Insurance (Life) Claims Processing Workflow...Insurance (Life) Claims Processing Workflow C l a i m...
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Adobe Adobe Adobe Insurance (Life) Claims Processing Workflow Claims Processing Agents Customer Customer Service Call Center Data Flow Answer call and identify self CSR 1.1 Verify call reason CSR 1.3 Can CSR Resolve Call? Transfer or redirect call to correct number CSR 1.4 No Open claim form CSR 1.6 Search and Locate Claim CSR 1.13 Yes File a Claim Check the Status of an Open Claim Pre-Claim Service? No Enter data (complete only top portion of form) CSR 1.7 Open job aid for claim assignment information CSR 1.10 Assign claim to examiner CSR 1.11 Save documents CSR 1.8 Send documents to customer and/or examiner CSR 1.9 Documents Received? Provide claim status update to customer CSR 1.17 Transfer to claims examiner CSR 1.20 Send any required documents to customer CSR 1.14 Notate claim account CSR 1.19 Provide pre-claim service (payments, benefit questions, policy changes) CSR 1.5 Yes Pre-Claim Service? Enter Payment Information CSR 1.22 Yes Enter Claimant Personal Data in Initial Request Form CSR 1.24 Save All Documents CSR 1.25 Notate Claim Account CSR 1.26 No Notate Account CSR 1.23 Verify Insurance Coverage and Authenticate Caller CSR 1.2 Status Notes Updated? No Yes Yes No Notate claim account CSR 1.15 Offer Customer Opportunity to Take Survey CSR 1.12 Offer Customer Opportunity to Take Survey CSR 1.16 Offer Customer Opportunity to Take Survey CSR 1.21 Offer Customer Opportunity to Take Survey CSR 1.18 Life Insurance Claims Open Claim Work Item Examiner 2.1 Open Claim Files Examiner 2.2 Date of Death Provided? Search for Date of Death information Examiner 2.3 No Date of Death Found? Terminate policy Examiner 2.4 Change status to “Pending – Follow Up with Beneficiary” Examiner 2.5 Keep in active queue Examiner 2.6 No Yes Yes Is policy status changed to terminated? Contact System Analyst for policy termination issues Examiner 2.7 No Enter member information Examiner 2.8 Yes Enter policy value Examiner 2.9 Send out policy service information to beneficiary Examiner 2.10 Notate claim with beneficiary information Examiner 2.11 Update Data Sheet with system information Examiner 2.12 Attach completed Data Sheet onto recording system work item Examiner 2.13 Pend Claim for 20 days Examiner 2.15 Change status to “Pending - Requirements not received” Examiner 2.14 Forms received Claimant 2.16 Forms completed Claimant 2.17 Are all forms received from Claimant? Change status to “Pending – Follow up with Claimant” Examiner 2.18 No Send first follow-up letter Examiner 2.19 Follow-up Call 1 Examiner 2.45 Follow-up Call 2 Examiner 2.46 Follow-up Call 3 Examiner 2.47 Has claimant responded? No Has claimant responded? Has claimant responded? Has claimant responded? Email sent to Claimant Examiner 2.48 Has claimant responded? Create escheatment letter and send to Claimant Examiner 2.49 No No No No No Assign claim to escheatment team for processing Examiner 2.50 Open work item with status “Review Needed” Examiner 2.20 Yes Yes Print Claim Data Sheet Examiner 2.21 All required information available? No Open policy for review Examiner 2.22 Yes Review all documents received Examiner 2.23 Review Death Certificate Examiner 2.24 Original Death Certificate needed Examiner 2.26 Is claim over $25K? Yes Original not required Examiner 2.25 No Review cause of death on original death certificate Examiner 2.27 Match member information to death certificate Examiner 2.28 Document cause of death Examiner 2.29 Un-pend claim for Claim Payment Examiner 2.30 Enter the date the forms were received in good order Examiner 2.31 Enter Beneficiary address from claim statement Examiner 2.32 Does the policy have reinsurance? Place reinsurance reminder in notes and send Explanation of Benefits to agent Examiner 2.34 Send Explanation of Benefits to agent Examiner 2.33 Assign claim to reinsurance department and print extra copy of documents Examiner 2.35 Is claim within approval limit? Yes No Overnight process to generate check to beneficiary Examiner 2.36 Yes Assign to manger to approval Examiner 2.41 Select approval range Examiner 2.42 Place claim in second approval que Examiner 2.43 No Change sub-status to “output reviewed” Examiner 2.37 Manager review for approval Manager 2.44 Match Explanation of Benefits to system work item. Verify claim processed overnight Examiner 2.38 Clear sub-status, sent to “blank” Examiner 2.39 Change prim “Process C Pa Examiner Enter claim data sheet information Examiner 2.51 Beneficiary information extracted from Policy Admin System Examiner 2.53 Create new work item Examiner 2.52 Beneficiary information entered into Claims Manager Examiner 2.54 Enter Claimant information in Payment Manager Examiner 2.55 Next business day processing Examiner 2.56 Work item attached in system Examiner 2.57 Account balancing in Payment Manager Examiner 2.58 Policy updated in Admin System Examiner 2.59 All correspondents reviewed Examiner 2.60 Overnight process to generate check to beneficiary Examiner 2.66 Match Explanation of Benefits to system work item Examiner 2.67 Process complete system work item Examiner 2.68 Match Member Information to death certificate Examiner 2.61 Place cause of death on Member Information screen Examiner 2.62 Un-pend claim on Claim Payment Screen Examiner 2.63 Enter date forms received in good order on Service Information screen Examiner 2.64 Enter beneficiary address on Beneficiary Address and Information screen from claim statement Examiner 2.65 Claims Manager Payment Manager Network Drive Claims Manager DoD Search Claims Manager Policy Admin System Claims Manager Outlook Claims Manager Claims Manager Payment Manager Claims Manager Claims Manager Claims Manager Claims Manager Claims Manager Claims Manager Claims Manager Claims Manager Policy Admin System Network Drive Claims Manager Policy Admin System Claims Manager Claims Manager Claims Manager Claims Manager Claims Manager Policy Admin System Claims Manager Policy Admin System Claims Manager Policy Admin System Claims Manager Claims Manager Claims Manager Claims Manager Claims Manager Claims Manager Claims Manager Claims Manager Policy Admin System Claims Manager Claims Manager Payment Manager Policy Admin System Network Drive Claims Manager Policy Admin System Claims Manager Claims Manager Claims Manager Claims Manager Claims Manager Payment Manager Payment Manager Policy Admin System Claims Manager Claims Manager Fax Outlook Network Drive Fax Outlook Claims Manager Claims Manager Claims Manager Claims Manager Network Drive Claims Manager Claims Manager Payment Manager Technology Improvement: CSRs must lookup information in multiple systems. The use of multiple systems causes them to put more than 30% of callers on hold simply to find the relevant information. Process Improvement: 10% of transfers from the Call Center to Claims Examiners are due to Claims Examiners failing to notate accounts in Claims Manager. This results in reduced productivity and customer satisfaction.. Process Improvement: Claims activity is not tracked end to end from the call center to the end of the claims process. This results in limited insight into performance and customer experience. Process Improvement: First call resolution is not monitored in the customer service center, which focuses on average handle time. The misalignment increases return calls and reduces customer satisfaction. Technology Improvement: 10% of call handle time is spent manually entering data on PDF form as well as in Claims Manager. This redundant work results in increased handle times and reduced productivity. Best Practice: Develop standard training procedures and support documents and ensure they are used consistently across the company. Best Practice: Provide quick- reference links to all policy document to reduce hold times and handle time while improving customer service. Information: Customers become troubled when information not showing in system Best Practice: Replace existing system with a single system to reduce re-entry of data and improve productivity. Best Practice: Conduct transaction training with all employees who enter data into the system. Process Improvement: 95% of the time “Insured” and “Deceased” are the same person but the two fields on the form confuse claimants, resulting in inbound data errors. Process Improvement:75% of the new online claims forms submitted show noticeable confusion. Incorrect information in fields increases cycle time lost