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Insurance / APPLICATION BLUEPRINT

Health Benefits Loss Evidence Collection Appointments

Coordinates approved evidence-gathering visits for health benefit service cases, records permissions and assigns qualified service providers.

Start with this blueprintExplore illustrative interface

13 workspace menus · 13 business workflows · 5 role profiles

Application blueprint only. This is a proposed design, not a deployed or production-tested system. Screens and sample figures are illustrative; workflows, business rules, approvals, permissions and integrations require confirmation before build.

Designed for insurance operations coordinators and the responsible business owners

Health Benefits Loss Evidence Collection Appointments workspace interface preview; illustrative records and figures.
Health Benefits Loss Evidence Collection Appointments — operational workspaceIllustrative interface · Sample dataView full interface →

Explore an illustrative interface.

Illustrative workspace and record review. Select a concept screen to inspect it in full.

Health Benefits Loss Evidence Collection Appointments workspace interface preview; illustrative records and figures.
Health Benefits Loss Evidence Collection Appointments — operational workspaceIllustrative interface · Sample dataView full interface →
Health Benefits Loss Evidence Collection Appointments record interface preview; illustrative records and figures.
Health Benefits Loss Evidence Collection Appointments — record and workflow reviewIllustrative interface · Sample dataView full interface →

Operational dashboards and work queues.

Operational views

Review work, evidence, exceptions and authorised decisions within a defined operating scope.

Portfolio / service teamPeriodAssigned teamReview state

Dashboard measures

  • Active service bookings
    Count of all records in the selected workspace.
  • Review queue
    Records at the third stage of the business workflow.
  • Needs attention
    Records with an assigned review requirement.
  • Final-stage records
    Records in the fourth business workflow stage.

Business workflow and operating scope

Coordinates approved evidence-gathering visits for health benefit service cases, records permissions and assigns qualified service providers. Tracks submitted records, missed appointments and reviewer questions without determining fraud, causation, coverage or liability from the collected material alone.

Operations

Operational overview

Review the work position and priority actions.

Evidence-gathering visits

Coordinate evidence-gathering visits with assigned responsibilities, linked records and review history.

Permissions

Coordinate permissions with assigned responsibilities, linked records and review history.

Qualified service providers

Coordinate qualified service providers with assigned responsibilities, linked records and review history.

Submitted records

Coordinate submitted records with assigned responsibilities, linked records and review history.

Missed appointments

Coordinate missed appointments with assigned responsibilities, linked records and review history.

Reviewer questions

Coordinate reviewer questions with assigned responsibilities, linked records and review history.

Causation

Coordinate causation with assigned responsibilities, linked records and review history.

Coverage or liability

Coordinate coverage or liability with assigned responsibilities, linked records and review history.

Insights

Reports and saved views

Review the reporting scope and export agreed operational views.

Governance

Approvals and exceptions

Review delegated decisions, exceptions and recorded conditions.

Audit history

Trace accepted changes, decisions and accountable actions.

Access and configuration

Manage the agreed role permissions and configurable operating rules.

The end-to-end business journey.

From intake to authorised completion, with evidence at each decision.

01

Capture the service request

Establish the scope of evidence-gathering visits, capture the required records and assign the accountable team.

02

Confirm capacity and prerequisites

Coordinate permissions, qualified service providers, with linked evidence and visible outstanding actions.

03

Coordinate the scheduled service

Review the relevant conditions and exceptions. Record the authorised outcome and its supporting evidence.

04

Record completion and follow-up

Confirm the resulting records and handovers. Track remaining obligations, later changes and follow-up actions.

Business workflows

Select a workflow to review the steps, responsibilities, approval and exception handling.

01 · Coordinate approved evidence-gathering visits

Coordinate approved evidence-gathering visits within Health Benefits Loss Evidence Collection Appointments.

Trigger
Approved evidence-gathering visits requires a new record, an agreed review or a controlled change.

Responsible role
Specialist reviewer

  • Register approved evidence-gathering visits and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

02 · Record permissions

Coordinate permissions within Health Benefits Loss Evidence Collection Appointments.

Trigger
Permissions requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register permissions and its operating scope
  • Check permitted purpose, prerequisites and authority
  • Record the delegated approval or refusal
  • Track term, withdrawal and later changes

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Authority is missing, permission changes or the requested purpose exceeds the accepted scope.

Outcome
A scoped permission or recorded refusal, its conditions and review history.

03 · Assign qualified service providers

Coordinate qualified service providers within Health Benefits Loss Evidence Collection Appointments.

Trigger
Qualified service providers requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register qualified service providers and its operating scope
  • Assign the accountable owner and required actions
  • Review the relevant evidence and unresolved conditions
  • Confirm the accepted outcome and retain its history

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Required information or responsibility is missing, or an operating condition changes.

