Insurance Business Services

Discussion DocumentDecember 11, 2007

Breaking Down the Insurance Framework

Business Process Service

Business ProcessService

Area of process standards development

in the context of business

capabilities and business processes

Process Group

Process Process 4.2.1.2.2

Investigate/ Evaluate

Claim

ActivityActivity

4.2.1.2.2.2Order Investigative Report

Business Task

Capabilities(Claims Administration)

Process Group4.2.1.2

(Manage the Claim)

Business Service

Process Definition: The process of providing the benefit to the claimant under the terms of the insurance agreement. The life-cycle of a claim ranges from the recognition of something that may result in a claim (an incident for pre-authorization or a requested service) to the final settlement with the client and, where applicable, the recovery of money from reinsurers or third parties.

Process Service Definition: When the insurer validates the claim additional information is required to investigate the claim to determine liability and

settle the claim. This service supports obtaining additional information and documents to investigate the claim and liability. (Should describe the expected outcome)

4.2.1.2 Manage the Claim

Sample Illustration

4.2.1.2.1

Record

Claim…

Note: There may be one to many tasks for a process

activity

2.4.4.1

Order Investigative Reports

Denotes: Process Service Definition

Process Service Definition: When the insurer validates the claim additional

Information is required to investigate the claim to determine liability and

settle the claim. This service supports obtaining additional information and

documents to investigate the claim and liability. (Should describe the expected outcome)

Business Information needs: TBD

Business Messages:

PCS: TRP0075/TRP0076 Claim Investigation Add Request/Response

L&A: 7.215/7.216/7.217 MIB Request/MIB Service Descriptor/MIB Service Option

RLC: ClaimMovement “Claim Movement Message”

Process Definition: The process of providing the benefit to the claimant under the terms of the insurance agreement. The life-cycle of a claim ranges from the recognition of something that may result in a claim (an incident for pre-authorization or a requested service) to the final settlement with the client and, where applicable, the recovery of money from reinsurers or third parties.

Enterprise Capability: Customer Service (Level 1)Capability Area: Claims Administration (Level 2) 4.2.1 Claims Lifecycle Management (Level 3)Process Area: Manage the Claim (Level 4) Record the Claim (Level 5) Process Service:

4.2.1.2.2

Investigate/

Evaluate

Claim

4.2.1.2.3

Estimate

Claim Amt

4.2.1.2.4

Determine

Settlement or

Benefit Offering

4.2.1.2.5

Manage claims

Co-insurnace

4.2.1.2.7

Manage

Claim Pmts

Components of the Business Process Service Definitions Repository

Common Business Glossary

Business Terms

Business Terms

Components of the Business Process Service Repository

Single Data Model

Business Messages