Claims processing hierarchy for insured

• US 8,010,391 B2
• Filed: 06/29/2007
• Issued: 08/30/2011
• Est. Priority Date: 06/29/2007
• 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 M
• Application Number:
  US11/824,599
• Publication Number:
  US 20090006140A1
• Time in Patent Office: 1,523 Days
• Field of Search: 705 2- 4, 705 35- 45
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Methods and systems are provided for processing claims. A hierarchy may be created for claims specific to the insured that includes a claim management case level, a policy level, and a coverage level. The claim management case level may include a claim management case node. The policy level may include one or more policy nodes. Each of the policy nodes may relate to an insurance policy covering the insured. The one or more insurance policies covering the insured are associated with the claim management case. The coverage level may include one or more coverage nodes. Each of the coverage nodes may relate to an insurance coverage covering the insured. Each of the insurance coverages may be associated with one of the insurance policies.

Claims

1. A method of processing insurance claims relating to 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 insurance policy covering the insured;

creating a node hierarchy, wherein creating the node hierarchy comprises;

the computer system creating a claim management case node relating to the insured at a claim management case level;

the computer system creating one or more policy nodes at a policy level separate from and below the claim management case level, each of at least one of the policy nodes corresponding to an insurance policy covering the insured;

the computer system creating one or more coverage nodes at a coverage level separate from and below the policy level, each of at least one of the coverage nodes corresponding to an insurance base coverage or a rider under one of the insurance policies covering the insured;

the computer system attaching at least one of the coverage nodes at the coverage level to the at least one of the policy nodes at the policy level;

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

the computer system attaching at least a first one of the benefit nodes to at least one of the policy nodes of the policy level and attaching at least a second one of the benefit nodes to at least one of the coverage node of the coverage level, wherein the level of the node to which each of the first one of the benefit nodes and the second one of the benefit nodes 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;

the computer system performing, at a claim management case level, using the claim management case node, at least one process for the claim management case, wherein the at least one process performed at the claim management case level applies to all of the policies and all of the coverages associated with the claim management case;

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 for the claim management case, wherein the at least one process performed at the policy level or at the coverage level applies to only one of the policies associated with the claim management case or to only one of the coverages associated with the claim management case;

the computer system performing, at the benefit level, using at least one of the benefit nodes, at least one process for the claim management case, wherein the at least one process performed at the benefit level applies to only one of the benefits associated with 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, wherein the one or more policy nodes comprises two or more policy nodes, each of the policy nodes relating to an insurance policy covering the insured, wherein two or more insurance policies covering the insured are associated with the claim management case, wherein the at least one process performed at the claim management case level applies to at least two insurance policies covering the life or health of the insured.

3. The method of claim 2, wherein the at least one process performed at the claim management case level applies to all the insurance policies covering the life or health of the insured carried by a particular carrier.

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

5. The method of claim 1, further comprising inhibiting adjudication of any of the insurance policies covering the insured 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.

9. The method of claim 1, further comprising:

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

the computer system associating at least a first one of the designee nodes with at least one of the policy nodes of the policy level and associating at least a second one of the designee nodes with at least one of the coverage nodes of the coverage level.

10. The method of claim 9, further comprising, for at least one policy node or the coverage node associated with at least one of the benefit nodes and at least one of the designee nodes:

attaching one or more requirements to the policy node or the coverage node;

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

attaching one or more requirements to the at least one designee node associated with the policy node or the coverage node,

wherein the computer system performing, at a policy level or coverage level, at least one process for the claim management case comprises;

the computer system performing at least one process at a policy level or a coverage level to satisfy at least one of the one or more requirements attached to the policy or coverage node;

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; and

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

11. The method of claim 1, wherein the computer system performing, at a claim management case level, at least one process for the claim management case comprises:

the computer system performing, at a claim management case level, at least one process to fulfill an information requirement for adjudicating the insurance policies, wherein the information requirement applies to at least two of the insurance policies associated with the claim management case,

wherein the computer system performing, at a policy level or coverage level, at least one process for the claim management case comprises;

the computer system performing, at a policy level, one or more processes to fulfill an information requirement for adjudicating an insurance policy associated with the claim management case, wherein the at least one of the one or more processes performed at the policy level applies to only one of the insurance policies associated with the claim management case; and

the computer system performing, at a coverage level, one or more processes to fulfill an information requirement for a coverage associated with the claim management case, wherein the at least one of the one or more processes performed at the coverage level applies to only one of the insurance coverages associated with one of the insurance policies;

the method further comprising;

the computer system determining whether predetermined information requirements for the claim management case have been met at the case management level, the policy level, and the coverage level;

the computer system inhibiting adjudication of any the insurance policies in the claim management case or adjudication of any of the insurance coverages in the claim management case until the predetermined information requirements for the claim management case are satisfied at the case management level, the policy level, and the coverage level; and

adjudicating claims under the one or more of the insurance policies covering the insured.