Outcome
A completed operating record with its linked evidence and remaining obligations.

04 · Track submitted records

Coordinate submitted records within Health Benefits Loss Evidence Collection Appointments.

Trigger
Submitted records requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register submitted records and its operating scope
  • Assign the accountable owner and required actions
  • Review the relevant evidence and unresolved conditions
  • Confirm the accepted outcome and retain its history

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Required information or responsibility is missing, or an operating condition changes.

Outcome
A completed operating record with its linked evidence and remaining obligations.

05 · Track missed appointments

Coordinate missed appointments within Health Benefits Loss Evidence Collection Appointments.

Trigger
Missed appointments requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register missed appointments and its operating scope
  • Compare suitable capacity and existing commitments
  • Confirm the provider, service window and accepted conditions
  • Track fulfilment, cancellation and capacity release

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Demand exceeds suitable capacity or a provider withdraws its commitment.

Outcome
An accepted capacity commitment with service conditions and completion evidence.

06 · Track reviewer questions

Coordinate reviewer questions within Health Benefits Loss Evidence Collection Appointments.

Trigger
Reviewer questions requires a new record, an agreed review or a controlled change.

Responsible role
Specialist reviewer

  • Register reviewer questions and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

07 · Coordinate causation

Coordinate causation within Health Benefits Loss Evidence Collection Appointments.

Trigger
Causation requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register causation and its operating scope
  • Assign the accountable owner and required actions
  • Review the relevant evidence and unresolved conditions
  • Confirm the accepted outcome and retain its history

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Required information or responsibility is missing, or an operating condition changes.

Outcome
A completed operating record with its linked evidence and remaining obligations.

08 · Coordinate coverage or liability

Coordinate coverage or liability within Health Benefits Loss Evidence Collection Appointments.

Trigger
Coverage or liability requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register coverage or liability and its operating scope
  • Assign the accountable owner and required actions
  • Review the relevant evidence and unresolved conditions
  • Confirm the accepted outcome and retain its history

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Required information or responsibility is missing, or an operating condition changes.

Outcome
A completed operating record with its linked evidence and remaining obligations.

09 · Register the operating requirement

Coordinate operating requirement within Health Benefits Loss Evidence Collection Appointments.

Trigger
Operating requirement requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register operating requirement and its operating scope
  • Compare options, dependencies and operating constraints
  • Review the selected option with its accountable owners
  • Accept the plan and track its delivery conditions

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
An assumption changes, prerequisites are missing or stakeholders cannot accept the proposed commitment.

Outcome
An approved operating plan and owned actions for its accepted conditions.

10 · Resolve operating exceptions

Coordinate operating exceptions within Health Benefits Loss Evidence Collection Appointments.

Trigger
Operating exceptions requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register operating exceptions and its operating scope
  • Gather the relevant evidence and review options
  • Route the case to the delegated decision owner
  • Record the outcome, conditions and follow-up obligations

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
The case exceeds delegation, contains a conflict or has disputed evidence.

Outcome
An authorised decision or escalation with accountable resolution actions.

11 · Verify completion and follow-up

Coordinate completion and follow-up within Health Benefits Loss Evidence Collection Appointments.

Trigger
Completion and follow-up requires a new record, an agreed review or a controlled change.

Responsible role
Specialist reviewer

  • Register completion and follow-up and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

12 · Review controlled operating changes

Coordinate controlled operating changes within Health Benefits Loss Evidence Collection Appointments.

Trigger
Controlled operating changes requires a new record, an agreed review or a controlled change.

Responsible role
Specialist reviewer

  • Register controlled operating changes and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

13 · Prepare scoped operational reports

Coordinate scoped operational reports within Health Benefits Loss Evidence Collection Appointments.

Trigger
Scoped operational reports requires a new record, an agreed review or a controlled change.

Responsible role
Insurance operations coordinator

  • Register scoped operational reports and its operating scope
  • Assign the accountable owner and required actions
  • Review the relevant evidence and unresolved conditions
  • Confirm the accepted outcome and retain its history

Approval
Authorised decision maker records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Required information or responsibility is missing, or an operating condition changes.

Outcome
A completed operating record with its linked evidence and remaining obligations.