time for the Examiners who must correct the forms. Process Improvement: 100% of claims rejected for second approval are controllable and cause by incorrect data entry or missed processing steps. These claims generate rework for the examiner and increase cycle times by 1 business day at least. Process Improvement: Claims are distributed by product line and last name of the insured. This results in a uneven distribution of workload and decreases examiners' productivity. Process Improvement: 20% of Life Insurance Claims cannot be processed due to incorrectly completed forms. This results in reduced productivity. Best Practice: Simply form designs and incorporate specific instructions to reduce inbound data quality errors. Best Practice: Information is double- checked to ensure accuracy and confirm keying instructions to avoid cancellation and delivery delays. Best Practice: Train employees on the importance of proper account notation to reduce transfers and improve customer service. Process Improvement: 10% of claims submitted lack date of death information, requiring manual lookup by examiners. This results in reduced productivity and increased cycle time. Best Practice: Provide easy to read instructions on how to comprehend a complicated form and mail it in the initial welcoming package. Best Practice: Streamline and document the process currently being used to handle incoming forms. Best Practice: Form Complexity Prompts Customer to Call Customer Service Adobe Adobe Adobe Adobe Adobe Adobe Adobe Claims Manager Adobe Claims Manager Claims Manager Claims Manager
Transcript of Insurance (Life) Claims Processing Workflow...Insurance (Life) Claims Processing Workflow C l a i m...
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Insurance (Life) Claims Processing WorkflowC
la
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s
Pro
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ssin
g
Ag
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tsC
usto
me
r
Customer Service Call Center
Da
ta
F
lo
w
Answer call and identify
self
CSR 1.1
Verify call reason
CSR 1.3
Can CSR Resolve
Call?
Transfer or redirect call
to correct number
CSR 1.4
No
Open claim form
CSR 1.6
Search and Locate Claim
CSR 1.13
Yes
File a Claim
Check the Status of an Open Claim
Pre-Claim Service? No
Enter data (complete
only top portion of form)
CSR 1.7
Open job aid for claim
assignment information
CSR 1.10
Assign claim to examiner
CSR 1.11
Save documents
CSR 1.8
Send documents to
customer and/or
examiner
CSR 1.9
Documents
Received?
Provide claim status
update to customer
CSR 1.17
Transfer to claims
examiner
CSR 1.20
Send any required
documents to customer
CSR 1.14
Notate claim account
CSR 1.19
Provide pre-claim service
(payments, benefit
questions, policy
changes)
CSR 1.5
Yes
Pre-Claim Service?Enter Payment
Information
CSR 1.22
Yes
Enter Claimant Personal
Data in Initial Request
Form
CSR 1.24
Save All Documents
CSR 1.25
Notate Claim Account
CSR 1.26
No
Notate Account
CSR 1.23
Verify Insurance
Coverage and
Authenticate Caller
CSR 1.2
Status Notes
Updated?
No
Yes
Yes
No
Notate claim account
CSR 1.15
Offer Customer
Opportunity to Take
Survey
CSR 1.12
Offer Customer
Opportunity to Take
Survey
CSR 1.16
Offer Customer
Opportunity to Take
Survey
CSR 1.21
Offer Customer
Opportunity to Take
Survey
CSR 1.18
Life Insurance Claims
Open Claim Work Item
Examiner 2.1
Open Claim Files
Examiner 2.2
Date of Death
Provided?
Search for Date of Death
information
Examiner 2.3No
Date of Death
Found?
Terminate policy
Examiner 2.4
Change status to
“Pending – Follow Up
with Beneficiary”
Examiner 2.5
Keep in active queue
Examiner 2.6
No
Yes
Yes
Is policy status
changed to
terminated?
Contact System Analyst
for policy termination
issues
Examiner 2.7
No
Enter member
information
Examiner 2.8
Yes Enter policy value
Examiner 2.9
Send out policy service
information to beneficiary
Examiner 2.10
Notate claim with
beneficiary information
Examiner 2.11
Update Data Sheet with
system information
Examiner 2.12
Attach completed Data
Sheet onto recording
system work item
Examiner 2.13
Pend Claim for 20 days
Examiner 2.15
Change status to
“Pending - Requirements
not received”
Examiner 2.14
Forms received
Claimant 2.16
Forms completed
Claimant 2.17
Are all forms
received from
Claimant?
