Insurance Business Services
Discussion Document
December 11, 2007
Breaking Down the Insurance Framework
Capabilities
(Claims Administration)
Process Group
4.2.1.2
(Manage the Claim)
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 Group
Process
Process 4.2.1.2.2
Investigate/ Evaluate
Claim
Activity
Business
Task
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)
Activity
4.2.1.2.2.2
Order Investigative Report
Business Process
Service
Business
Service
Business Process
Service
Area of process
standards development
in the
context of business
capabilities and
business processes
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:
Sample Illustration
4.2.1.2 Manage the
Claim
Note: There may be one to
many tasks for a process
activity
4.2.1.2.1
Record
Claim
4.2.1.2.2
4.2.1.2.3
Investigate/
Estimate
Evaluate
Claim Amt
Claim
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.
4.2.1.2.4
4.2.1.2.5
Determine
Manage claims
Settlement or
Co-insurnace
4.2.1.2.7
…
Benefit Offering
2.4.4.1
Order
Investigative
Reports
Process Service Definition: When the insurer validates the claim additional
Denotes: Process Service
Definition
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”
Manage
Claim Pmts
Components of the Business Process
Service Definitions Repository
Business Process
Service Definitions
Components of the Business Process Service Repository
Definition
Inputs/
Outputs
Forms
Preconditions
Business
Information Needs
Common Business
Glossary
Business
Terms
Business
Terms
Single Data Model
Business Messages