Claims Management Systems (CMS) have long served as systems of record: passive tools designed to capture and store information after the real work has been done elsewhere. But that model has reached its limits. The next generation of CMS is not a place to log decisions. It’s where those decisions are made. Welcome to the agentic era of claims handling, where your claims management system becomes a system of action.
The Legacy CMS: A System of Record
For decades, claims management systems were designed to keep a reliable man-made history of what had already happened in a claim. The architecture and workflows focused on documentation: case notes, attachments, status updates, and logs of communication. Their value came from compliance, auditability, and consistency.
This approach was shaped by technical limitations at the time. With no practical way to connect multiple platforms, claims management systems focused on capturing and storing activity and addressing documentation needs rather than actively supporting claim execution.
But over time, even the most disciplined organizations found themselves operating outside the system: using Outlook for correspondence, phones for updates, and spreadsheets for coordination. The actual work of handling claims, like negotiating with claimants, contacting vendors, and escalating for review, took place elsewhere. The CMS was where you went to write it down after the fact, creating redundant manual work.
Some CMS, like Five Sigma, recognized this reality early and responded by embedding record-keeping action into the platform. Omnichannel communications (email, SMS, phone, video) were built into the platform. Every conversation was logged automatically, in the right context, with no extra effort from the adjuster. This was the first shift toward assigning the work to the system.
Still, even these advances didn’t change the fundamental nature of the CMS. It was a better witness, but not yet a participant.
Beyond Logging: Where the Claim Work Actually Happens
The real issue isn’t where the records live. It’s where the work happens. Adjusters spend hours updating systems instead of progressing claims. Inconsistencies and leakage go unchecked, and customers experience slower responses and less clarity.
When decisions, escalations, approvals, and actions take place outside the system, insurers lose visibility. It becomes harder to answer basic questions:
- What specific decision point caused the claim to stall or accelerate?
- Were the right vendors selected based on data, or based on habit?
- How did adjuster actions influence total cost, settlement time, or customer satisfaction?
Often, the answers are buried in the adjuster’s memory or scattered notes, if they exist at all.
That gap creates friction, inconsistency, and claim leakage. It makes it hard to analyze outcomes, improve workflows, or scale operations. It makes onboarding new adjusters slow and error-prone.
To solve this, the CMS can’t just track activity. It has to become the environment where the work is done. That requires agency.
What Defines a Claims System of Action
Agency means the system isn’t waiting to be told what to do. It understands the process, observes the state of the claim, and takes initiative to move it forward. It does the actual work of following the steps of a claim’s workflow, executing it according to the insurer’s rules.
This can be achieved through agentic AI: a breakthrough in the way AI technology has been operating up until now. Unlike traditional automation or recommendation engines, agentic AI is built to plan, decide, and act. It applies reasoning to the context of each claim, figures out what needs to happen next, and executes the appropriate task, adapting in real time as data changes.
A system of action puts this agency at its core. It moves the CMS from being a historical archive to a living, operational environment.
Here are the ten foundational capabilities that define a true system of action:
- Knowledge of process – The system must understand the workflows, rules, and procedures that govern each claim type and line of business.
- Knowledge of claim state
The system must always know what has been completed in each claim and what hasn’t. - Answer any claim query
The system must combine real-time awareness of the claim’s current state with a deep understanding of the underlying process, enabling accurate answers to any question about a specific claim. - Planning and analysis
It should analyze what’s been done against what should be done, identify gaps, and plan the next steps. - Execution
The system must be able to take action directly: sending messages, triggering tasks, generating documents, or advancing a workflow. - Human-in-the-loop escalation
It should bring issues to the surface for human review at the right time, for approvals, exceptions, or judgment-based decisions. - Feedback collection
Every override, delay, or manual correction is feedback. The system should learn from it, and improve accordingly, optimizing its handling processes. - Outcome traceability
Every claim outcome should be traceable to the decisions and actions that produced it. - Monitoring at scale
The system must monitor how well processes are working across users, claims, and time. - Customizability and control
Insurers should be able to define and refine all of the above, without code and without waiting.
Clive™ and the Agentic CMS
Five Sigma was designed from the beginning to be a system of action.
Clive™, Five Sigma’s Multi-Agent AI Claims Expert, is working inside the CMS, turning it into an execution layer. Clive understands each claim’s current state and what should happen next, based on the insurer’s workflows and SOPs. He plans, triggers, and executes the next action automatically. When human input is needed, he escalates. When feedback is given, he learns.
As a multi-agent, Clive manages multiple AI agents that handle and automate different tasks and claim handling stages, including: intake, triage, liability assessment, coverage, communications, fraud detection, compliance, settlement, and more.
Clive is the future that is already operational, delivering results and measurable benefits.
Ready for a CMS That Takes Action?
Operating on a system of action changes how claims organizations work. It creates clarity across every claim, consistency across every team, and confidence in every decision. Adjusters spend less time managing systems and more time delivering outcomes. Leaders gain visibility, control, and the ability to improve continuously. And customers experience faster, clearer, and more responsive service.
This is the foundation insurers need to handle modern claims complexity.
Ready to transform your CMS into an action system? Schedule a demo today!
