Claims

Claims VP, staff adjusters, SIU, compliance, CIO

Prepare claims overnight while keeping coverage decisions with adjusters

Can the file be ready without the model deciding coverage, denial, or payout?

Morning queue · this walkthrough

22 ready9 exceptions4 held

Last night’s history test · cyan ships

Three photos = completeFailed history

Tie lines to photo slotsPassed

Tag coverage mixPassed

Photo-line + tag mergeMerged

Adaptive completenessWinner

Counts are from the walkthrough file below — a sample Monday morning, not a promised customer result.

Overnight Engine prepares a claim the way a junior examiner should: documents in, gaps visible, inconsistencies tagged, the working file assembled. Coverage, denial, reserve, and payout stay with the licensed adjuster. If a shop line does not have a photo, the file is incomplete — not denied.

Overnight Engine

On-premChris Adelman · Staff adjuster8:07 AM

22Ready

9Exceptions

4Held

22 files are complete enough for an adjuster to work. Nine are missing evidence or show an inconsistency. No file in this queue has a coverage decision attached.

Guidewire ClaimCenterFNOL portalPhoto storeISO ClaimSearch

CLM-29-4418 · Missing rear-quarter photo

Needs attention

Assembly

CLM-29-4401 · File complete for assignment

Ready

Adjuster

CLM-29-4388 · Collision vs comprehensive

Review

Assembly

CLM-29-4370 · Prior loss on same VIN

Review

Completeness

Harbor Mutual, Monday 8:07 a.m. CLM-29-4418 is held for a missing rear-quarter photo and a collision FNOL with a hail refinish line. Chris Adelman still owns the coverage call.

What enters the system

The walkthrough is a personal-auto collision, CLM-29-4418, reported Saturday evening.

01
FNOL
Policy number, loss date, VIN, third-party carrier, injury flag, and the insured’s account of the loss.
02
Policy and history
Guidewire contract, deductibles, and an ISO prior-loss pull on the VIN.
03
Evidence as it arrives
Photos, the body-shop estimate, a police report if one exists, and later supplements.

What happens overnight

01
Completeness
Required slots are checked: FNOL fields, photo set, estimate, prior-loss search. Missing slots are requested, not invented.
02
Evidence assembly
Estimate lines are tied to photo slots. A $2,180 quarter-panel line with no photo keeps the file off the ready desk.
03
Inconsistency detection
A collision FNOL with a “hail-related refinish” line is tagged for the adjuster. The tag is not a coverage decision.
04
Routing
Complete files go to the assigned adjuster. Incomplete files stay in assembly. High-severity or SIU designations follow the carrier’s existing rules.

What the adjuster sees in the morning

Chris Adelman has twenty-two files that are complete enough to work and nine that are not. CLM-29-4418 is in the second group. He can see the FNOL, three photos, the estimate, the ISO glass claim from 2024, and two open questions: the missing quarter-panel photo, and the collision / comprehensive mix.

He does not get a recommended payout, a recommended denial, or a drafted reservation-of-rights letter unless Harbor later configures those as human-only drafts. In this workflow they are off.

What the engine is not permitted to do

Harbor’s claims-prep workflow is deliberately narrower than a full claims desk.

Can prepare

Check FNOL completeness and attach policy / ISO evidence
Map estimate lines to photo slots
Tag inconsistencies for a person
Route complete files to the assigned adjuster

Can execute

Create the claim in ClaimCenter if FNOL is valid
Send an insured document request on an approved template
Write completeness status onto the claim

Always needs approval

Coverage determination
Denial or partial denial
Reserve changes
Any payment, including glass or rental
SIU referral finalization

How a correction becomes a validated improvement

If Chris treats three photos as enough on a bumper-only loss, that labeled example can support a completeness hypothesis. If he refuses to work a quarter-panel loss without the photo, the opposite example is stored.

A hypothesis that auto-closes any three-photo set fails Harbor history and does not ship. Tying estimate lines to photo slots passes. The winning model changes what is called complete — not what is called covered.

What a 30-day pilot measures

Pilot on one line of business, one office. No settlement KPIs until prep quality is trusted.

Metric	How it is measured	Pilot target
Time to a workable file	FNOL → adjuster can act without chasing basics	Most standard auto files ready next business morning
Completeness precision	% of “ready” files the adjuster agrees were ready	High; a false ready is worse than a false hold
Adjuster handle time	Minutes spent assembling vs. deciding	Assembly down; decision time is not the target
Unauthorized outcomes	Coverage or payment written by the engine	Zero. This is a stop-the-pilot metric.

Implementation

Systems: Guidewire ClaimCenter or equivalent, FNOL intake, photo store, ISO or prior-loss bureau.
Data required: Closed-file examples of complete vs. incomplete, plus adjuster notes on why a file was sent back.
Deployment: Hardware in the carrier environment. Shadow on historical FNOL, then supervised completeness, then ClaimCenter status writes.
Who operates it: Staff adjusters own every coverage and payment decision. Claims ops owns templates. Compliance reviews the boundary list before go-live.

Security and deployment architecture

Claims files, photos, and bureau pulls stay on carrier infrastructure. The engine can run air-gapped from the public internet except for the bureaus you already allow.

If a later program adds payout drafts, that is a separate workflow with a separate authority matrix — not a toggle on this one.

More workflow briefs

Flagship

Payment-ready overnight

Vendor match, three-way match, duplicates held for AP.

Finance

Clear expenses overnight

Policy-clean reports ready. Exceptions keep their controls.

Healthcare

Coding without the backlog

Pre-coded charts with citations. Coder still signs.

Research

Protocol-amendment review

Redlines and eTMF gaps. RA still files.

Credit

Cleaner underwriting files

Docs, DTI, exceptions. No credit recommendation.

Next step

Request a claims-prep assessment

Start with first-notice completeness on one line of business. No settlement authority on the machine.

Request a claims-prep assessment Private-deployment architecture