Straight-through claims payment

Straight-through claims payment (STP) is not a goal in itself. It is a controlled shortcut for claims that are already simple, well-documented, and unlikely to need human judgment. A claims-ops lead should treat STP as a narrow gate at the end of intake, triage, and assessment, not a blanket policy that every low-dollar file must clear without an adjuster.

The workflow auto-approves and settles eligible claims end-to-end when three independent facts are already on the file and can be cited on the payment record. If any cite is missing, the payment fields stay empty and the claim routes to an adjuster. STP does not invent a settlement amount, infer coverage from context, or assume fraud clearance because nothing flagged upstream.

Upstream work matters. AI FNOL intake and claim triage should have classified the loss as low complexity before STP is even considered. Damage amounts often come from computer vision damage assessment or a structured estimate tied to FNOL facts. Fraud posture should reflect output from real-time fraud pattern detection. STP pays only when those inputs are present as cites, not as tribal knowledge in the workflow log.

A straight-through payment is valid only when the disbursement record explicitly references three sources. Empty fields remain empty. Do not backfill from model confidence, adjuster notes, or a prior draft amount.

Coverage confirmation. The payment must cite the coverage decision that applies to this loss: policy period, covered peril, applicable limits, deductibles, and any endorsement that changes payment eligibility. This is not a summary of the policy PDF. It is the structured outcome of coverage analysis for this claim number. If coverage is provisional, disputed, or waiting on documentation, the coverage cite field stays blank and STP does not run.

Estimate or FNOL facts. The payment must cite either a completed repair estimate (or total loss valuation) or the FNOL fact set the payment is based on when the loss is simple enough that estimate and intake align. The cite should point to the specific artifact: estimate ID, line items, or the FNOL field bundle used to derive the payable amount. If the payable amount is not yet tied to a named artifact, do not populate the payment amount.

Fraud-clear flag. The payment must cite an explicit fraud-clear outcome for this claim: screened, no referral, or cleared after rules review. "No fraud hits" in a log message is not a cite unless the fraud system emitted a structured clear signal tied to this claim. Pending SIU review, elevated score without disposition, or a manual hold all mean the fraud cite stays empty.

An adjuster still owns exceptions. STP is the happy path for files where all three cites exist before funds move. Everything else remains in the adjuster queue with the same SLA and authority model you use today.

Load the three inputs before any pay-or-route decision. Treat loading as a read of authoritative systems, not a scrape of email or PDF attachments.

Step 1: Load coverage. Pull the coverage confirmation object for the claim from your policy admin or claims platform (Guidewire, Duck Creek, Snapsheet, CCC Intelligent Solutions, or equivalent). Confirm the object is bound to this claim ID and reflects the latest coverage determination. If the platform returns partial coverage or a pending state, stop. Do not proceed to payment.

Step 2: Load estimate or FNOL facts. Retrieve the estimate or the FNOL fact bundle the business rules allow for this loss type. For auto physical damage, that is usually a completed estimate with a stable total. For straightforward contents or glass claims, rules may allow FNOL fields plus a fee schedule. If multiple estimates exist, the workflow should use the one your triage rules designated as authoritative, not the highest or lowest.

Step 3: Load fraud clear. Read the fraud disposition from your fraud layer. Only a structured clear or equivalent cleared status counts. A silent pass with no record is not sufficient.

Step 4: Pay only with three cites. If coverage, estimate or FNOL facts, and fraud clear are all present and consistent with business rules (within authority limits, correct payee, no lien flags), create the payment with all three cites populated on the disbursement record. If any cite is missing, leave payment amount and payee fields empty and assign to the adjuster workbench with the reason code for the missing cite.

Step 5: Leave blanks blank. Resist UI defaults that pre-fill a suggested payment. A blank amount is correct when STP cannot run. Operators should see "not ready for STP" rather than a number they might approve by habit.

This is the operational contract: load, verify cites, pay or route. No fourth path where the workflow "helps" by guessing.

Payment with no coverage cite. The most common production failure is releasing funds because triage said "looks covered" while the coverage object was never written to the claim. Auditors and regulators ask what coverage determination authorized the check. Without a cite, you cannot answer. Build a hard block: no coverage cite, no payment object, regardless of dollar size.

Treating STP as always paid. Teams sometimes measure STP rate as success and pressure workflows to clear the queue. That inverts the control. STP success is paying only when cites are complete; routing to an adjuster is also success when cites are incomplete. Dashboards should show routed-for-missing-cite as a healthy outcome, not rework.

Inventing a settlement amount. Language models and rule engines can propose amounts. STP must not use a proposed amount unless it is cited to estimate or FNOL facts. If the model suggests $1,847 but the estimate total is $1,920, the payment cites $1,920 or STP does not run. Never round, blend, or "helpfully" reconcile without an adjuster action.

Stale cites after change. Coverage can change after new facts arrive. An estimate can be superseded. Fraud status can flip on late data. If any authoritative input updates after a draft payment was built, invalidate the payment draft and re-run the three-cite check.

A policyholder reports a cracked windshield through digital FNOL. Triage classifies the loss as low complexity: single pane, comprehensive coverage, no injury, no third party. Coverage analysis runs automatically and writes coverage_confirmed with comprehensive glass benefit and a $0 deductible per endorsement. A photo-based assessment returns a fixed glass fee schedule total tied to estimate EST-88412. Fraud screening returns fraud_clear with no referral.

The STP workflow loads all three objects. The payment record is created for the schedule total only, with cites: coverage_confirmed (claim coverage ID), EST-88412 (estimate total), fraud_clear (screening run ID). Funds release to the selected glass vendor per payee rules.

If the policyholder later reports the crack was from a tracked rock on a commercial policy with a glass exclusion, coverage is updated to not_covered. The prior payment draft, if any uncashed, is voided. No new STP payment is created because the coverage cite is no longer valid. An adjuster owns the exception and any goodwill conversation. The workflow did not invent a lower payment or partial goodwill without human authority.

STP is the last automated step on a thin slice of claims volume. Most carriers run it against rules in the claims admin platform or a orchestration layer that sits above policy, billing, and payment rails. Guidewire, Duck Creek, Snapsheet, and CCC Intelligent Solutions each expose different hooks for coverage decisions, estimates, and payments; your integration pattern is the same class of problem: read authoritative objects, write payments with cites, route exceptions to the adjuster desktop.

Payment execution may still flow through your existing disbursement or vendor payment module. The STP workflow should not bypass lien, subrogation, or mortgagee rules encoded in those systems. For claims that touch billing questions after payment (copay confusion, installment plans on premium, not the claim itself), keep that traffic on channels like a billing inquiry voice agent separate from STP so ops teams do not mix premium service with claim settlement authority.

Define eligibility in policy language your adjusters already use: loss types, dollar caps, peril lists, and excluded scenarios (injury, total loss, contested liability, SIU referral). Review routed claims monthly for cite gaps that indicate upstream fixes (better triage, faster estimates, clearer fraud dispositions) rather than pressure to auto-pay more files.

Straight-through payment earns trust when every automated check is visible on the disbursement record and every exception has an owner. Load coverage, estimate or FNOL facts, and fraud clear; pay only when all three cite; leave blanks when they do not. Adjusters keep authority over everything else.

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