insurance-claims v1.0.0A

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---
name: insurance-claims
description: Analyze insurance claims processing software for lifecycle completeness, automation rules, fraud indicators, reserve estimation, and regulatory compliance.
version: "1.0.0"
category: analysis
platforms:
  - CLAUDE_CODE
---

You are in AUTONOMOUS MODE. Do NOT ask questions. Analyze every aspect of the claims processing system systematically.

TARGET:
$ARGUMENTS

If no arguments provided, analyze the entire claims processing codebase in the current working directory.

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PHASE 0: SYSTEM DISCOVERY
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Auto-detect the claims processing system architecture:

TECH STACK:
- `requirements.txt` / `pyproject.toml` -> Python (Django, Flask, FastAPI, ML models)
- `pom.xml` / `build.gradle` -> Java (Guidewire ClaimCenter, Duck Creek, custom)
- `package.json` -> Node.js (API layer, adjuster portal, customer portal)
- `go.mod` -> Go (microservices, event processing)
- `.csproj` / `*.sln` -> .NET (custom claims platforms)

SYSTEM COMPONENTS:
- Identify claims intake: FNOL forms, API endpoints, batch imports, EDI/ACORD
- Identify workflow engine: state machines, rule engines, BPM platforms
- Identify adjuster tools: investigation, documentation, communication
- Identify payment systems: settlement, disbursement, recovery
- Identify analytics: reserves, fraud scoring, automation rules
- Identify integrations: agency management, reinsurance, external data providers
- Identify document management: storage, OCR, classification

Produce a system architecture map before proceeding.

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PHASE 1: CLAIMS LIFECYCLE ANALYSIS
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Evaluate the end-to-end claims lifecycle:

FIRST NOTICE OF LOSS (FNOL):
- Check FNOL intake channels: web form, mobile app, phone (API), email, agent portal
- Verify required data collection: policy number, date of loss, description, claimant info
- Check FNOL validation: policy active on date of loss, coverage verification, duplicate detection
- Verify FNOL acknowledgment: confirmation number, expected timeline, adjuster assignment
- Check for multi-peril FNOL handling (single event, multiple coverage types)
- Verify FNOL data mapping to internal claim record structure

INVESTIGATION:
- Check for claim assignment logic: adjuster expertise, workload balancing, geography
- Verify investigation workflow: documentation requirements, evidence collection, timeline tracking
- Check for third-party integration: police reports, medical records, repair estimates
- Verify statement collection workflow: recorded statements, witness statements
- Check for special investigation unit (SIU) referral triggers
- Verify coverage determination workflow: coverage analysis, exclusion checking

ADJUSTMENT:
- Check for damage assessment workflow: field inspection, desk adjustment, virtual inspection
- Verify estimate review and approval process
- Check for supplement handling (additional damages discovered)
- Verify depreciation calculation: actual cash value (ACV) vs replacement cost value (RCV)
- Check for total loss determination logic (threshold-based)
- Verify appraisal and independent adjuster workflows

SETTLEMENT:
- Check settlement calculation logic: deductible application, coverage limits, coinsurance
- Verify settlement offer generation and approval workflow
- Check for multi-party settlement handling (multiple claimants, lienholders)
- Verify settlement acceptance workflow and release documentation
- Check for structured settlement calculation if applicable
- Verify holdback logic for replacement cost policies (recoverable depreciation)

PAYMENT:
- Check payment disbursement: check, ACH, wire, payment card
- Verify payee determination: insured, claimant, vendor, lienholder, attorney
- Check for multi-payee handling (joint checks, escrow)
- Verify payment approval hierarchy based on amount thresholds
- Check for 1099 reporting requirements on claim payments
- Verify payment reconciliation between claims and finance systems

For each finding: lifecycle stage, file path, severity, description, recommendation.

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PHASE 2: AUTOMATION ANALYSIS
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Evaluate claims automation and straight-through processing:

STRAIGHT-THROUGH PROCESSING (STP):
- Identify claims eligible for auto-adjudication
- Check STP criteria: claim type, amount threshold, coverage clarity, fraud score
- Verify STP decision documentation (why auto-approved)
- Check for human-in-the-loop fallback when STP criteria not met
- Verify STP rate tracking and optimization metrics

AUTO-ADJUDICATION RULES:
- List all automated decision rules
- Check rule logic for accuracy and completeness
- Verify rule conflict detection (contradictory rules)
- Check for rule versioning and audit trail
- Verify rule testing/simulation capability before deployment
- Check for rule performance metrics (accuracy, override rate)

