risk score.

Q: What notifications will I receive? A: Email and SMS notifications for: claim submitted, under review, approved, rejected, and settlement updates.

Q: How do I reset my password? A: Click "Forgot Password" on the login page. Enter your email to receive a reset link (valid for 1 hour).