Commercial Lines Claims workflows

  • Release version: Washingtondc
  • Updated February 1, 2024
  • 5 minutes to read
    • Summarize
    Summarized using AI
    This content was generated using new OpenAI-powered functionality. Results are provided on an as is basis and are not guaranteed to be accurate or complete.

    Summary of Commercial Lines Claims Workflows

    The Commercial Lines Claims application offers automated workflows designed to enhance efficiency in managing claims tasks. Upon initiation of a claim, workflows are triggered that categorize claims, identify potential fraud, and route tasks to appropriate personnel. This system utilizes a business rules engine to prioritize and manage claims effectively.

    Show full answer Show less

    Key Features

    • First Notice of Loss (FNOL): Claims are submitted by representatives who gather all relevant incident details and documents.
    • Claim Validation: Processors review claims, either approving or rejecting them, which then dictates the next steps in the workflow.
    • Adjuster Evaluation: Adjusters assess claims and can refer them for fraud investigations if necessary.
    • Special Investigation Unit (SIU): If fraud is suspected, claims are routed to SIU agents for detailed evaluation.
    • Claims Manager Approval: Any reserve or payment amounts exceeding an adjuster's authority require a claims manager's approval.

    Key Outcomes

    Through these structured workflows, ServiceNow customers can expect improved case management, efficient task routing, and enhanced collaboration among departments. By implementing these automated processes, organizations can better manage claims, reduce fraud instances, and ensure timely claim closures, ultimately improving customer satisfaction and operational efficiency.

    The Commercial Lines Claims application installs automated workflows that you can configure for any claims tasks. These workflows create cases and routes any tasks accordingly.

    Overview

    After a claim case is initiated, an automated workflow begins. A business rules engine that is driven by base system, configurable rules, can help your organization to categorize a claim as a potential fraud or as a duplicate claim. Here are some example business rules:
    • If the number of properties or participants submitted for the claim is greater than two, the claim is considered as high priority.
    • If a claim is identified as duplicate claim, then a claim validation task is created to the processor for further review.
    • If a claim is identified as close proximity claim, then a task is created to the Special Investigation Unit (SIU) team for further review.
    The following example shows a workflow that routes the case and tasks for investigating and managing insurance claims to five different roles in different departments. In this example, the front and back-office agents log in to the Workspace to work on the tasks in their queue. The playbook guides agents through this process to fulfill claims:
    • Submitting first notice of loss
    • Claim validation
    • Adjuster claim evaluation
    • Fraud evaluation
    • Claim closure
    Figure 1. Claims process workflow – Commercial Auto Claim​

    Workflow showing the claims process for a commercial auto claim using the Commercial Lines Claims application. For the image description, see the text that follows.

    First notice of loss (FNOL) stage

    Submitting a claim as a first-notice-of-loss representative
    1. In the First notice of loss (FNOL) stage, an insurance policy claimant reports a loss with an FNOL representative. After the case is created, a workflow triggers automatically with playbook tasks for managing the case to resolution.
    2. The FNOL representative documents the incident, property, injury, and participant details for the claim, as well as the coverages that are available. The representative also collects and submits the applicable inbound documents for verification, such as the driver's license, and initiates the claim by submitting the case.
    3. After the case is submitted, your business decision rules:
      • Can prioritize the claim case, depending on the number of properties or participants reported in the claim
      • Can trigger a task and refer a claim case to the Special Investigation Unit department for further evaluation
      • Can trigger the claim validation task for further review
      • Can forward the claim to an adjuster for loss evaluation

    Claim validation stage

    Validating and closing a claim as a claims processor
    1. In the Claim validation stage, the processor updates task details, and rejects or approves the claim task accordingly.
    2. If the processor validates the task by approving it, it moves to the adjuster evaluation stage.

    Adjuster evaluation stage

    Evaluating and settling a claim as an adjuster
    1. In the Adjuster evaluation stage, the adjuster reviews and verifies or rejects the submitted claim documents. The adjuster also reviews coverages, and updates or adds coverages if appropriate.
    2. The adjuster can refer the claim to the SIU department for claim investigation. Once the SIU department completes the fraud review task, the adjuster can settle or reject the claim.
    3. The adjuster evaluates a claim and assigns a reserve amount against relevant coverage, based on loss details.
      • If the assigned reserve amount is within the approval authority of the adjuster, the adjuster approves the results.
      • If the assigned reserve amount is beyond the approval authority of the adjuster, the adjuster assigns the request to the claims manager for approval. If the reserve amount is approved by the claims manager, the adjuster proceeds with the claim payment evaluation. If the amount isn’t approved, the adjuster re-evaluates and revises reserve amount based on the recommendations from the claims manager.
    4. The adjuster updates the claim record with either loss reserve, expense reserve, or both.
    5. The adjuster creates payment amounts against the created reserves, based on finalized evaluation.
      • If the created payment amount is within the approval authority of the adjuster, the adjuster approves the results.
      • If the amount is beyond the approval authority of the adjuster, the adjuster assigns the request to the claims manager for approval. If the claims manager approves the payment amount, the adjuster proceeds with a claim payment evaluation. If the amount isn't approved, the adjuster re-evaluates and creates a new payment amount based on the recommendations from the claims manager.
    6. The adjuster approves or rejects the review task. If the adjuster approves the review task to settle the claim, the claim case moves to the fulfillment stage to be closed by the claims processor. If the adjuster rejects all related tasks, the claim case automatically closes.

    Special Investigation Unit (SIU) tasks

    Investigating a potential fraud claim as a special investigation unit agent
    1. If business rules determine that the claim requires validation, or if the adjuster determines possibility of fraud, a task triggers to the SIU department for investigation. An SIU agent reviews the fraud task, updates details in the evaluation task record, and approves or rejects the task. An approved evaluation task indicates a determination of fraud not found. A rejected evaluation task indicates that the claim is determined to be invalid and potentially fraud.
    2. If the task is approved, the claim is concluded as fraud not found, and can be approved by the adjuster. When the claim is approved, the case moves to the fulfillment stage, which the claim processor completes.

    Claims manager approval tasks

    Approving reserve or payment amounts as a claims manager
    1. If an assigned reserve amount is beyond the approval authority of the adjuster, the system assigns the reserve amount request to the claims manager for approval. If the claims manager approves the reserve amount, the adjuster proceeds with the claim payment evaluation. If the claims manager rejects the reserve amount and provides a recommendation, the adjuster should revise the reserve amount as per recommended.
    2. If a created payment amount is beyond the approval authority of the adjuster, the system assigns the payment amount request to the claims manager for approval. The claims manager reviews the payment amount and claim details, and approves or rejects the claim payment. If the claims manager approves the payment amount, the adjuster can proceed to settlement. But if the manager rejects the request and provides recommendation, the adjuster should revise and submit payment amount as per recommended. System-generated work notes stating the approval or rejection automatically add to the Activity stream for the task and claim case.

    Closure

    The case is complete when the states and stage of the case sets to Closed Complete.