DOCUMENT AUTOMATION:
- Check for OCR/document classification on incoming documents
- Verify automated data extraction from forms, estimates, medical records
- Check for document completeness validation
- Verify automated correspondence generation (acknowledgment, status updates, denials)

WORKFLOW AUTOMATION:
- Check for automated task assignment and escalation
- Verify diary/follow-up automation
- Check for automated vendor assignment (preferred vendors, repair networks)
- Verify automated status notifications to claimants
- Check for SLA tracking and automated escalation on breaches

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PHASE 3: FRAUD INDICATOR ANALYSIS
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Evaluate fraud detection within claims:

DUPLICATE CLAIM DETECTION:
- Check for duplicate claim identification logic
- Verify matching criteria: claimant, date of loss, location, description, amount
- Check for fuzzy matching on names and addresses
- Verify cross-policy duplicate detection

SUSPICIOUS PATTERN DETECTION:
- Check for red flag rules: claim filed shortly after policy inception
- Verify detection of: excessive claim frequency, escalating claim amounts
- Check for staged accident indicators
- Verify medical treatment pattern analysis (if applicable)
- Check for arson indicators for property claims
- Verify slip-and-fall fraud indicators for liability claims

NETWORK ANALYSIS:
- Check for relationship mapping between claimants, attorneys, providers, repair shops
- Verify fraud ring detection algorithms
- Check for social network analysis integration
- Verify geographic clustering analysis for suspicious patterns

FRAUD SCORING:
- Check for fraud score calculation methodology
- Verify score threshold configuration for SIU referral
- Check for model performance tracking (precision, recall)
- Verify human review of high-score claims before SIU referral
- Check for false positive tracking and feedback loop

VENDOR FRAUD:
- Check for vendor billing pattern analysis
- Verify estimate inflation detection
- Check for phantom vendor detection
- Verify vendor license and certification validation

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PHASE 4: RESERVE ESTIMATION
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Evaluate claims reserve accuracy and methodology:

CASE RESERVES:
- Check for initial reserve setting methodology
- Verify reserve adequacy rules (minimum by claim type, severity)
- Check for reserve update triggers (new information, status change)
- Verify reserve approval hierarchy based on amount thresholds
- Check for adjuster reserve authority limits
- Verify reserve change documentation requirements

IBNR (INCURRED BUT NOT REPORTED):
- Check for IBNR calculation methodology (chain ladder, Bornhuetter-Ferguson, frequency-severity)
- Verify development factor calculation and updating
- Check for loss triangle generation and maintenance
- Verify IBNR segmentation by line of business, accident year, geography
- Check for seasonality adjustments

BULK RESERVES:
- Check for bulk reserve methodology on open claims
- Verify bulk reserve update frequency
- Check for bulk reserve segmentation
- Verify bulk vs case reserve reconciliation

RESERVE MONITORING:
- Check for reserve adequacy monitoring and reporting
- Verify reserve development tracking (initial vs ultimate)
- Check for large loss reserve monitoring (above threshold)
- Verify actuarial review integration with claims reserves
- Check for reserve release timing and authorization

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PHASE 5: SUBROGATION
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Evaluate subrogation and recovery:

RECOVERY IDENTIFICATION:
- Check for automated subrogation potential identification
- Verify recovery opportunity scoring based on liability indicators
- Check for at-fault party identification workflow
- Verify property damage vs bodily injury subrogation handling
- Check for third-party claim filing automation

WORKFLOW TRACKING:
- Check subrogation lifecycle: identification, demand, negotiation, arbitration, litigation
- Verify demand letter generation and tracking
- Check for arbitration filing (inter-company, AAA) workflow
- Verify recovery tracking by stage and aging
- Check for statute of limitations tracking and alerting

RECOVERY ACCOUNTING:
- Check for recovery application to claim (deductible reimbursement priority)
- Verify recovery allocation across coverage types and parties
- Check for recovery fee deduction handling
- Verify recovery reporting and reconciliation
- Check for salvage management workflow (vehicle claims)

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PHASE 6: REGULATORY COMPLIANCE
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Evaluate regulatory compliance specific to claims:

STATE FILING REQUIREMENTS:
- Check for state-specific claim handling regulations
- Verify claim acknowledgment timelines by state (typically 10-15 days)
- Check for payment timeline compliance (30-60 days from proof of loss)
- Verify multi-state compliance in claim handling workflows

PROMPT PAYMENT LAWS:
- Check for interest calculation on late claim payments
- Verify payment timeline tracking and SLA monitoring
- Check for state-specific interest rate application
- Verify penalty tracking for late payments
- Check for DOI (Department of Insurance) complaint tracking

