Get Started with Claims Management for Digital Insurance

Learning Objectives

After completing this unit, you’ll be able to:

Explain why modernizing claims management is a strategic priority for insurers.
Describe how Claims Management for Digital Insurance supports the claims lifecycle.
Identify where Claims Management fits within the Digital Insurance architecture.
Summarize the core jobs to be done for key claims personas.

Before You Start

Before you start this module, consider completing this recommended content.

This badge describes Claims Management, a feature in Digital Insurance built into the Salesforce Platform. For details about similar features in the managed package, complete the Insurance Claims Foundations badge.

Learn About Claim Demands

Claims are where insurance becomes real. Until a loss occurs, coverage language, deductibles, and exclusions exist as contractual promises. A claim is what you use to test and fulfill those promises.

Operationally, claims are among the most complex functions insurers run. A single claim can involve multiple coverages, damaged assets, and regulatory obligations. It’s important that decisions are made quickly, but it’s also important for them to be defensible, and ensure that every action aligns with policies and stands up to audit.

Customers feel this complexity directly. They expect speed, clarity, and fairness. They have little patience for repeated questions, unexplained decisions, or delays caused by internal rework. Every inconsistency makes customers lose trust when they need it most.

Legacy claims environments struggle under this pressure. Intake, assessment, and financials are often spread across disconnected systems. Product administrators often assemble claim structures manually. As a result, reps and adjusters interpret rules and reconcile data instead of focusing on the loss itself. Finance teams trust reports only after reconciliation.

Modern claims management requires a different foundation in which claims are structured consistently, policy logic is applied automatically, workflows support both automation and human judgment, and financial controls are implemented from first notice through settlement.

That’s exactly what Claims Management for Digital Insurance is designed to do.

This badge introduces Claims Management and how it transitions product and policy design into governed, end-to-end claim execution. In this unit, you learn why claims modernization matters and where Claims Management fits within Digital Insurance. You also explore the claims lifecycle and key roles.

Explore How Claims Management Fits into the Digital Insurance Platform

Salesforce Digital Insurance manages the full insurance lifecycle: product design, quoting, policy administration, billing, and claims.

The core components and features of Digital Insurance.

Every claim references an existing policy. Each claim applies defined limits and deductibles and affects customers that an insurer is already serving across channels. When claims are disconnected from product and policy data, inconsistency and risk follow.

Digital Insurance provides a shared foundation that Claims Management builds on. Here are the parts of that shared foundation and what they do.

A unified experience layer supports agents, adjusters, and customers across channels.
Agentforce surfaces real-time policy context and guides intake and service actions.
A shared insurance data model tracks claims, coverages, and transactions.
Omnistudio and Flows orchestrate intake and servicing without code.
Business Rules Engine evaluates policy and claim logic at run time.

Claims Management extends this foundation with claims specific design and execution. Claim products are configured using the same classification and attribute framework used in Product Administration. Workflow rules govern how claims move through stages. Claim context maps product structures to claim data.

Claims Management also delivers core claims business functions through granular APIs. These APIs power the standard claims experience and are also available through invocable actions in Flow. For broader orchestration patterns, Salesforce provides Apex support so insurers can use the same underlying claims logic across Omnistudio capabilities and other Apex based implementations.

This architecture gives insurers flexibility without fragmenting the logic. The same underlying claims functions can support guided user experiences, automated flows, and custom orchestration patterns.

This connected architecture has practical benefits. The same attribute scopes that define deductibles and limits for quoting and policy servicing are reused when reserves are set and payments are made. When a rule is updated, it applies everywhere that rule is referenced. When an auditor asks how a payment was calculated, the answer traces back to configured policy terms, claim data, and rules.

Trace a Claim Through Its Lifecycle

Claims Management is organized into three connected areas that share the same product and policy model: Claims Foundation, Claims Intake, and Claims Financials.

Claims Foundation is the design-time backbone. Product administrators define claim products and handling definitions, map policy terms stored as Insurance Policy Limit records to the insurance policy product, and configure claim context and workflow rules. This foundation tells the platform what a claim looks like, how it can move, and which rules and operations can act on it.

Claims Intake is when customers and service teams first report a loss. Guided experiences built with Flow and Omniscripts are deployed across rep consoles and customer portals. These experiences use the claim model to verify coverage, route and assign work, and create or update structured claim records. Connect APIs and invocable actions execute the underlying claim logic, ensuring that every intake interaction produces a governed claim hierarchy.

Claims Financials is when financial work begins. Adjusters and specialists use the Claim Financials workspace to create and maintain claim coverages, reserves, and payments, all driven by the policy terms mapped during foundation setup. The underlying financial operations apply authority rules, validate limits, and support accurate, auditable transactions.

Together, these three areas cover the journey from configuration to intake to financial resolution. In the next three units, you examine each phase and explore how design-time choices drive behavior during intake and financial handling.

Match Capabilities to Claims Roles

Claims Management supports several key personas, all sharing the same platform, data, and rules.

Persona	Core Job	How Claims Management Helps
Claims adjusters	Assess loss, apply policy terms, and settle claims fairly.	Use one workspace to review claim details, parties, items, and payments and apply configured limits, deductibles, and coverage rules.
Customer service representatives (CSRs)	Answer questions, gather information, and initiate claims.	Use guided intake flows to collect relevant information in sequence while viewing policy context, coverage terms, and existing claims.
Finance teams	Manage reserves, forecast exposure, and report accurately.	Rely on governed reserve and payment transactions tied directly to policy and product terms that roll up correctly by coverage, region, or portfolio.
Product administrators	Design and maintain product and policy logic across the lifecycle.	Reuse classifications, attributes, and scopes from Product and Policy Administration to drive claim structure and behavior.
Claimants	Report a loss, understand coverage, and receive timely resolution.	Use digital or assisted channels that follow the same guided intake logic.

Together, these personas share a single view of the claim and rely on the same Digital Insurance foundation. Claims Management gives each of them what they need, without fragmenting data or logic across separate tools.

Accelerate Claims Management

Claims often start as a stressful conversation. For example, after an auto accident, a customer calls a CSR and asks what the policy covers. It’s important for the CSR to explain the next step without making promises the policy cannot support.

Agentforce helps claims teams move faster by bringing trusted context into the workspace. Service teams can use Agentforce to:

Generate policyholder and policy summaries that surface key coverage details, limits, and recent activity.
Review claim context and interaction history before responding.
Prepare or prefill intake information so agents can move from inquiry to claim creation.
Draft clear, consistent responses about status and next steps.

Agentforce works within guardrails. It helps users understand and act on what’s already in Salesforce, but coverage decisions, adjudication, and financial authorization still follow configured rules, approvals, and human judgment.

What’s Next

In this unit, you learned that Claims Management extends product and policy design into governed claim execution. Digital Insurance supports that execution through structured data, core claims business functions, and configurable experiences.

In the next unit, you step into claims foundation and learn how claim products are designed. By using many of the same building blocks you know from Product Administration, you define the structure, attributes, and rules that make everything else consistent.

예상 시간

주제

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