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Insurance (Life) Claims Processing WorkflowC

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Customer Service Call Center

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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

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Fax

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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

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