System and method of administering, tracking and managing of claims processing
First Claim
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1. A computer implemented method of capturing initial insurance claim data comprising:
- receiving an insurance claim;
determining the type of user initiating the insurance claim;
presenting the user with a first plurality of questions regarding an insurance policy under which the claim is being submitted depending on the type of user;
determining if the claim is covered under a valid policy;
retrieving profile information of the user that relates to the claim and pre-populating a subset of a second plurality of questions with the profile information;
presenting the user with the second plurality of questions regarding the insurance claim in which a subset of questions subsequent to an initial subset of questions presented in the second plurality of questions vary depending on the user'"'"'s answers to the initial subset of questions, where both the initial and subsequent subset of question vary according to the type of user;
storing the answers to the first and second plurality of questions in a data format that is useable by an insurance claim system.
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Abstract
A system and method of administering, tracking and managing of claims processing.
552 Citations
14 Claims
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1. A computer implemented method of capturing initial insurance claim data comprising:
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receiving an insurance claim;
determining the type of user initiating the insurance claim;
presenting the user with a first plurality of questions regarding an insurance policy under which the claim is being submitted depending on the type of user;
determining if the claim is covered under a valid policy;
retrieving profile information of the user that relates to the claim and pre-populating a subset of a second plurality of questions with the profile information;
presenting the user with the second plurality of questions regarding the insurance claim in which a subset of questions subsequent to an initial subset of questions presented in the second plurality of questions vary depending on the user'"'"'s answers to the initial subset of questions, where both the initial and subsequent subset of question vary according to the type of user;
storing the answers to the first and second plurality of questions in a data format that is useable by an insurance claim system. - View Dependent Claims (2, 3, 4, 5)
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6. A computer implemented method for classing a task associated with an insurance claim comprising:
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receiving insurance claim data including a plurality of data elements, which serve as assignment criteria;
scoring each data element according to a scoring table set up by an insurance carrier;
summing each score assigned to each data element;
automatically assigning a priority to the insurance claim according to the summed score of the insurance claim;
automatically determining the class of the task associated with the insurance claim according to the application of classing rules to a number of the data elements;
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7. The computer implemented method of assigning a task associated with an insurance claim to at least one of assignees, the method comprising:
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determining a plurality of potential assignees that handle the task associated with the insurance claim of a determined class from a database containing a plurality of assignees by matching a profile of an assignee with a profile of the determined class;
scoring each profile of the plurality of potential assignee that handle the task of the determined class according to the application of business rules to the data elements;
selecting the most highly scored potential assignees;
determining the capacity of each of the highly scored potential assignees to accept the task;
assigning the assignment to a number of assignees that have the greatest capacities to complete the assignment.
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8. A computer implemented method of creating a database for storing data associated with a plurality of insurance claims comprising:
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receiving a first plurality of data related to the plurality of insurance claims, the first plurality of data includes administrative information, estimate data, and transactional data, received from a plurality of different insurance claim systems;
retrieving a second plurality of data from a plurality of different insurance claim systems, the second plurality of data includes administrative information, estimate data, and transactional data, received from a plurality of different insurance claim systems;
storing the first and second plurality of data in a data format readable by a plurality of different insurance claim systems;
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9. A computer implemented method for managing claim data comprising:
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retrieving a plurality of claim data;
viewing the plurality of claim data;
editing a subset of the plurality of claim data;
providing a portal point from which to link to a plurality of claim processing systems.
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10. A computer implemented method of collecting customer satisfaction information and generating a customer satisfaction index score comprising:
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transmitting an electronic request to a customer;
providing a link back to a computer system with a survey with a plurality of questions;
receiving answers to the plurality of questions;
from the answers received, generating a customer satisfaction index score.
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11. A computer implemented method of aggregating, centrally managing and communicating insurance claim data comprising:
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receiving work assignments containing data on tasks that need to be completed to satisfy an insurance claim receivable from a plurality of different insurance claim systems;
attaching data that describes a plurality of work required to satisfy the insurance claim and estimated cost to insurance carrier of satisfying the work required to the initial work assignment data;
attaching digital images, photographs and data that depict the nature of work required to satisfy the insurance claim;
attaching supplemental information that describes the claim;
storing the initial work assignment data and attached data locally in a data format that is;
readable by a plurality of different proprietary insurance claim systems;
organizing the locally stored data in a searchable and manageable structure;
retrieving and presenting the data in an organized format; and
transmitting the attached data to an insurance claim system.
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12. A computer implemented method for auditing a plurality of data associated with an insurance claim to determine if the insurance claim has been accurately processed comprising:
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receiving a plurality of data, which includes initial claim data, a transaction history of the claim, estimates, and payment requests;
comparing the received data representing the transactional history of claim handling to governmental regulatory requirements to determine if additional action is required;
comparing the received data representing the transactional history of claim handling to a plurality of business rules to determine if additional action is required;
determining from application of a plurality of business rules to the received data representing generated estimates whether to validate the estimate and if there is a potential for fraud;
determining from the application of a plurality of business rules to the received data representing payment requests whether to validate the payment request and if there is a potential for fraud.
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13. A computer implemented method of automating an insurance carrier'"'"'s payments associated with an insurance claim comprising:
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receiving a payment request;
determining whether to approve the payment request by first validating the insurance claim under which the request is being made and then validating the request according to the insurance carrier'"'"'s business rules;
and based on whether a payee requesting the payment is making a request for a preapproved payment, a DRP, or based on information taken from a repair estimate, if the request is approved, bundling the payment request with a plurality of payment requests made to the insurance carrier;
sending a bundled payment request which contains a plurality of payment requests to the insurance carrier'"'"'s bank;
transferring the funds equaling the bundled payment request to an intermediary bank clearing house which will store the funds in trust account;
directing payments from the intermediary bank clearing house to individual payees; and
tracking a plurality of payment data for each payment made and transmitting a subset of the plurality of payment data to the insurance carrier and the insurance carrier and to the payee.
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14. A computer implemented method for analyzing a plurality of data related to claims comprising:
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retrieving a plurality of data elements from a centralized claim database;
applying business rules to the data elements;
formatting the data elements into a generated report on the data elements retrieved.
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Specification