Claims Management (FNOL to Settlement) — Host-to-Host Integration

Insurance • Real-time, system-to-system connectivity (no SLA section)

Purpose of Host-to-Host

Receive First Notice of Loss (FNOL) directly from partners (workshops, hospitals, portals, mobile apps).
Exchange claim status, authorizations, and payment outcomes in real time.
Reduce manual re-keying and accelerate cycle time from FNOL to settlement.

Core Data Objects

Claim header (claimNo, policy, coverage, peril, loss date, place)
Parties (insured, claimant, provider, repairer, adjuster)
Documents & evidence (photos, invoices, medical reports, estimate sheets)
Tasks & authorization (inspection, estimate approval, medical approval, repair authorization)
Payments (reserve, partial/ final settlement, recovery/ subrogation)
Events: fnolSubmitted, estimateReceived, authorizationGranted, paymentIssued, claimClosed

Example API Endpoints

POST /fnol
Create FNOL with policyNo, loss details, contact

POST /claims/{id}/documents
Upload photos, invoices, medical reports

POST /claims/{id}/estimate
Submit repair/medical estimate for review

POST /claims/{id}/authorize
Request and record authorization (amount, scope)

POST /claims/{id}/status
Partner pulls or receives callback for status changes

POST /payments/notify
Bank/PG callback for settlement/ refund status

Reference Flows

Workshop/Hospital → Insurer (FNOL)

Partner submits FNOL + documents
System validates policy coverage & opens claim
Claim number returned; inspection scheduled if needed

Estimate & Authorization

Partner sends estimate → rules/adjuster review
Insurer responds with approve/ counter/ decline + notes
Authorized scope saved; repair/treatment begins

Settlement & Payment

Final invoice received → reconciliation against authorization
Payment order to bank; /payments/notify updates status
Claim closed; documents archived

Status Callbacks

Insurer pushes authorizationGranted, paymentIssued, etc. to partner callback URL
Partners display real-time progress to customers

Security & Controls

mTLS, OAuth2/JWT, IP allow-listing, and message signing (JWS).
Field-level encryption for PII/medical data; secure document storage with access logs.
Idempotency keys, replay protection, and rate limiting.

Monitoring & Audit

Correlation-ID for request/callback pairs; structured JSON logs.
Metrics: error rates, queue lag (if async), callback retries.
Full claim timeline and document access trails.

What You Get

Partner onboarding kit (OpenAPI, mock server, Postman collection).
Mapping templates (claim, estimate, payment objects) and example payloads (JSON).
Callback samples and retry strategy.
Branded documents and email templates.
Annual maintenance incl. change requests; on‑prem or cloud.