Industries / Claims management teams
More claims handled. Same claims team.
Your case managers have new lodgements, certificates of capacity, treatment requests, provider invoices and weekly payments in the same queue. The time goes in finding the missing report, checking an approval and chasing the next person. We embed with your team, map how those files really move and put AI on the routine checks and follow-ups. Your people make every claim decision.
Where your team's week goes.
Notifications and lodgements arrive
A worker's injury claim form, employer notification and certificate of capacity, or a CTP Application for personal injury benefits with a Certificate of Fitness. Your team links them to the right claimant, employer, policy and incident.
The file is built for a liability decision
Incident dates, employer accounts, medical reports and prior correspondence have to line up. Missing evidence gets requested and the decision clock is tracked. The claims officer weighs the evidence and records the liability decision, including provisional liability where the scheme allows.
Capacity and payments change
New certificates alter the periods and capacity on file. Case managers check pre-injury average weekly earnings, weekly payment calculations and the suitable duties in the return-to-work or injury management plan.
Treatment requests need an answer
An Allied Health Recovery Request (AHRR), specialist recommendation or rehabilitation proposal is matched to the accepted injury, earlier approvals and clinical reports. In NSW workers compensation, the insurer's treatment decision has a 21-day clock.
Invoices and reimbursements are checked
Provider ABN, claim number, service date, SIRA item code, approval, fee order and duplicate history all matter. NSW's standard calls for valid approved-treatment invoices to be paid within 10 working days, or the provider's terms if later.
Reviews, reserves and disputes stay visible
A new report can change the reserve and the next action. The team tracks outstanding evidence, review requests, decision reasons and the right dispute path, including the Personal Injury Commission where the NSW scheme provides for it.
The cases that eat the time.
Most of the work goes smoothly. These are the ones that come back to someone's desk, and they're where a case engine earns its keep.
A CTP file without its fitness evidence
The Application for personal injury benefits arrives, but the GP's Certificate of Fitness is still missing.
Two incident dates
The worker's injury claim form says 12 September; the employer notification says 13 September.
A gap in certified capacity
The latest certificate ends on Friday and the next starts on Tuesday, across a weekly payment period.
An AHRR that needs context
A physiotherapist requests more sessions, but the latest report does not explain progress against the recovery goals.
An invoice beyond the approval
A PTA002 subsequent consultation is billed as visit seven when the approval letter covers six.
Earnings that do not reconcile
The payroll extract includes an allowance that is missing from the pre-injury earnings worksheet.
A return-to-work plan overtaken by a certificate
The plan still lists full shifts after a new certificate records capacity for shorter hours.
A review request in the wrong queue
A CTP claimant disputes a weekly benefit amount, but the internal review request sits in general correspondence.
What stays with your people.
The engine prepares a source-linked file. Your authorised claims people apply the policy, the scheme rules and their judgement.
Liability and entitlements
A claims officer decides whether to accept or reject a claim, what weekly payments are due and what to tell the claimant. Where AFS claims-handling authorisation applies, those activities sit within the licensee's obligations under ASIC INFO 253.
Treatment and recovery decisions
Your case manager decides whether requested treatment is reasonably necessary and approves or declines it under the relevant scheme. An AHRR, certificate and prior approval can be assembled for review; the engine cannot make the clinical or claims judgement.
Disputes and difficult conversations
A worker challenging a work capacity decision, a CTP internal review or a disputed reserve goes to the appropriate claims specialist. They own the reasons, the communication and the escalation.
What we'd measure together.
Before anything is built, we measure how your cases move today. Every change is measured against that, on your own cases.
Files ready for a decision
The share of incoming claims and requests with the required forms and source evidence assembled before a case manager opens them.
Time spent on an exception
Minutes spent finding the missing certificate, approval or report, and resolving the handoff after it is found.
Decision and payment clocks
Treatment requests and valid approved invoices completed within the applicable scheme timeframe, tracked by claim type and jurisdiction.
Rework and wrong turns
Duplicate invoices, reopened files, missed follow-ups and review requests that reach the wrong queue.
Works alongside what you already use
- Guidewire ClaimCenter
Questions claims teams ask us.
☛We already use Guidewire. What's left to do?+
We start in your actual queue to see what Guidewire already covers. The gaps may be a certificate in an inbox, an approval in a PDF or a review request filed as general correspondence. If there is a useful gap, we scope a way to prepare checks and source links alongside your claims system. Any integration needs your IT and security approval.
☛Will it decide liability or approve treatment?+
No. It can assemble the claim chronology, compare documents with your written rules and point out missing or conflicting evidence. A case manager makes the liability, entitlement and treatment decisions, records the reasons and sends the notice.
☛What happens to our claimants' medical records?+
The free first session needs no claim files. Before any sample or pilot, we agree what records are needed, whether they can be de-identified, who can access them, where and how they will be processed, and when they will be deleted. Your privacy and security teams review that plan before any transfer.
☛Can it keep the SIRA timeframes straight?+
We can test a deadline and follow-up queue against your NSW workers compensation or CTP rules, including the event that starts each clock. The rule set needs your team's sign-off and maintenance when scheme guidance changes. A flagged deadline still has a named staff owner.
☛Where would you start with our claims team?+
With a free 30-minute session. If there is a fit, Mitch and the engineers sit with your team to map one claim type, the documents, queues, handoffs and exceptions. We agree what to measure and only build a small test if the work and data access make sense.
Find out how much of your caseload could run itself.
Start with a free 30-minute session. We'll learn how your cases arrive and tell you honestly how much could run on its own, and what that could mean for your growth.