Getting Started with PeopleSoft Enterprise Policy and Claims Presentment

This chapter provides an overview of Policy and Claims Presentment and discusses:

Policy and Claims Presentment business processes.
Policy and Claims Presentment integrations.
Policy and Claims Presentment implementation.

Policy and Claims Presentment Overview

Policy and Claims Presentment utilizes the power of PeopleSoft Enterprise CRM and provides industry-specific functionality to meet your business needs. Policy and Claims Presentment enables you to provide full-featured support for all the products and services you offer to customers.

To support the unique data requirements of life, health, and property and casualty policy types, service representatives can:

Respond to customer inquiries by accessing policy details.

This includes status, type, and coverage period, deductibles, limits, options, as well as covered people and assets.
Make changes to a policy.
Retrieve billing and payment history in real-time.

Policy and Claims Presentment provides the ability to work with industry-specific policy requirements including:

Property & Casualty policies

Displays for each covered person or asset the coverage that has been selected, as well as the deductible amounts, limits, options, and exclusions.
Health plan policies

Displays the benefits that apply to the plan, coinsurance for each service, yearly deductible, and lifetime limits.
Life plan policies

Displays the death benefit amount and financial terms associated with the policy, insured party and beneficiaries, and current policy cash value.
All policy type

Displays premium information, policy status, agent and broker associated with selling the policy, and the entity responsible for servicing the policy.

Regardless of the channel, Policy and Claims Presentment enables the representative to respond to customer inquiries including claim status, claimant information, assigned adjusters, assessed damages, and settlement payments processed.

A customer, or an insurer’s representative on behalf of a customer, can file a first notice of loss via the web-based user interface. Policy and coverages are verified and then, based on policy type, details of the loss such as; date/time, location, policy report, injuries and damages, and other parties/property involved are captured. When submitted, the report is packaged as an XML message and is sent to the insurer’s claims management system. The claims management system responds by creating and sending back a claim number that is stored in the PeopleSoft CRM database. Users can then inquire on claim status and details.

Note. This PeopleBook focuses on the set up and usage of Policy and Claims Presentment functionality and does not discuss core PeopleSoft Enterprise CRM setup or usage. It is highly recommended that you review the references that appear in each chapter before beginning the implementation.

Policy and Claims Presentment Business Processes

The following summarizes Policy and Claims Presentment business processes:

Policy management
Claims management.
Self-service transactions.

We discuss these business processes in the business process chapters in this PeopleBook.

Policy Management

Policy and Claims Presentment enables users to:

Work with covered assets.
Manage policies, including relationships, terms and conditions, address history, asset details, manage billing history and payment history.
Make policy changes.

Claims Management

Policy and Claims Presentment enables users to:

Manage first notice of loss (FNOL) reporting through a customer service representative.

This includes initiating a first notice of loss (FNOL) and confirming policy details.
Work with First Notice of Loss (FNOL).

This includes associating a first notice of loss (FNOL) to related claims.
Work with claims, including viewing claims and claim details.

Self-Service Transactions

Policy and Claims Presentment enables self-service users to:

Perform customer care transactions, including creating a first notice of loss (FNOL), searching for solutions, and viewing frequently asked questions and troubleshooting guides.
Make policy changes.
Select and apply for products.
Report a first notice of loss (FNOL).
View claims.

Policy and Claims Presentment Integrations

PeopleSoft provides the flexibility to address your unique requirements for integrating applications and data. PeopleSoft’s Integration Broker supports real-time, two-way integration to legacy systems whether it be your ratings engine, policy administration system, claims management system, or billing system. Our pre-built integration enables users to access data in these legacy systems, without requiring them to extract, load and continuously synchronize that data into the CRM solution. The Integration Broker provides pre-built Enterprise Integration Points (EIPs) that support message triggers, message routing, and any data transformation that must take place for both inbound and outbound messages. With it, the PeopleSoft CRM for Insurance solution can retrieve data from your legacy systems at run time, unify and display that data, manipulate it, and send it back to the source. This is a huge advantage in terms of solution deployment time and cost, ongoing cost of ownership, and quality customer service.

Policy and Claims Presentment Implementation

PeopleSoft Setup Manager enables you to generate a list of setup tasks for your organization based on the features you are implementing. The setup tasks include the components that you must set up, listed in the order in which you must enter data into the component tables, and links to the corresponding PeopleBook documentation.

Other Sources of Information

In the planning phase of your implementation, take advantage of all PeopleSoft sources of information, including the installation guides, data models, business process maps, and troubleshooting guidelines. A complete list of these resources appears in the preface in the PeopleSoft Enterprise CRM 9 Application Fundamentals PeopleBook, with information about where to find the most current version of each.