Insurance Claim and Risk Adjustment

One of the most common misconceptions in insurance case management is treating claim processing as a linear workflow. I’ve seen teams spend months designing rigid BPMN flows only to find they break at the first unexpected document or medical report. The truth is, insurance claims are inherently unpredictable. That’s where CMMN shines — not as a replacement for structure, but as a framework that embraces ambiguity.

The key insight? Not every claim follows the same path. Some require immediate risk adjustment. Others stall on missing documentation. A few demand expert review. CMMN insurance claim modeling isn’t about defining every step in advance — it’s about setting up the right conditions to handle what comes next.

This chapter walks through a real-world CMMN claim example to demonstrate how to design a flexible, event-driven case plan that adapts to actual business events. You’ll learn how to model actor responsibilities, document dependencies, approval thresholds, and risk triggers — all within a single, maintainable diagram.

Core Components of a CMMN Insurance Claim Model

Defining the Case Plan Structure

Start by defining the case as a single, adaptive entity. The case plan model should reflect the claim lifecycle, not a rigid sequence. Use stages to group related tasks and events.

Common stages for insurance claims include:

• Claim Submission – Initial intake, data capture, policy validation
• Document Collection – Gathering medical reports, police reports, repair estimates
• Risk Assessment – Evaluating claim legitimacy and risk profile
• Adjustment & Approval – Determining settlement amount and authorization
• Payout or Denial – Final decision and communication

Each stage is a container for tasks and milestones. The power lies in not forcing every claim through every stage — some may skip directly to review if the risk is low.

Modeling Case Actors and Responsibilities

Insurance claims involve multiple actors: the claimant, adjuster, medical reviewer, risk analyst, and claims manager. In CMMN, these are modeled as human services or actors assigned to tasks.

Assign tasks dynamically based on conditions. For example:

• If the claim amount exceeds $10,000 → assign to Senior Adjuster
• If medical report is pending → assign to Medical Reviewer
• If claim involves a totaled vehicle → trigger repair estimate task

Use case file items to capture actor decisions. A claimStatus item can store whether the claim is “Pending”, “Under Review”, or “Approved”.

Using Sentries to Drive Dynamic Behavior

Sentries are the heartbeat of CMMN. They trigger task activation based on events or conditions.

For example:

• Entry Sentries on the Risk Assessment stage: Activate only when all documents are uploaded and policy is valid.
• Event Sentries: If a medical report is submitted, activate the Medical Review task.
• Conditional Sentries: If claim type is “accident” AND damage exceeds $5,000 → escalate to Risk Analyst.

These sentries are not just triggers — they’re decision points that adapt the case path in real time.

Designing a CMMN Claim Example: A Step-by-Step Workflow

Step 1: Set Up the Case Plan

Create a case named InsuranceClaim. Define these stages:

1. Claim Intake
2. Document Collection
3. Risk Adjustment
4. Adjustment Approval
5. Payout or Denial

Each stage contains tasks and milestones. Use visual modeling tools like Visual Paradigm to organize the layout clearly.

Step 2: Define Case File Items

Create the following items in the case file:

Item	Type	Usage
claimAmount	Number	Determines risk level and approval path
claimType	String (e.g., accident, theft, fire)	Triggers specific review rules
status	String (Pending, Under Review, Approved, Denied)	Tracks progress
documentsSubmitted	Boolean	Used in sentry conditions

These items are referenced in sentry conditions and task assignments.

Step 3: Implement Conditional Task Activation

Here’s how a typical sentry might look:

[Stage: Risk Adjustment]
  [Task: Risk Assessment]
    Entry Condition: 
      claimAmount > 5000 AND claimType = "accident"
    Event Condition:
      documentType = "medicalReport" AND status = "submitted"

When both conditions are met, the task activates. If the claim is under $5,000, the risk adjustment may be auto-approved.

Step 4: Handle Escalations via Milestones

Use milestones to define key decision points:

• Milestone: Document Complete – All required documents are uploaded
• Milestone: Risk Threshold Met – Claim exceeds $7,500
• Milestone: Final Approval – All reviewers have signed off

These milestones are not tasks. They’re signals that help determine the next stage. For example, if status = "approved" and milestone: Final Approval is reached, the claim proceeds to payout.

Insurance Modeling CMMN: Real-World Trade-offs

Flexibility vs. Control: Finding the Balance

One of the biggest challenges I’ve seen is over-modeling. Teams want to anticipate every possible scenario, leading to complex sentry conditions and tangled logic.

My advice: Model only what you can reasonably monitor. For example, don’t create 15 different document types unless necessary. Use generic document items with type and status fields instead.

Also, avoid setting too many entry conditions. If a stage requires 5 conditions, you risk blocking the case when one field is missing. Instead, use event-based activation for non-critical tasks.

When to Use CMMN vs. BPMN

Not every insurance task needs CMMN. For example:

• BPMN is ideal for automated workflows like “notify customer after payout”
• CMMN is better for “assess claim risk” — where decisions depend on unstructured data

Integrate both. Use CMMN for adaptive parts and BPMN for structured subprocesses.

Validating Your CMMN Model

Run simulations to test edge cases:

• What if the claimant submits only partial documents?
• What if the medical report arrives after the adjuster has already approved?
• How does the system handle duplicate claims?

Use tools that support dynamic simulation to test multiple claim paths. Build test cases for high-risk scenarios — not just the ideal flow.

Frequently Asked Questions

What is a CMMN claim example used for in insurance?

A CMMN claim example demonstrates how to model adaptive case workflows — from claim submission to payout — using event-driven tasks and dynamic decision logic. It shows how different claim types, amounts, and documents trigger distinct paths.

How does CMMN modeling help with risk adjustment in insurance?

CMMN allows risk adjustment to be modeled as a conditional task triggered by claim amount, type, or document status. Sentries evaluate risk thresholds dynamically, enabling automatic escalation or manual review based on real-time data.

Can I use CMMN for both simple and complex claims?

Absolutely. CMMN handles both. Simple claims may follow a direct path: submit → verify → approve → payout. Complex claims activate multiple stages and tasks based on sentry conditions — such as medical review or legal hold.

Is CMMN insurance claim modeling suitable for automation?

Yes — but only when integrated with other standards. CMMN defines the adaptive logic. Use DMN for decision rules (e.g., “Is claim eligible for settlement?”) and BPMN for automated handoffs (e.g., “Notify customer via email”).

How do I avoid over-modeling in CMMN insurance claim workflows?

Start with the core stages. Add tasks and sentries only when business events require them. Use case file items to capture state rather than hardcoding conditions. Test with realistic scenarios — if you need more than 3–4 sentry conditions per task, re-evaluate the design.

What tools support CMMN modeling for insurance?

Visual Paradigm, Camunda, and IBM BPM support CMMN modeling. Choose one with simulation, validation, and integration capabilities. I recommend Visual Paradigm for its clean interface and strong CMMN support, especially when building insurance modeling CMMN diagrams.

Key Takeaways

• CMMN insurance claim modeling thrives on adaptability, not linearity.
• Use stages, sentries, and case file items to manage complexity.
• Insurance modeling CMMN is not about automating every step — it’s about enabling expert judgment.
• Integrate CMMN with DMN for decision logic and BPMN for execution.
• Test real-world scenarios to validate your model — not just ideal flows.

Mastering CMMN insurance claim modeling isn’t about memorizing rules. It’s about building a responsive system that guides, not dictates — empowering adjusters, reviewers, and managers to do their best work when it matters most.