Insurance Business Services Discussion Document December 11, 2007

Breaking Down the Insurance Framework Business Process Service Business Process Service Area of process standards development in the context of business capabilities and business processes Process Group Process Process Investigate/ Evaluate Claim Activity Order Investigative Report Business Task Capabilities (Claims Administration) Process Group (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)

Manage the Claim Sample Illustration Record Claim … Note: There may be one to many tasks for a process activity 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)  Claims Lifecycle Management (Level 3) Process Area: Manage the Claim (Level 4)  Record the Claim (Level 5) Process Service: Investigate/ Evaluate Claim Estimate Claim Amt Determine Settlement or Benefit Offering Manage claims Co-insurnace Manage Claim Pmts

Components of the Business Process Service Definitions Repository Business Process Service Definitions Definition Inputs/ Outputs Preconditions Business Information Needs Forms Common Business Glossary Business Terms Components of the Business Process Service Repository Single Data Model Business Messages