Health Insurance Value Streams

Three Parties, and Only One of Them Is the Customer

Health Insurance Value Streams is a set of 34 pre-built flows covering how work moves through a health plan — group sold to members enrolled, provider recruited to contracted and credentialed, service rendered to claim adjudicated, denial to resolved appeal — in editable PowerPoint, with a guide to putting them to use.

A health plan runs almost every flow across three parties at once: the member who receives care, the provider who delivers it, and the employer or exchange that buys the coverage. Each has a different relationship with the plan and a different tolerance for delay, and almost no flow serves only one of them.

That is why a health plan cannot be described by an org chart. Member services, network management and claims each own part of the same sequence, and the parts that fall between them — an eligibility record that has not loaded, a credentialing file that expired, an authorization that was approved under a different plan year — generate most of the volume on the phones.

These 34 flows are drawn at that level. They are broken into steps rather than shown as a member journey, so a team can mark ownership, note where a provider or vendor takes over, and identify which step turns into a call.

Three Questions No Single Department Can Answer

Each of these crosses at least two functions, which is why they persist.

What actually generates the call volume? Member service handles the symptom. The cause is usually an upstream step — an eligibility file, an authorization, a claim edit. Flows connect the two.

Where does provider abrasion come from? Providers experience credentialing, authorization and claims as one relationship with the plan. Plans manage them as three. Mapped flows expose the seams the provider is feeling.

What does a plan year change touch? Benefit design changes ripple into configuration, authorization rules, and claim edits. Carriers that mapped it scope the change; the rest discover it in January.

Why This Matters Now

Interoperability rules and automated review are both landing on named steps in these flows.

Prior Authorization Is Being Rebuilt Around Data Exchange

Electronic authorization changes which steps a request passes through and how long each takes. Scoping that needs the current steps written down first.

Auto-Adjudication Rates Are Won at Specific Edits

The gap between an 80% and a 90% auto-adjudication rate is a handful of edits and configuration steps, not a general improvement to claims.

Appeals and Grievances Run on a Regulatory Clock

Turnaround obligations attach to particular steps. Flows put the clock where it applies rather than in a policy nobody reconciles to the queue.

What Is Included

Two files:

Who This Is Built For

These flows pair with the Health Insurance Capability Model, which states what a plan does; the value streams state in what order and across which party. Neither substitutes for the other.

How to Put It to Work

• Trace call volume back to the upstream step that caused it.
• Mark every step a provider experiences, across all three relationships.
• Attach turnaround obligations to the steps they actually govern.
• Use the flows as the impact inventory for a plan year or benefit design change.

Where Plans Typically Start

What You Are Actually Buying Is Time

Mapping 34 flows internally means weeks of sessions across member services, network, utilization management and claims — all of which are queue-driven operations that cannot pause.

• You edit rather than originate. The flows are drafted; your effort goes to your lines of business, your delegated arrangements, and your configuration.
• Reviewers get something to correct. A claims manager corrects a wrong map far faster than they narrate a right one.
• It stays useful. The same flows serve a platform change, an authorization program, and a provider experience effort.

Those first two columns describe what comparable efforts tend to involve, not a quoted benchmark — your figures depend on scope and who does the work.

Built From Real Engagements

We are software entrepreneurs and business consultants who have delivered business architecture and transformation work across financial services firms. These flows are the distilled, reusable output of that work rather than a theoretical exercise — which is also why they carry the limits described below.

An Honest Note on Fit

These are generic flows designed as a starting point. Customization is expected, not a sign that something went wrong.

Specifically:

Terms You Should Know Before Purchasing

Read the description above in full before you buy. Delivery is immediate and the files are yours to keep, which is also why we cannot take returns, issue refunds, or swap a purchase for a different product once it has been downloaded. What you receive is what is listed — no warranty beyond that, and no bundled customization, implementation help, or support. A Enterprise License covers everyone inside one organization; if you intend to reuse the material across several clients, the Consultancy License is the one you need. The full digital product terms govern the sale.