Insurance Claim Handling End‑to‑End

Estimated reading: 7 minutes 8 views

When a customer files an insurance claim, the process begins with data entry—but doesn’t end there. The real work starts when you need to assess fraud risk, coordinate inspections, review medical records, or negotiate settlements. Most teams default to a rigid, linear flow, but that often collapses under the weight of exceptions, missing data, or evolving evidence.

What works better is a hybrid model: use BPMN to manage the predictable parts—like validation and initial triage—while reserving CMMN for the adaptive core: the claim investigation and settlement. This approach respects both the need for control and the reality of unpredictable knowledge work.

Over 20 years in business modeling, I’ve seen teams force-fit complex claims into BPMN workflows, only to end up with diagrams that are too complex to maintain. The breakthrough came when I started treating the claim as a *case*—not a process. The result? Cleaner models, faster decision-making, and more accurate process predictions.

You’ll learn how to split responsibilities between BPMN and CMMN, where to use a CMMN subcase, and when to trigger a full case plan. This is not theory—this is how we model real insurance processes today.

Why a Hybrid Model Works for Insurance Claims

Insurance claim handling is neither fully predictable nor entirely unstructured. It begins with rules: validate policy coverage, check claim type, confirm date of loss. But once those are met, the path diverges.

One claim may require a vehicle inspection, another a medical report, a third a fraud investigation. These decisions aren’t scripted. They depend on evidence, expert judgment, and evolving information.

BPMN excels at handling the high-volume, rule-based steps. CMMN is designed for the human-centered, dynamic work that follows. This division of labor prevents over-engineering the flow while preserving traceability and control.

Key Decision Points

Start with BPMN for initial validation: policy in force, claim within timeframe, valid documentation.
Delegate to CMMN for investigation: evidence gathering, expert review, settlement negotiation.
Use a CMMN subcase when the investigation has a lifecycle of its own and requires independent task management.
Integrate both via a gateway: after validation, trigger the CMMN case plan.

Step-by-Step: Designing the Hybrid Claim Model

Step 1: Model the BPMN Validation Flow

BPMN is ideal for the front-end. Use a sequence flow to capture:

Claim submission event
Automatic validation: policy status, claim type, date range
Check for missing documents → send notification
Pass or fail decision

If validation fails, send to a retry loop or escalate. If passed, proceed to the CMMN subprocess.

Step 2: Create the CMMN Subcase for Investigation

This is where the real complexity lives. When the claim passes validation, you trigger a CMMN subprocess embedded within the BPMN flow. This is a CMMN subcase example—a case that runs as part of a larger process but maintains its own lifecycle.

Define the case plan with:

Stages: Preliminary Review, Investigation, Settlement Negotiation
Tasks: Assign to adjuster, request inspection report, obtain medical records
Milestones: Fraud suspicion identified, evidence reviewed, settlement proposed
Case files: attach claim form, photos, medical reports, adjuster notes

Each task is initiated based on conditions and evidence—not a fixed sequence. This is where CMMN shines.

Step 3: Define Entry and Exit Criteria

Use sentries to control when a stage or task activates:

Entry condition: “Validated claim submitted and no fraud flags”
Exit condition: “All evidence collected and adjuster approval obtained”

These conditions can be dynamic. If new evidence emerges, you can reopen the investigation stage—no need to rework the entire flow.

Step 4: Link Back to BPMN for Closure

Once the CMMN case completes, return control to BPMN to finalize settlement, issue payment, and close the claim.

Use a boundary event in BPMN to catch the completion of the CMMN case. This keeps the main flow clean and modular.

Visualizing the Integration

Here’s a simplified flow of the interaction:

BPMN:
[Start] → Validate Claim → [Pass? Yes] → Trigger CMMN Subcase → [Wait for Completion] → Issue Payment → [End]

CMMN Subcase (Embedded):
Stages: Preliminary Review → Investigation → Settlement Negotiation
Tasks: Adjuster assigned, Inspection scheduled, Medical report received
Sentries: Check fraud risk, Verify evidence, Secure approval

This integration is not a workaround. It’s the foundation of adaptive process modeling in practice.

