Claims processing can look straightforward from the outside.

A claim is received.

Someone reviews it.

A decision is made.

The claim is completed.

In reality, claims operations can involve multiple work types, different levels of complexity, missing information, pends, follow-ups, corrections, rework, escalations and strict turnaround expectations.

As volumes grow, simply knowing that a claim exists is not enough.

Operations teams need to know:

  • Which claims are ready to be worked
  • Which employee is eligible to process them
  • Who currently owns each claim
  • Which claims are approaching SLA
  • Which claims are pending additional information
  • When follow-ups are due
  • Which work types are creating backlog
  • How much time claims are taking
  • Whether productivity and quality are sustainable
  • Where management intervention is required

That is where case management principles become valuable in claims processing.

What Is Claims Case Management?

Claims case management means treating each claim as a controlled unit of operational work throughout its lifecycle.

Instead of a claim existing only as a row in a spreadsheet or an item in a queue, the operation maintains structured information about:

The claim

Its status

Its owner

Its age

Its priority

Its processing history

Any pending actions

Its final outcome

The objective is not simply to store claim information.

It is to manage the operational journey from intake to resolution.

A simplified flow may look like:

Claim Received
↓
Classified
↓
Validated
↓
Prioritized
↓
Assigned to an Eligible Processor
↓
Processed
↓
Pend / Hold / Follow-Up if Required
↓
Rework or Additional Review
↓
Completed
↓
SLA, Productivity and Quality Reporting

Different organizations will have different claims rules, but the underlying operational controls are often similar.

Step 1: Structured Claim Intake

Every claims workflow begins with intake.

Claims may arrive through:

  • Core claims platforms
  • Batch files
  • Excel or CSV files
  • Electronic submissions
  • Internal queues
  • Customer or provider channels
  • Other upstream systems

Before work can be allocated effectively, the operation needs enough structured information to understand what has arrived.

Useful fields might include:

  • Claim ID
  • Received date
  • Claim type
  • Product
  • Customer or member reference
  • Provider or source
  • Priority
  • Billed amount
  • Service date
  • Required work type
  • Current status
  • Due date

The exact fields depend on the organization.

The important point is that structured intake creates the foundation for routing and reporting.

Different Claims May Require Different Worktypes

Not every claim should necessarily follow the same operating workflow.

For example, a healthcare claims operation may have different work categories such as:

  • Professional claims
  • Hospital claims
  • Corrected claims
  • Reconsiderations
  • Adjustments
  • Provider-related requests

Another insurance operation may classify work differently.

Each work type may have different:

  • Skills
  • Expected handling times
  • Processing rules
  • SLA targets
  • Complexity
  • Required information
  • Outcomes

A case-management environment should therefore allow the operation to separate work logically rather than treating every claim as identical.

Step 2: Determine Who Can Process the Claim

Once the claim enters the operation, one of the first questions is:

Who is qualified to work it?

Not every processor may be trained for every claim type.

Some employees may have expertise in:

  • Specific products
  • Specific claim categories
  • High-complexity claims
  • Corrected claims
  • Escalations
  • Specialized adjustments

Assigning a claim to someone without the appropriate skill can result in:

  • Reassignment
  • Longer handling time
  • Quality issues
  • Processing delays
  • Additional supervisory intervention

This is where skill-based eligibility becomes important.

The workflow should first establish:

Which employees can process this claim?

Only then should it decide who receives it.

Step 3: Decide Which Claim Should Be Worked Next

Once eligible processors are identified, the operation still needs to determine which claim should receive attention first.

Several routing methods can be used.

FIFO

First In, First Out prioritizes the oldest eligible claim.

This helps control aging.

Priority-Based Routing

High-risk or urgent claims can receive preference over standard work.

SLA-Based Routing

Claims closest to their service deadline can be prioritized.

Skill-Based Routing

Only processors with the correct skill are considered.

In practice, these rules can be combined.

For example:

Skill Eligibility

↓

Priority

↓

SLA Risk

↓

FIFO

This helps ensure the next claim is selected according to operational rules rather than employee preference.

For a deeper comparison, see:

FIFO vs Priority vs Skill-Based Work Allocation: Which Is Better?

https://www.praevexa.com/insights/fifo-priority-skill-based-work-allocation

Why Claims Should Not Always Be Self-Selected

Allowing processors to freely choose claims can create an unintended problem.

Employees may naturally select:

  • Familiar claims
  • Easier claims
  • Lower-complexity work
  • Newer claims
  • Claims that can be completed quickly

More difficult work may remain behind.

Now the operation can experience:

Strong productivity

while simultaneously developing:

Older backlog and SLA risk

That creates a misleading picture.

Controlled work allocation can make claims distribution more consistent and reduce reliance on self-selection.

Step 4: Establish Clear Claim Ownership

Once a claim is assigned, ownership should be unambiguous.

Management should always be able to answer:

Who owns this claim right now?

