Claims processing hierarchy for designee

• US 8,000,986 B2
• Filed: 06/29/2007
• Issued: 08/16/2011
• Est. Priority Date: 06/04/2007
• Status: Active Grant

• Current Assignee: Computer Sciences Corporation (DXC Technology Company)
• Original Assignee: Computer Sciences Corporation (DXC Technology Company)
• Inventors: Wait, Julian F., Knifton, Jess V.
• Primary Examiner(s): Abdi; Kambiz
• Assistant Examiner(s): Ziegle; Stephanie
• Application Number:
  US11/824,539
• Publication Number:
  US 20090006137A1
• Time in Patent Office: 1,509 Days
• Field of Search: 705 2- 4, 705 35- 45
• US Class Current: 705/4
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Methods and systems are provided for processing claims. A hierarchy is created including a claim management case level and a policy level. The claim management case level includes a claim management case node. The claim management case node relates to a designee under a first insurance policy. The policy level includes one or more policy nodes. Each of the policy nodes is associated with an insurance policy relating to the designee. At least one process for the claim management case is performed at the claim management case level. The process applies to at least one insurance policy relating to the designee.

Claims

1. A method of processing insurance claims relating to the life or health of an insured, comprising:

a computer system receiving at least one notice of an event or condition that gives rise to a claim for payment under a first policy, the first policy having a one or more designees;

the computer system creating a hierarchy, wherein the computer system creating the hierarchy comprises;

the computer system creating a claim management case for a particular designee on the first policy , the claim management case comprising, at a claim management case level, a claim management case node for the particular designee;

the computer system creating, at a policy level under the claim management case level, two or more policy nodes associated with the claim management case, wherein each of at least two of the policy nodes corresponds to a different policy in which the particular designee is a designee of the policy;

the computer system creating, at a coverage level below the policy level, one or more coverage nodes, wherein each of the one or more coverage nodes corresponds to a base coverage or rider under a policy in which the particular designee for the claim management case is a designee of the coverage;

attaching at least one of the coverage nodes at the coverage level to the policy node corresponding to the policy that the base coverage or rider is under;

the computer system creating, at a benefit level, one or more benefit nodes, each of at least one of the benefit nodes corresponding to a benefit under at least one of the policies associated with the claim management case or corresponding to a benefit under at least one of the base coverages or riders associated with one of the policies; and

the computer system attaching at least one of the benefit nodes to at least one of the policy nodes of the policy level or at least one of the coverage nodes of the coverage level, wherein the level of the node to which the at least one benefit node is attached depends on whether the benefit corresponding to the benefit node pertains to a policy as a whole or pertains to a particular base coverage or a rider under one of the policies, wherein the at least one benefit node is attached to a policy node if the benefit corresponding to the at least one benefit node pertains to a policy as a whole, wherein the benefit node is attached to a coverage node if the benefit corresponding to the benefit node pertains to a particular base coverage or a particular rider under one of the policies; and

the computer system performing, at the claim management case level, using the claim management case node for the particular designee, at least one process for the claim management case pertaining to all of the policies associated with the claim management case for the particular designee and all of the coverages associated with the claim management case for the particular designee,

the computer system performing, at the policy level or the coverage level, using at least one of the policy nodes or one of the coverage nodes, at least one process pertaining to a particular one of the policies associated with the claim management case for the particular designee or pertaining to a particular one of the coverages associated with the claim management case for the particular designee, and

the computer system performing, at a benefit level, at least one process pertaining to a particular benefit under the policy for the claim management case;

the computer system performing at least one rendezvous, wherein at least one rendezvous comprises;

a queued item waiting for a response from a policy administration system;

the queued item receiving response data from the policy administration system;

the computer system comparing the response data from the policy administration system to expected data; and

the computer system determining that a rendezvous is effective based on a match of the response data and the expected data; and

adjudicating at least one claim under one or more of the policies.

2. The method of claim 1, further comprising:

for at least one of the one or more policy nodes, the computer system associating at least one benefit node with the policy node, wherein the at least one benefit node is associated with a benefit to the particular designee for the claim management case;

attaching one or more requirements to the at least one benefit node associated with the policy node; and

the computer system performing at least one process at a benefit level to satisfy at least one of the one or more requirements attached to the at least one benefit node.

3. The method of claim 1, further comprising displaying a policy portfolio view for the claim management case, wherein the policy portfolio view comprises a representation of the policies for the particular designee in relation to the claim management case.

4. The method of claim 1, wherein creating the hierarchy comprises creating at least one claim management case object, one or more policy objects, and one or more coverage objects.

5. The method of claim 1, further comprising inhibiting adjudication of any the insurance policies in the claim management case until one or more predetermined requirements are satisfied for the claim management case.

6. The method of claim 1, further comprising suspending activity for the claim management case at the policy level until one or more predetermined conditions are satisfied at the claim management case level.

7. The method of claim 1, further comprising providing a report to the particular designee, wherein the report relates to all of the policies for which the designee receiving the report is a designee.

8. The method of claim 1, wherein the particular designee is a beneficiary.

9. The method of claim 1, wherein the particular or at designee is a collateral assignee.

12. The method of claim 1, wherein performing the at least one process at the claim management case level comprises fulfilling a requirement for the particular designee for two or more insurance policies associated with the claim management case.

13. The method of claim 1, performing the at least one process at the claim management case level comprises fulfilling a requirement for the designee for two or more insurance policies associated with the claim management case.

14. The method of claim 1, wherein the particular designee comprises the members of a family, wherein performing the at least one process at the claim management case level comprises fulfilling a requirement for the members of the family for two or more policies associated with the claim management case.

15. The method of claim 1, wherein the node hierarchy comprises two or more procedures and two or more data structures in a service-oriented architecture.