Benefits of the Hybrid Approach

The advantages go beyond just better diagrams. This model supports:

Clarity: No more spaghetti logic in BPMN. The investigation is self-contained.
Traceability: Every decision, task, and document is linked to the claim.
Flexibility: If an adjuster needs to re-open a stage, they can do so without changing the BPMN flow.
Automation readiness: CMMN tasks can be linked to workflow engines or AI tools for document analysis.

Common Pitfalls and How to Avoid Them

Even with a smart design, missteps happen. Here’s what to watch for:

Overloading BPMN: Don’t force all claim logic into BPMN. Keep it for validation and coordination.
Weak CMMN criteria: Vague conditions like “adjuster decides” lead to confusion. Use measurable triggers: “if fraud score > 70” or “if medical report delayed by 7 days”.
Missing case file integration: Ensure evidence, notes, and reports are stored in the CMMN case file—not scattered across systems.
Ignoring the human role: CMMN is not a replacement for human judgment. Models should reflect decision-making, not just task execution.

Real-World Application: Auto Claim Example

Consider a car insurance claim:

BPMN validates: policy active, claim within 30 days, damage reported.
Triggers CMMN subcase for vehicle inspection and repair cost estimation.
Adjuster opens the case. A task is created: “Schedule inspection.”
Sentry activates: “If inspection not scheduled in 48 hours, escalate to supervisor.”
After inspection, the adjuster reviews photos, estimates repair cost, and proposes settlement.
CMMN case completes. BPMN proceeds to payment.

This is insurance process modeling done right—structured, scalable, and adaptive.

Why CMMN Subcase Example Matters

Using a CMMN subcase isn’t just about embedding a case within a process. It’s about treating the claim investigation as a micro-case with its own goals, tasks, and rules.

This pattern supports:

Reusability: the same investigation logic can be applied to theft, fire, or liability claims.
Scalability: multiple claims can run in parallel, each with their own subcase.
Transparency: stakeholders see a clear audit trail of decisions and evidence.

This is the power of CMMN subcase example in action—modular, flexible, and grounded in reality.

Frequently Asked Questions

When should I use BPMN vs CMMN for insurance claims?

Use BPMN for predictable steps: claim submission, validation, policy checks. Use CMMN for adaptive work: evidence gathering, negotiation, fraud checks. The hybrid model ensures clarity and control.

Can I use CMMN without BPMN?

Yes, but only for standalone cases. For end-to-end claim handling, BPMN provides the framework. CMMN handles the adaptive core. Use both for full lifecycle control.

How do I model the transition from BPMN to CMMN?

Use a sequence flow in BPMN that triggers a CMMN case plan. In Visual Paradigm, this is done via a BPMN call activity that references a CMMN case model. Ensure the gateway handles both success and failure paths.

Is CMMN harder to learn than BPMN?

CMMN introduces new concepts—stages, sentries, case files—but it’s more intuitive for adaptive work. It doesn’t require complex gateways or swimlanes. The learning curve is steeper at first, but the payoff in clarity is immediate.

What tools support hybrid BPMN-CMMN modeling?

Visual Paradigm, Camunda, and Signavio offer integration. Visual Paradigm allows embedding CMMN subcases in BPMN flows, with automatic syncing and version control.

How do I ensure model consistency between BPMN and CMMN?

Use a shared model repository. Define common data elements (claim ID, status, date) in both models. Use checklists to verify that all claims are traceable and that exit criteria are met.

Final Thoughts

Insurance claim handling is not a single flow. It’s a dynamic interaction between rules, data, and human judgment. The best models reflect that reality—not just process mechanics.

By using BPMN for validation and CMMN for investigation, you create a model that’s both structured and flexible. This hybrid approach is not just best practice—it’s the only way to model real-world complexity without sacrificing maintainability.

For deeper exploration, refer to the Hands-On Exercise in the next chapter, where you’ll build this model step by step in Visual Paradigm.