Without clear ownership:

  • Two employees may work the same claim
  • Work may be assumed to belong to someone else
  • Reassignments may become difficult to trace
  • Follow-ups can be missed
  • Accountability becomes unclear

A structured workflow should establish exclusive ownership until the claim is completed, reassigned or moved according to defined business rules.

Step 5: Capture Actual Processing Activity

Claims frequently require more than one action.

A processor might need to:

  1. Review claim information
  2. Validate supporting data
  3. Research a discrepancy
  4. Check another application
  5. Contact another team
  6. Document findings
  7. Update the claim
  8. Complete or pend the transaction

Capturing meaningful activity information helps management understand where processing time is being spent.

It can also help identify:

  • Bottlenecks
  • High-AHT activities
  • Rework
  • Training needs
  • Automation opportunities
  • Complex work types

This becomes important when claims productivity is being measured.

Step 6: Manage Pends Properly

Not every claim can be completed during the first processing attempt.

A claim may be pended because:

  • Information is missing
  • Documentation is required
  • Another department needs to respond
  • Additional research is required
  • An external dependency exists
  • A correction is required

A pend should not simply mean:

“This claim is no longer in my active queue.”

The workflow should ideally record:

  • Why the claim was pended
  • When it was pended
  • Who owns the next action
  • Whether a follow-up is required
  • When that follow-up is due
  • How long the claim has remained pending

Otherwise, pending claims can become invisible backlog.

Step 7: Make Follow-Ups Part of the Workflow

Follow-up management is particularly important in case-based work.

If a claim requires additional information, the operation may need to revisit it later.

In manual environments this is sometimes handled through:

  • Outlook reminders
  • Email flags
  • Excel dates
  • Personal notes
  • Individual memory

That creates dependency on the processor.

A better operating model makes the follow-up date part of the claim.

Management can then identify:

  • Follow-ups due today
  • Overdue follow-ups
  • Future follow-ups
  • Claims repeatedly followed up
  • Follow-ups by employee
  • Follow-ups by work type

The process owns the follow-up rather than relying entirely on an individual's memory.

Step 8: Handle Rework Separately

A completed or partially completed claim may sometimes require additional work.

This could arise from:

  • Incorrect processing
  • New information
  • Quality findings
  • Upstream correction
  • Additional review
  • Customer or provider response

Rework should ideally be distinguishable from first-time processing.

Otherwise, the operation may unintentionally inflate completed volume.

For example:

A single claim processed three times should not necessarily be treated as three unique claims received.

Management may want separate measures for:

Unique claims

Processing activities

and

Rework

This provides a more accurate operational picture.

Step 9: Track Claim Aging

Claim age is one of the most important indicators in a processing operation.

At a basic level:

Claim Age = Current Date − Received Date

Operations may then group claims into aging buckets.

For example:

0–5 days

6–10 days

11–15 days

16–20 days

21–30 days

30+ days

The appropriate buckets depend on the organization's SLA and operating model.

Managers should be able to identify where claims are accumulating rather than only seeing the total backlog.

Backlog Volume Alone Can Be Misleading

Suppose two claims teams have the following backlog.

Team A

10,000 open claims

Most are less than five days old.

Team B

4,000 open claims

A significant portion is approaching or already beyond the required turnaround target.

Team A has considerably more work.

Team B may have considerably more operational risk.

This is why claims backlog should be analyzed using both:

Volume

and

Aging

For a detailed framework, see:

How to Manage Backlog, Aging and SLA in Case-Based Operations

https://www.praevexa.com/insights/manage-backlog-aging-sla-case-operations

Step 10: Monitor SLA Before It Is Breached

SLA reporting should not only tell management how many claims breached yesterday.

That is retrospective.

A stronger operational view should identify claims that are approaching breach now.

For example:

SLA target: 30 days

Claim age: 27 days

Remaining SLA window: 3 days

That claim represents a different risk from one received yesterday.

Managers should therefore distinguish between:

  • Within SLA
  • Approaching SLA
  • At risk
  • Breached

This allows the operation to intervene before performance is lost.

TAT and SLA Should Be Viewed Together

Turnaround Time — TAT describes how long claims actually take.

Service Level Agreement — SLA describes the required service expectation.

For example:

Average TAT may be:

8.2 days

while the SLA could require:

95% within 15 days

Both measures provide useful information.

The average alone can hide old claims.

SLA alone can hide changes in typical processing time.

Looking at both provides a more complete picture.

Step 11: Connect Claims to AHT and CPH

Claims operations also need to understand processing capacity.

Two useful measures are:

AHT — Average Handling Time

How much handling time does the average claim require?

CPH — Claims Per Hour

How many claims are completed per productive processing hour?

For example:

Completed claims: 240

Productive hours: 40

CPH:

240 ÷ 40 = 6 CPH

If the team has 100 productive hours available tomorrow:

100 × 6 = approximately 600 claims of theoretical capacity

This provides a bridge between workload and staffing.

But complexity must be considered.