Change status to
“Pending – Follow up
with Claimant”
Examiner 2.18
No
Send first follow-up letter
Examiner 2.19
Follow-up Call 1
Examiner 2.45
Follow-up Call 2
Examiner 2.46
Follow-up Call 3
Examiner 2.47
Has claimant
responded?No
Has claimant
responded?
Has claimant
responded?
Has claimant
responded?Email sent to Claimant
Examiner 2.48
Has claimant
responded?
Create escheatment
letter and send to
Claimant
Examiner 2.49
No No No No No
Assign claim to
escheatment team for
processing
Examiner 2.50
Open work item with
status “Review Needed”
Examiner 2.20
Yes
Yes
Print Claim Data Sheet
Examiner 2.21
All required
information
available?
No
Open policy for review
Examiner 2.22
Yes
Review all documents
received
Examiner 2.23
Review Death Certificate
Examiner 2.24
Original Death Certificate
needed
Examiner 2.26
Is claim over $25K?
Yes
Original not required
Examiner 2.25
No
Review cause of death
on original death
certificate
Examiner 2.27
Match member
information to death
certificate
Examiner 2.28
Document cause of
death
Examiner 2.29
Un-pend claim for Claim
Payment
Examiner 2.30
Enter the date the forms
were received in good
order
Examiner 2.31
Enter Beneficiary
address from claim
statement
Examiner 2.32
Does the policy have
reinsurance?
Place reinsurance
reminder in notes and
send Explanation of
Benefits to agent
Examiner 2.34
Send Explanation of
Benefits to agent
Examiner 2.33
Assign claim to
reinsurance department
and print extra copy of
documents
Examiner 2.35
Is claim within
approval limit?
Yes
No
Overnight process to
generate check to
beneficiary
Examiner 2.36
Yes
Assign to manger to
approval
Examiner 2.41
Select approval range
Examiner 2.42
Place claim in second
approval que
Examiner 2.43
No
Change sub-status to
“output reviewed”
Examiner 2.37
Manager review for
approval
Manager 2.44
Match Explanation of
Benefits to system work
item. Verify claim
processed overnight
Examiner 2.38
Clear sub-status, sent to
“blank”
Examiner 2.39
Change primary status to
“Process Complete -
Paid”
Examiner 2.40
Enter claim data sheet
information
Examiner 2.51
Beneficiary information
extracted from Policy
Admin System
Examiner 2.53
Create new work item
Examiner 2.52
Beneficiary information
entered into Claims
Manager
Examiner 2.54
Enter Claimant
information in Payment
Manager
Examiner 2.55
Next business day
processing
Examiner 2.56
Work item attached in
system
Examiner 2.57
Account balancing in
Payment Manager
Examiner 2.58
Policy updated in Admin
System
Examiner 2.59
All correspondents
reviewed
Examiner 2.60
Overnight process to
generate check to
beneficiary
Examiner 2.66
Match Explanation of
Benefits to system work
item
Examiner 2.67
Process complete
system work item
Examiner 2.68
Match Member
Information to death
certificate
Examiner 2.61
Place cause of death on
Member Information
screen
Examiner 2.62
Un-pend claim on Claim
Payment Screen
Examiner 2.63
Enter date forms
received in good order
on Service Information
screen
Examiner 2.64
Enter beneficiary
address on Beneficiary
Address and Information
screen from claim
statement
Examiner 2.65
Claims
ManagerPayment
Manager
Network
DriveClaims
ManagerDoD
Search
Claims
Manager
Policy Admin
System
Claims
Manager
Outlook
Claims
Manager
Claims
Manager
Payment
Manager
Claims
Manager
Claims
Manager Claims
ManagerClaims
Manager
Claims
Manager
Claims
Manager
Claims
Manager
Claims
ManagerPolicy Admin
System
Network
Drive
Claims
Manager
Policy Admin
System
Claims
Manager
Claims
Manager
Claims
ManagerClaims
Manager
Claims
Manager
Policy Admin
System
Claims
Manager
Policy Admin
System
Claims
Manager
Policy Admin
System
Claims
Manager
Claims
Manager
Claims
ManagerClaims
Manager
Claims
Manager
Claims
Manager
Claims
Manager
Claims
ManagerPolicy Admin
System Claims
Manager
Claims
ManagerPayment
Manager
Policy Admin
System
Network
Drive
Claims
Manager
Policy Admin
System
Claims
Manager
Claims
ManagerClaims
Manager
Claims
ManagerClaims
Manager
Payment
Manager
Payment
Manager
Policy Admin
System
Claims
ManagerClaims
Manager
Fax
OutlookNetwork
Drive
Fax
Outlook
Claims
Manager
Claims
Manager
Claims
Manager
Claims
Manager
Network
Drive
Claims
Manager
Claims
ManagerPayment
Manager
Technology Improvement: CSRs
must lookup information in multiple
systems. The use of multiple
systems causes them to put more
than 30% of callers on hold simply
to find the relevant information.