Governance and control

  • Role permissions reflect the agreed responsibilities and restricted record access.
  • Sensitive information is restricted to the agreed roles and permitted sharing scope.
  • Required information and evidence are checked before the relevant decision or handover.
  • Exceptions have a named owner, recorded reason and an authorised resolution.
  • Approved changes retain their previous values, accountable decisions and linked evidence.
  • Integration mappings, business rules and acceptance criteria are reviewed with the customer.
Operating rules by business workflow
  • For approved evidence-gathering visits, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For permissions, the request stays within the recorded permission and delegated authority.
  • For qualified service providers, the record retains an accountable owner, its supporting evidence and accepted outcome.
  • For submitted records, the record retains an accountable owner, its supporting evidence and accepted outcome.
  • For missed appointments, capacity is committed only after prerequisites and the responsible provider are confirmed.
  • For reviewer questions, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For causation, the record retains an accountable owner, its supporting evidence and accepted outcome.
  • For coverage or liability, the record retains an accountable owner, its supporting evidence and accepted outcome.
  • For operating requirement, the accepted plan records assumptions, rejected alternatives, dependencies and conditions.
  • For operating exceptions, a decision retains its authority, reason, supporting evidence and resulting obligations.
  • For completion and follow-up, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For controlled operating changes, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For scoped operational reports, the record retains an accountable owner, its supporting evidence and accepted outcome.

Data, interfaces and operating requirements.

Core records

Service bookingEvidence-gathering visitsPermissionsQualified service providersSubmitted recordsMissed appointmentsDecisionSupporting evidenceActivity history
Record fields and linked information
  • Record identifier — Stable reference for the operating transaction.
  • Portfolio / service team — Business scope used for responsibility and reporting.
  • Operating subject — The request, commitment or work item being handled.
  • Accountable owner — Named responsibility for the next action.
  • Workflow stage — Current position in the agreed business journey.
  • Review requirement — Required review and outstanding decision.
  • Due or review date — Agreed action window or review trigger.
  • Linked evidence — Source records supporting the operating decision.
  • Decision authority — The delegated authority relevant to the accepted outcome.
  • Accepted outcome — Recorded decision and its business consequences.
  • Follow-up obligation — Remaining responsibilities after an accepted action.
  • Revision history — Trace of accepted changes and their evidence.
  • Evidence-gathering visits reference — Link the relevant evidence-gathering visits to the operating transaction and its decision evidence.
  • Permissions reference — Link the relevant permissions to the operating transaction and its decision evidence.
  • Qualified service providers reference — Link the relevant qualified service providers to the operating transaction and its decision evidence.
  • Submitted records reference — Link the relevant submitted records to the operating transaction and its decision evidence.
  • Missed appointments reference — Link the relevant missed appointments to the operating transaction and its decision evidence.

Systems and interfaces

  • Policy, claims and financial records
  • Approved broker, repair or service-network interfaces
  • Identity and role-based access services
  • Approved document and communication services

Interface scope, data mapping and testing are agreed for each engagement.

Implementation requirements
Confirm the operating boundaries, evidence-gathering visits, responsible roles, review authority, record retention, interface mappings and acceptance scenarios.

Mobile and tablet access

Authorised users can review evidence-gathering visits, supporting records and assigned actions through mobile and tablet access. The relevant tasks and permissions are agreed for the deployment.

Access approved workflows through the Dalfin mobile app. Device tasks and permissions are confirmed for the deployment.

Apple App Store ↗Google Play ↗

AI extensions

Core workflows and approval rules are defined with your business owners. Operational AI can be assessed separately against a specific business outcome and review requirements.

AI extensions are scoped around the required data, business outcome and review controls.

Engineered with Genesis.

Structured application engineering

Connect requirements, roles, records, workflows and interfaces through the agreed Genesis engineering process.

Controlled changes

Review dependency impact and validation requirements. Context Memory supports governed changes and accepted application revisions.

Deployment and support

Agree customer cloud or on-premises requirements, device access, implementation acceptance and ongoing engineering support.

AN EXAMPLE OPERATING SCENARIO

What to validate in a scoped demonstration.

Start with evidence-gathering visits and follow the record through confirm capacity and prerequisites. Introduce a missing item or operating exception, record the authorised resolution and inspect the final handover, evidence and history.

What to review

  • A saved end-to-end transaction
  • An exception and its authorised resolution
  • Different operator, approver and reviewer permissions
  • Final records, history and the relevant report
Discuss this solution

Questions before implementation.

What can we review in a tailored demonstration?

Review a representative service booking, its workflow stages, accountable roles, an exception and the resulting operational report. Bring the business process and existing system requirements that matter to your organisation.

How is the solution adapted to our organisation?

The operating scope covers your records, role permissions, review authority, business rules and integration boundaries. These requirements are agreed with the responsible business owners.

How does the solution connect with existing systems?

Connection design defines interfaces, data ownership, mapping, authentication and exception handling. The agreed implementation includes validation against the selected systems and workflows.

How are subsequent changes controlled?

The agreed engineering approach covers review of change impact, bounded implementation, validation and accepted revisions. Discuss the relevant Genesis Context Memory and support requirements during solution scoping.