Claims Complexity Can Distort Productivity

Suppose:

Processor A completes 50 simple claims.

Processor B completes 25 complex claims.

Looking only at completed claims makes Processor A appear twice as productive.

But suppose expected handling times are:

Simple claim: 8 minutes

Complex claim: 16 minutes

Their underlying performance may actually be similar.

Productivity analysis should therefore consider factors such as:

  • Claim type
  • Complexity
  • Expected AHT
  • Product
  • Outcome
  • Rework
  • Skill

This helps avoid misleading performance comparisons.

Step 12: Translate Claims Backlog into Capacity

Backlog can also be converted into workload hours.

Suppose:

Claims backlog: 18,000

Expected CPH: 6

Required productive hours:

18,000 ÷ 6 = 3,000 hours

Now suppose the operation has:

30 FTE

with

7 productive hours per day

Daily productive capacity:

30 × 7 = 210 hours

At 6 CPH:

210 × 6 = 1,260 claims/day

Management can now compare capacity against:

  • Existing backlog
  • Expected incoming claims
  • SLA requirements
  • Available staffing

This turns claims operations into a measurable capacity problem.

Incoming Volume Determines Whether Backlog Will Actually Reduce

Suppose the team can process:

1,260 claims/day

But it receives:

1,100 new claims/day

Net backlog reduction is only:

160 claims/day

With an existing backlog of 8,000:

8,000 ÷ 160 = approximately 50 working days

So saying:

“We can process 1,260 claims every day”

does not mean the backlog can be cleared quickly.

Incoming demand must always be considered.

Claims Managers Need One Operational View

A useful claims-management dashboard should bring several measures together.

Workload

  • Claims received
  • Claims completed
  • Opening backlog
  • Closing backlog
  • Net backlog movement

Aging

  • Claims by aging bucket
  • Average age
  • Oldest claims
  • Claims approaching SLA
  • Breached claims

Workflow

  • Assigned
  • In progress
  • Pended
  • On hold
  • Follow-up due
  • Rework

Productivity

  • Claims processed
  • CPH
  • AHT
  • Productive hours
  • Utilization

Quality

  • Accuracy
  • Error rate
  • Rework
  • Critical errors

No single metric gives management the complete operational picture.

Quality Must Stay Connected to Productivity

Claims operations frequently face pressure to increase output.

But pushing CPH without monitoring quality can create an unintended cycle:

Higher processing speed

↓

More errors

↓

More rework

↓

Additional workload

↓

Higher backlog

So claims performance should ideally balance:

Productivity

Quality

SLA

Aging

Rework

Capacity

The objective is not simply to complete more claims.

It is to complete the right claims correctly and within the required timeframe.

Management Should Look for Operational Exceptions

A strong claims-management environment should help managers identify exceptions rather than forcing them to search through thousands of transactions.

Examples include:

  • Claims approaching SLA
  • Old claims with no recent activity
  • Overdue follow-ups
  • Unassigned claims
  • High-priority claims waiting
  • Employees with excessive assigned workload
  • Worktypes with rising AHT
  • Queues accumulating backlog
  • Claims repeatedly reworked

This shifts management from manual tracking toward exception-based control.

From Claims Tracking to Claims Operations Management

The operating model often evolves like this:

Claim List

↓

Claim Tracker

↓

Controlled Assignment

↓

Case Ownership

↓

Pend and Follow-Up Management

↓

SLA and Aging Control

↓

Productivity Measurement

↓

Operations Intelligence

The value is not simply replacing Excel with another screen.

The value is creating a structured operating environment where claims, people, capacity and service performance can be managed together.

How Praevexa CaseFlow Can Help

Praevexa CaseFlow is designed for case-based and transaction-processing operations, including claims workflows that require stronger control over allocation, ownership and operational performance.

CaseFlow supports capabilities such as:

  • Configurable Departments, Queues and Worktypes
  • Excel-defined operational fields
  • Skill-based eligibility
  • Priority-based routing
  • FIFO/LIFO allocation
  • Manual supervisor assignment
  • Exclusive case ownership
  • Processing activities
  • Pend and hold workflows
  • Follow-up management
  • Rework and reassignment
  • TAT and SLA monitoring
  • AHT and CPH
  • Productivity and utilization
  • Backlog and aging visibility
  • Role-based Operations Intelligence

The objective is to help claims teams move from disconnected work queues and manual allocation toward a more controlled, measurable and accountable processing environment.

Learn more about Praevexa CaseFlow:

https://www.praevexa.com/CaseFlow.aspx

Related Reading

What Is Case Management Software for Back-Office Operations?

https://www.praevexa.com/insights/case-management-software-back-office-operations

How to Manage Backlog, Aging and SLA in Case-Based Operations

https://www.praevexa.com/insights/manage-backlog-aging-sla-case-operations

FIFO vs Priority vs Skill-Based Work Allocation: Which Is Better?

https://www.praevexa.com/insights/fifo-priority-skill-based-work-allocation