Evaluate a commercial claim for fraud

  • Release version: Washingtondc
  • Updated February 1, 2024
  • 1 minute to read

    • A special investigations agent can review a claim to determine whether a claim is fraudulent.

    Before you begin

    Role required: sn_ins_siu.agent

    Use the case playbook that provides the activities and tasks required to update and close the tasks of the claim case.

    About this task

    When business rule logic identifies a claim case as a 'close proximity' claim- a claim case very close to the policy start date- then a task triggers to the SIU department for evaluation of fraud. An adjuster can also refer a claim for fraud evaluation during the adjuster's claim evaluation.

    Procedure

    1. Navigate to All > Financial Services Operations > Workspace.
    2. Select the lists icon (lists icon.).
    3. Open the task from the special investigation tasks list.
      OptionDescription
      From the Special Investigation tasks list
      1. In the Lists tab, under Special Investigation tasks, open the task list.
        • For your assigned tasks, select Assigned to me.
        • For all special investigation tasks, select All.
      2. In the list, select the task that you want to work on.
      To work on a task that is not assigned to you yet, assign it to yourself by clicking Assign to me.
    4. Finish the work that is required to complete the task in your claims system.
    5. Optional: In the Work notes field, enter any comments that are related to your findings.
    6. Close the task from the special investigation task form.
      Special investigation taskAction
      To submit a fraud evaluation Select Approve to conclude the claim as not fraudulent or Reject to validate the claim as fraud.

    Result

    • If the task is approved, the task moves to Closed Complete.
    • If the task is rejected, the task moves to Closed Rejected.