Process Improvement: 10% of
transfers from the Call Center to Claims
Examiners are due to Claims Examiners
failing to notate accounts in Claims
Manager. This results in reduced
productivity and customer satisfaction..
Process Improvement: Claims
activity is not tracked end to end
from the call center to the end of the
claims process. This results in
limited insight into performance and
customer experience.
Process Improvement: First call
resolution is not monitored in the
customer service center, which
focuses on average handle time. The
misalignment increases return calls
and reduces customer satisfaction.
Technology Improvement: 10% of
call handle time is spent manually
entering data on PDF form as well as
in Claims Manager. This redundant
work results in increased handle times
and reduced productivity.
Best Practice: Develop standard
training procedures and support
documents and ensure they are used
consistently across the company.
Best Practice: Provide quick-
reference links to all policy document
to reduce hold times and handle time
while improving customer service.
Information: Customers become troubled when information not showing in system
Best Practice: Replace existing
system with a single system to reduce
re-entry of data and improve
productivity.
Best Practice: Conduct transaction
training with all employees who enter
data into the system.
Process Improvement: 95% of the
time “Insured” and “Deceased” are
the same person but the two fields
on the form confuse claimants,
resulting in inbound data errors.
Process Improvement:75% of the
new online claims forms submitted
show noticeable confusion. Incorrect
information in fields increases cycle
time lost time for the Examiners who
must correct the forms.
Process Improvement: 100% of
claims rejected for second approval are
controllable and cause by incorrect data
entry or missed processing steps. These
claims generate rework for the examiner
and increase cycle times by 1 business
day at least.
Process Improvement: Claims are
distributed by product line and last
name of the insured. This results in
a uneven distribution of workload
and decreases examiners'
productivity.
Process Improvement: 20% of Life
Insurance Claims cannot be
processed due to incorrectly
completed forms. This results in
reduced productivity.
Best Practice: Simply form designs
and incorporate specific instructions to
reduce inbound data quality errors.
Best Practice: Information is double-
checked to ensure accuracy and
confirm keying instructions to avoid
cancellation and delivery delays.
Best Practice: Train employees on
the importance of proper account
notation to reduce transfers and
improve customer service.
Process Improvement: 10% of
claims submitted lack date of death
information, requiring manual lookup
by examiners. This results in
reduced productivity and increased
cycle time.
Best Practice: Provide easy to read
instructions on how to comprehend a
complicated form and mail it in the
initial welcoming package.
Best Practice: Streamline and
document the process currently being
used to handle incoming forms.
Best Practice: Form Complexity
Prompts Customer to Call Customer
Service
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Claims
Manager
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Claims
Manager
Claims
Manager
Claims
Manager
![Aviva Life and pensions UK Limited SFCR 2017€¦ · S.02.01 Balance Sheet S.05.01 Premium claims and expenses (by line of business) [life] S.05.02 Premium claims and expenses (by](https://static.fdocuments.us/doc/165x107/5ebc2662af0b0d19ea6cf032/aviva-life-and-pensions-uk-limited-sfcr-2017-s0201-balance-sheet-s0501-premium.jpg)
