I. End-to-End Workflow Collaboration
· Functions: Builds a closed-loop process across five core modules: claim reporting, document receipt, case registration, review management, and approval management.
o Claim Reporting: Supports multi-channel information collection and automatically triggers subsequent processes.
o Document Receipt: Enables digital receipt of claim documents, reducing manual handover.
o Case Registration: Automatically links policies and claim data based on predefined rules, accelerating case initialization.
o Review & Approval: Automated task allocation and electronic approval flows ensure seamless process handoffs.
· Value: Shortens cross-stage data transfer time and resolves inefficiencies in traditional claims workflows.
II. Data Architecture Framework
· Functions: Establishes five themed data domains—case information, claim process, claim expenses, claim calculation, and duplicate claim records—for centralized governance and structured management.
o Integrates core claim data, avoiding fragmented storage and duplicate entry.
o Standardizes calculation rules to ensure traceable processes and full-chain expense management.
· Value: Resolves data fragmentation and consistency issues, enhances data reuse, and improves decision-making accuracy.
III. Integrated System Architecture
· Functions: Achieves seamless interaction with both internal and external systems through standardized APIs and service orchestration.
o Internal Interfaces: Cover core business functions such as claim calculation matching and case cancellation, enabling module-level reuse.
o External Interfaces: Connect with customer view systems, workflows, and imaging platforms; standardized messaging reduces interaction costs.
· Value: Breaks down system silos, enhances cross-system data exchange, and supports full-chain collaboration.
IV. Risk Control & Quality Inspection System
· Functions: Leverages a business rules engine and quality inspection modules for precise oversight.
o Business Rules: Define verification logic (e.g., identity checks) and automatically block non-compliant operations.
o Quality Inspection: Automated sampling combined with manual review ensures claim quality.
o Secondary Review & Investigation: Integrates external information sources to strengthen risk-based decision-making.
· Value: Mitigates human oversight gaps, reduces compliance risks, and lowers the probability of claim disputes.
V. Customer Experience & Transparency Enhancement
· Functions: Improves customer-facing service touchpoints across multiple modules.
o Task Monitoring: Provides real-time claim progress tracking, including current status and estimated completion time.
o Claim Care: Proactive follow-up services for major claims cases.
o Unified Query: Consolidates policy, document, and image queries, streamlining operations.
· Value: Enhances transparency, reduces customer communication costs, and alleviates claim-related anxiety.
