Claims Processing Flow
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Transcript of Claims Processing Flow
INSURANCE PROCESS FLOW PPT CLAIMS
Claim Intimation By Claimant
Accept Intimation And Do Policy Enquiry
Validate Claim Against Policy
Is Policy In Force
Y/N?
Decline Claim AndInform Claimant
A
A
Claim Survey Process
IsReinsurance Applicable
Y/N?
Claim Processing Flow DiagramStart
Claim Assignment
Reinsurance(clm)
Is ClaimValid Y/N?
Stop
Decline Claim andInform Claimant
N
Stop
Is ClaimValid Y/N?
Determine EstimatesAuthorize & Update Reserves
Y
IsCash call Limit <Claim Reserve/
Estimate?
Loss Advice To Reinsurer
B
B
Reinsurance processto check whetherto get amount from reinsurer before settlementdue to cash call limit
INSURANCE PROCESS FLOW PPT CLAIMS
N
N
Y
Y
Y
N
N
Y
Recovery Process
IsRecoveryPossible
Y/N?
Close Claim
Stop
B
Prepare Discharge & Release Documents
Intimate Client & GetAcceptance
DoesClient Accept
Y/N?
Claim Settlement
Litigation
C
C
Reinsurance(Clm)
Y
Claim Processing Flow Diagram
ClaimantWinsY/N?
N
Y N
IsCash Call Limit >
Claim Reserve/Estimate
Reinsurance processto get amount from reinsurer after settlement
INSURANCE PROCESS FLOW PPT CLAIMS
IsReinsurance Applicable
Y/N?
Y
N
Y
N
Policy
Reserves
Occurrence
Claim Coverage
ClaimClaimant(s)
Payments
LitigationRecoveries
Claims Processing Entity Relationship Diagram
Role
1 1
n
1
n 1 1
1
n
1
n
1 nn 1
1 1
1n
Reserves
1
n
assign
checkReinsurer
intimate1
n
make linked
consist
can leadcan have
settle update
validate
1
consist
INSURANCE PROCESS FLOW PPT CLAIMS
Claim Processing
Claim Survey 2.0
Claim Recording1.0
Claim Settlement3.0
Claim Intimation 1.1
Claim Assignment 1.2
Claim Recording 1.3
AssignSurveyors 2.1
Conduct Survey 2.2
Claim AmtEstimation 3.1
Reinsurance Data 3.2
Payments 3.3
Reporting 3.4
Claims Processing Process Chart
INSURANCE PROCESS FLOW PPT CLAIMS
Client/Claimant
Claim Recording1.0
UnderwritingSection
Reserve_data
Policy_data
Logical Data Flow Diagram of Claims Recording
Agent/Broker Agent_data
Client_data
Claim_data
Claim Intimation
ClaimStatus
Claim Intimation
Ack/Declineclaim
Underwriting clauses
Store Claim data
Agent Information
Client Information
Claim Reserve amt
Policy Validation
INSURANCE PROCESS FLOW PPT CLAIMS
Claim Intimation& Enquiry
1.1
Claim Recording
& Validation1.3
Agent/Broker
Client/claimant
Underwriting Section
Policy_dataAgent_data Client_data
Reserve_data
Claims_data
Claims Recording - II Level Data Flow Diagram
Claim Assignment
1.2
ClaimStatus
Claim Intimation
AckDecline/Accept Claim
UnderwritingClauses
Agent_data, Client_data, Policy_data are used for claim validation
ClientInfoAgent Info
Claim Reserve Amt
Policy Info
INSURANCE PROCESS FLOW PPT CLAIMS
Claim Survey2.0
UnderwritingSection
Policy_data
Logical Data Flow Diagram of Claims Survey
Agent_data
Client_data
Claim_data
Underwriting clauses
Agent Information
Client Information
Policy Validation
Reserve_dataReserve data info
Claim data for reference
Survey_dataSurvey data
Survey help
Surveyor_data
MVR/MIB
Reqforinfo
Reqinfo
Surveyor data
Updatesurvey info
Survey Section
ReinsurerClaim Int.Acknowledge
ClaimantDischarge & Rel Doc
Acceptance/Rejection
INSURANCE PROCESS FLOW PPT CLAIMS
Assign Claim surveyors
2.1
ConductSurvey
2.2
Surveyor_data
Surveyor data
Claim_data
Claim data for reference
UpdateSurveyor
Survey help
Survey_data
Surveydata
UnderwritingSection
Underwriting clauses
Agent_data Client_data Policy_data Reserve_data
Agent_data, Client_data, Policy_data and Reserve_data are used for validation
Claims Survey - II Level Data Flow Diagram
Survey Section
MVR/MIBInfo request
Report
ReinsurerClaim int
Ack/pay.
Update statusLitigation
ClaimantDoc
INSURANCE PROCESS FLOW PPT CLAIMS
Claim Settlement3.0
UnderwritingSection
Policy_data
Logical Data Flow Diagram of Claims Settlement
Agent_data
Client_data
Claim_data
Agent information
Client information
Policy validation
Reserve_dataReserve data info
Claim data for reference
Survey_data Survey data
ReinsurerReinsured claim amount
Update claim status
Payment transaction
Reports
Clearing HouseACH
Management
Paymentdetail
Reports
Update reserve
Agent
Client
Payment info
Payment info
Accounts
State Gov/Legal Org.Reports
INSURANCE PROCESS FLOW PPT CLAIMS
Claim AmtEstimation
3.1
Reinsurance Data3.2
Payments3.3
Reporting3.4
Survey_dataSurvey info
ManagementACH
UnderwritingSection
Reports
Reports
Payment infoPayment info
Reinsurer
Reinsurance data
Claim_data Agent_data Client_data
Client Agent
Payment info
Reserve_data Policy_data
Reservedata
Agent_data, Client_data, Policy_data and Reserve_data are used for validation
Claims Settlement - II Level Data Flow Diagram
Update approx lossamt
Policy data
Accounts
INSURANCE PROCESS FLOW PPT CLAIMS