12. The method of claim 1, wherein at least one of the coverage nodes created at the coverage level corresponds to a policy rider for one of the insurance policies covering the insured,

the method further comprising attaching one or more information requirements to the at least one coverage node corresponding to the policy rider,

wherein the computer system performing, at a policy level or coverage level, at least one process for the claim management case comprises:

the computer system performing at least one process at a coverage level to satisfy, at a coverage level, at least one information requirement for the policy rider.

13. The method of claim 1, wherein at least one of the coverage nodes created at the coverage level corresponds to a policy rider for one of the insurance policies covering the insured,

the method further comprising attaching one or more information requirements to the at least one coverage node corresponding to the policy rider,

wherein the computer system performing, at a policy level or coverage level, at least one process for the claim management case comprises:

the computer system performing at least one process at a policy level to satisfy at least one information requirement attached to a policy node; and

the computer system performing at least one process at a coverage level to satisfy, at a coverage level, at least one information requirement for the policy rider.

14. The method of claim 1, wherein the first one of the benefit nodes associated with the at least one of the policy nodes and the second one of the benefit nodes associated with the at least one of the coverage nodes are each associated with the most general node to which the data for the benefit node applies.

15. The method of claim 9, wherein at least the first one of the benefit nodes and the first one of the designee nodes are both associated with the same one of the policy nodes, and wherein at least the second one of the benefit nodes and the second one of the designee nodes are both associated with the same one of the coverage nodes.

16. 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.

7. A system, comprising:

a processor;

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

receiving at least one notice of an event or condition that gives rise to a claim for payment under a first insurance policy covering the life or health of an insured;

creating a node hierarchy, wherein creating the node hierarchy comprises;

creating a claim management case node relating to the insured at a claim management case level; and

creating one or more policy nodes at a policy level separate from and below the claim management case level, each of at least one of the policy nodes corresponding to an insurance policy covering the insured;

creating one or more coverage nodes at a coverage level separate from and below the policy level, each of at least one of the coverage nodes corresponding to an insurance base coverage or a rider under one of the insurance policies covering the insured;

attaching at least one of the coverage nodes at the coverage level to the at least one of the policy nodes at the policy level;

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

attaching at least a first one of the benefit nodes to at least one of the policy nodes of the policy level and attaching at least a second one of the benefit nodes to at least one of the coverage nodes of the coverage level, wherein the level of the node to which each of the first one of the benefit nodes and the second one of the benefit nodes 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;

performing, at a claim management case level, using the claim management case node, at least one process for the claim management case, wherein the at least one process performed at the claim management case level applies to all of the policies and all of the coverages associated with the claim management case;

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 for the claim management case, wherein the at least one process performed at the policy level or at the coverage level applies to only one of the policies associated with the claim management case or to only one of the coverages associated with the claim management case; and

performing, at the benefit level, using at least one of the benefit nodes, at least one process for the claim management case, wherein the at least one process performed at the benefit level applies to only one of the benefits associated with 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.

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

receiving at least one notice of an event or condition that gives rise to a claim for payment under a first insurance policy covering the life or health of the insured;

creating a node hierarchy, wherein creating the node hierarchy comprises;

creating a claim management case node relating to the insured at a claim management case level; and

creating one or more policy nodes at a policy level separate from and below the claim management case level, each of at least one of the policy nodes corresponding to an insurance policy covering the insured;

creating one or more coverage nodes at a coverage level separate from and below the policy level, each of at least one of the coverage nodes corresponding to an insurance base coverage or a rider under one of the insurance policies covering the insured;

attaching at least one of the coverage nodes at the coverage level to the at least one of the policy nodes at the policy level;

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

attaching at least a first one of the benefit nodes to at least one of the policy nodes of the policy level and attaching at least a second one of the benefit nodes to at least one of the coverage nodes of the coverage level, wherein the level of the node to which each of the first one of the benefit nodes and the second one of the benefit nodes 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; and

performing, at a claim management case level, using the claim management case node, at least one process for the claim management case, wherein the at least one process performed at the claim management case level applies to all of the policies and all of the coverages associated with the claim management case;

performing, at the policy level or the coverage level, at least one process for the claim management case, wherein the at least one process performed at the policy level or at the coverage level applies to only one of the policies associated with the claim management case or to only one of the coverages associated with the claim management case; and

performing, at the benefit level, using at least one of the benefit nodes, at least one process for the claim management case, wherein the at least one process performed at the benefit level applies to only one of the benefits associated with 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.