16. The method of claim 1, wherein creating the claim management case comprises:

performing a search for policies against one or more policy administrative host systems;

associating at least two policies found in the search with the claim management case; and

displaying, in a claim policy portfolio table, at least two policies found in the search against the one or more policy administrative host systems.

17. The method of claim 1, further comprising associating at least one policy with the claim management case by adding the policy to the claim policy portfolio table.

10. A system, comprising:

a processor;

a memory coupled to the processor and configured to store program instructions executable by the processor to;

receiving at least one notice of an event or condition that gives rise to a claim for payment under a first policy, the first policy having one or more designees;

creating a hierarchy, wherein creating the hierarchy comprises;

creating a claim management case for a particular designee on the first policy, the claim management case comprising, at a claim management case level, a claim management case node for the particular designee;

creating, at a policy level under the claim management case level, two or more policy nodes associated with the claim management case, wherein each of at least two of the policy nodes corresponds to a different policy in which the particular designee for the claim management case is a designee of the policy;

attaching at least one of the coverage nodes at the coverage level to the policy node corresponding to the policy that the base coverage or rider is under;

creating, at a coverage level below the policy level, one or more coverage nodes, wherein each of the one or more coverage nodes corresponds to a base coverage or a rider under a policy in which the particular designee for the claim management case is a designee of the coverage;

creating, at a benefit level, one or more benefit nodes, each of at least one of the benefit nodes corresponding to a benefit under at least one of the policies associated with the claim management case or corresponding to a benefit under at least one of the base coverages or riders associated with one of the policies; and

attaching at least one of the benefit nodes to at least one of the policy nodes of the policy level or at least one of the coverage nodes of the coverage level, wherein the level of the node to which the at least one benefit node is attached depends on whether the benefit corresponding to the benefit node pertains to an policy as a whole or pertains to a particular base coverage or a rider under one of the policies, wherein the at least one benefit node is attached to a policy node if the benefit corresponding to the at least one benefit node pertains to a policy as a whole, wherein the benefit node is attached to a coverage node if the benefit corresponding to the benefit node pertains to a particular base coverage or a particular rider under one of the policies; and

performing, at the claim management case level, using the claim management case node for the particular designee, at least one process for the claim management case pertaining to all of the policies associated with the claim management case for the particular designee and all of the coverages associated with the claim management case for the particular designee;

performing, at the policy level or the coverage level, using at least one of the policy nodes or one of the coverage nodes, at least one process pertaining to a particular one of the policies associated the claim management case for the particular designee or pertaining to a particular one of the coverages associated with the claim management case for the particular designee;

performing, at a benefit level, at least one process pertaining to a particular benefit under the policy for the claim management case;

performing at least one rendezvous, wherein at least one rendezvous comprises;

a queued item waiting for a response from a policy administration system;

the queued item receiving response data from the policy administration system;

comparing the response data from the policy administration system to expected data; and

determining that a rendezvous is effective based on a match of the response data and the expected data; and

adjudicating at least one claim under one or more of the policies.

11. A tangible, computer readable storage medium comprising program instructions stored thereon, wherein the program instructions are computer-executable to:

receiving at least one notice of an event or condition that gives rise to a claim for payment under a first policy, the first policy having a one or more designees;

creating a hierarchy, wherein creating the hierarchy comprises;

creating a claim management case for a particular designee on the first policy, the claim management case comprising, at a claim management case level, a claim management case node for the particular designee;

creating, at a policy level under the claim management case level, two or more policy nodes associated with the claim management case, wherein each of at least two of the policy nodes associated with the claim management case corresponds to an different policy in which the particular designee is a designee of the policy;

creating, at a coverage level below the policy level, one or more coverage nodes, wherein each of the one or more coverage nodes corresponds to a an base coverage or rider under a policy on the life or health of an insured in which the particular designee or at least one designee in the set of particular designees for the claim management case is a designee of the insurance coverage;

attaching at least one of the coverage nodes at the coverage level to the policy node corresponding to the policy that the base coverage or rider is under;

creating, at a benefit level, one or more benefit nodes, each of at least one of the benefit nodes corresponding to a benefit under at least one of the policies associated with the claim management case or corresponding to a benefit under at least one of the base coverages or riders associated with one of the policies; and

attaching at least one of the benefit nodes to at least one of the policy nodes of the policy level or at least one of the coverage nodes of the coverage level, wherein the level of the node to which the at least one benefit node is attached depends on whether the benefit corresponding to the benefit node pertains to an insurance policy as a whole or pertains to a particular base coverage or a rider under one of the policies, wherein the at least one benefit node is attached to a policy node if the benefit corresponding to the at least one benefit node pertains to a policy as a whole, wherein the benefit node is attached to a coverage node if the benefit corresponding to the benefit node pertains to a particular base coverage or a particular rider under one of the policies; and

performing, at the claim management case level, using the claim management case node for the particular designee, at least one process for the claim management case pertaining to all of the policies associated with the claim management case for the particular designee and all of the coverages associated with the claim management case for the particular designee;

performing, at the policy level or the coverage level, using at least one of the policy nodes or one of the coverage nodes, at least one process pertaining to a particular one of the policies associated with the claim management case for the particular designee for the claim management case; and

performing, at a benefit level, at least one process pertaining to a particular benefit under the policy for the claim management case;

performing at least one rendezvous, wherein at least one rendezvous comprises;

a queued item waiting for a response from a policy administration system;

the queued item receiving response data from the policy administration system;

comparing the response data from the policy administration system to expected data; and

determining that a rendezvous is effective based on a match of the response data and the expected data; and

adjudicating at least one claim under one or more of the policies.