BAD FAITH PREVENTION:
- Check for thorough investigation documentation requirements
- Verify timely communication tracking with claimants
- Check for reasonable explanation of denial requirements
- Verify fair settlement offer calculation methodology
- Check for adequate reserve documentation (not lowballing)
- Verify claimant rights notification (appraisal, complaint, legal remedies)

REPORTING:
- Check for state loss experience reporting
- Verify catastrophe reporting (CAT coding, ISO reporting)
- Check for fraud referral reporting to state fraud bureaus
- Verify annual statement data extraction for claims
- Check for NAIC data call compliance

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PHASE 7: INTEGRATION ANALYSIS
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Evaluate system integrations:

AGENCY MANAGEMENT:
- Check for agency/broker claim submission integration
- Verify agent claim status visibility
- Check for commission impact tracking on claims

REINSURANCE:
- Check for reinsurance reporting on large/catastrophe claims
- Verify treaty/facultative recovery tracking
- Check for bordereau generation
- Verify reinsurance reserve reporting

PAYMENT SYSTEMS:
- Check for payment system integration (EFT, check printing)
- Verify payment authorization workflow
- Check for payment reconciliation between claims and accounting

EXTERNAL DATA:
- Check for weather/catastrophe data integration
- Verify medical cost benchmarking data access
- Check for repair cost database integration (Mitchell, CCC, Audatex)
- Verify public records integration

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OUTPUT
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## Insurance Claims Processing Analysis Report

**System:** [name/description]
**Stack:** [detected technologies]
**Lines of Business:** [auto, property, liability, workers comp, health, etc.]

### Summary

| Category | Status | Findings | Critical |
|----------|--------|----------|----------|
| Claims Lifecycle | [PASS/WARN/FAIL] | N | N |
| Automation/STP | [PASS/WARN/FAIL] | N | N |
| Fraud Detection | [PASS/WARN/FAIL] | N | N |
| Reserve Estimation | [PASS/WARN/FAIL] | N | N |
| Subrogation | [PASS/WARN/FAIL] | N | N |
| Regulatory Compliance | [PASS/WARN/FAIL] | N | N |
| Integrations | [PASS/WARN/FAIL] | N | N |

### Claims Lifecycle Coverage

| Stage | Implemented | Automated | Gaps |
|-------|------------|-----------|------|
| FNOL | [YES/PARTIAL/NO] | [STP %] | |
| Investigation | [YES/PARTIAL/NO] | [AUTO %] | |
| Adjustment | [YES/PARTIAL/NO] | [AUTO %] | |
| Settlement | [YES/PARTIAL/NO] | [AUTO %] | |
| Payment | [YES/PARTIAL/NO] | [AUTO %] | |
| Subrogation | [YES/PARTIAL/NO] | [AUTO %] | |

### Detailed Findings

For each category with WARN or FAIL:

#### [Category Name]

| # | Severity | File | Description | Regulatory Impact | Recommendation |
|---|----------|------|-------------|-------------------|----------------|

### Automation Opportunity Assessment
- **Current STP rate:** [estimated from code analysis]
- **STP expansion opportunities:** [list by claim type]
- **Estimated automation potential:** [assessment]

### Fraud Detection Gaps
- **Covered fraud types:** [list]
- **Missing fraud types:** [list]
- **False positive management:** [assessment]

### Remediation Priority
[Ordered list: regulatory compliance first, then lifecycle gaps, then automation, then fraud]

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NEXT STEPS
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After reviewing the analysis:
- "Run `/fraud-detection` to deep-dive into fraud detection algorithms and ML models."
- "Run `/financial-compliance` to review broader regulatory compliance (KYC/AML if applicable)."
- "Run `/analyze` to trace claims workflows end-to-end across all system layers."
- "Run `/arch-review` to evaluate system architecture for scalability and reliability."
- "Run `/owasp` to audit the claims portal and API for security vulnerabilities."

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DO NOT
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- Do NOT modify any claims processing code, rules, or workflows — this is an analysis skill.
- Do NOT access or display actual claim data, claimant PII, or policy details.
- Do NOT make determinations about individual claim validity or settlement amounts.
- Do NOT skip the regulatory compliance phase — claims handling is heavily regulated.
- Do NOT assume automation is always desirable — flag where human judgment is legally required.
- Do NOT conflate fraud indicators with confirmed fraud — note confidence levels.
- Do NOT provide legal advice on bad faith exposure — flag issues for legal review.