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Siebel Insurance Guide > Managing Claims >
Managing Fraud Information (End User)
End users use the Claims screen, then the SIU Dashboard view to record and track information regarding fraudulent claims. This task is a step in Process of Managing Claims. Cases of fraud relating to claims are usually handled by a special investigation unit (SIU). An adjuster can assign a claim to a SIU if he thinks there is fraud involved in the claims. One or more investigators in the SIU can then use the Claims screen - SIU Dashboard view to manage the fraud-related activities. A claim can be assigned to various investigators, for example, to arbitration or litigation specialists. Table 19 shows the primary fields in the SIU dashboard.
Table 19. SIU Dashboard Fields
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SIU Referral |
Indicates whether the claim has been referred to the SIU. |
Referral Source |
Identifies how the case was referred to the SIU:
- System. The case was referred automatically due to the suspicious claim score.
- Manual - adjuster. An adjuster referred the case manually.
- Manual - Reassignment. The case was reassigned.
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SIU Assignment Date |
Displays the time and date on which the claim was assigned to the SIU. |
SIU Closed Date |
Displays the time and date on which the SIU file was closed. |
Stop Payment |
Indicates whether the payment is on hold. |
Suspicious Claim Score |
Displays the combined fraud potential score. |
Prob. of Resolution |
Displays the probability of resolution value for the claim. This field is set through the Update Probability of Resolution task. |
SIU Status |
Select the status of the fraud case. Values include: Assigned, Accepted, Initial Review, Negotiations, Decision Pending, Closed, and Re-opened. |
SIU Disposition |
Select the final status of the fraud case after processing is complete. The values include: Abandoned, Deny, Litigate, Negotiated, Pay. |
Table 20 shows the fields in the dashboard that display the key financial information.
Table 20. SIU Dashboard Key Financials
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Total Claim Payment |
Displays the total of payments made on the claim to date. This field is updated by the Recalculate Payment task. NOTE: The value in this field comes from the Claims, then the Payment view for payments with a type other than Subrogation Expense or SIU Expense.
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Total Expenses |
Displays the total SIU expenses incurred to date. This field is updated by the Update SIU Expenses task. NOTE: The value in this field comes from the Claims, then the Payment view for payments with a type of SIU Expense.
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Recovery Potential |
Displays the recovery potential for the claim. The default value is (Prob. of Resolution % * Total Claim Payment). This field is updated by the Update Recovery Potential task. |
Table 21 shows the fields in the dashboard that display the final outcome of SIU investigation.
Table 21. SIU Dashboard Outcome Fields
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Conservation Amount |
Displays the total outstanding reserve amount for the claim. This field is updated by the Recalculate Conservation task. |
Recovery Amount |
Enter the total recovery amount for the claim. |
Debt Schedule |
Select the debt schedule for the fraud recovery. The values are: Installments and Single Payment. |
Table 22 shows the fields in the dashboard used for arbitration or litigation referrals.
Table 22. SIU Dashboard Litigation Referral Fields
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Litigation Referral |
Indicates whether the claim is assigned to a litigation or arbitration specialist. |
Assignment Date |
Displays the date and time when the case was assigned to litigation for further pursuit. |
Outside Counsel |
Select the organization; that is, the external counsel handling the case. If the organization is a business unit, the organization is added to the claims Service Provider list with a role of Fraud/Lit. Provider. |
Settlement Range |
Enter the minimum and maximum settlement amounts for the fraud case. |
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