Managing Claims

This chapter is about managing claims in Siebel Insurance. It contains the following topics:

About Managing Claims

Siebel Personal Lines Claims allows agents, call center representatives, and claims adjusters to capture notice of loss information, to view claim information and activities, and to link claims to customer and policy information. Incident and claim information is used across multiple business units including claims, policy servicing, sales, and underwriting, presenting an integrated view of the customer.

Claims management is an important part of service interactions with insurance companies. Therefore, Siebel claims management can be integrated with other software components, such as legacy claims management systems, to provide an integrated solution.

End users can use the Claims screen to open and track claims, as well as to track service requests and other activities associated with claims.

The overall process of managing a claim might involve the following:

Claims intake and First Notice of Loss (FNOL). A call center agent creates a First Notice of Loss, records the necessary details from the policy holder, and then assigns the claim to a claims adjuster.
Review and assignment. A claims adjuster reviews the claim and assigns parts of the claim to other people or third parties. For example, the adjuster can assign an appraiser to appraise the damage, or can assign claim elements to third-party vendors, such as glass vendors.
Reserve and adjustment. The claims adjuster creates a reserve with which the claim payment will be made.
Settlement. The adjuster makes the necessary payment to the policy holder to settle the claim.
Special unit investigation. Throughout the claims process, an adjuster can assign the claim to a special unit, such as a subrogation or fraud unit. An investigator in the special unit then processes the claim.

Insurance Claims Terminology

The following definitions are useful in understanding Siebel Claims:

Appraisal. A survey to determine a property's insurable value, or the amount of a loss.
Arbitration. The procedure in which an insurance company and the insured or a vendor agree to settle a claims dispute by accepting a decision made by a third party.
Bodily injury liability coverage. The portion of an auto insurance policy that covers the injuries that the policyholder causes to someone else.
Catastrophe. A single incident or a series of closely related incidents causing severe, insured property losses, totaling more than a given amount, which is currently $25 million.
Comprehensive coverage. The portion of an auto insurance policy that covers damage to the policyholder's car not involving a collision with another car (including damage from fire, explosions, earthquakes, floods, and riots), and theft.
Deductible. The amount of loss paid by the policy holder. Either a specified dollar amount, a percentage of the claim amount, or a specified amount of time that must elapse before benefits are paid.
First-party coverage. Coverage for the policyholder's own property or person. In no-fault auto insurance, first-party coverage pays for the cost of injuries. In no-fault states with the broadest coverage, the personal injury protection (PIP) part of the policy pays for medical care, lost income, funeral expenses and, where the injured person is not able to provide services such as child care, for substitute services.
Fraud. Intentional lying or concealment by policyholders to obtain payment of an insurance claim that would otherwise not be paid, or lying or misrepresentation by the insurance company managers, employees, agents, and brokers for financial gain.
Loss costs. The portion of an insurance rate used to cover claims and the costs of adjusting claims. Insurance companies typically determine their rates by estimating their future loss costs and adding a provision for expenses, profit, and contingencies.
No fault insurance. An auto insurance system that both requires drivers to carry insurance for their own protection, and which places limitations on their ability to sue other drivers for damages.
Subrogation. The legal process by which an insurance company, after paying a loss, seeks to recover the amount of the loss from another party who is legally liable for it.
Salvage. The damaged property an insurer takes over to reduce its loss after paying a claim. Insurers receive salvage rights over property on which they have paid claims, such as badly damaged cars.

Scenario for Opening and Managing a Claim for Property Loss

This scenario features sample tasks performed by a claims representative. Your company might follow a different workflow according to its business requirements.

A claims representative for a property insurance company is on the phone with a policy holder whose home was burgled. The claims representative must first check that the policy holder has a valid policy and that there is appropriate coverage.

To report this first notice of loss, the representative opens a claims file in Siebel Insurance by navigating to the Claims screen and creating a new Claims record. The claims representative enters the loss date and selects a Policy effective at the time of loss. The representative then moves on to the Loss Description view to capture additional details about the burglary.

Next, he creates a detailed list of the lost insured items in the Insured Property view. Then, he uses the Police And Fire Reports view to initiate an order for a policy report on the burglary. Because heirloom jewelry was among the property that was stolen, he goes to the Appraisals view to document the value of the stolen property. Finally, he documents the coverages for the lost items.

During the next few weeks, he uses other views to track the adjustment process, including reserving and recoveries (subrogation or salvage). After the claim is settled, he adds payment details.

In this scenario, the end users are claims representatives. They enter information to:

Create a loss claim and record details about it
Associate the loss with a contact
Create a list, record the worth, and the coverages for the lost insured items
Record any police or fire reports, if applicable
Track the adjustment process and record payment details

Scenario for Opening and Managing a Claim for Auto Damage

This scenario features sample tasks performed by call center agents and claims adjusters. Your company might follow a different workflow according to its business requirements.

A call center agent for an insurance company is on the phone with a policy holder whose car was damaged in a road traffic accident. The call center agent must first check that the policy holder has a valid policy and that there is appropriate coverage.

To report the first notice of loss, the call center agent opens a claims file in Siebel Insurance by navigating to the Claims screen and creating a new Claims record. She enters the loss date and selects a policy that was effective at the time of the loss. She then moves to the Loss Description view to capture some details about the damage to the vehicle and whether there were injuries or fatalities.

The call center agent navigates to the Involved Parties view to capture the contact and account information. She then goes to the Insured Property view to capture more information about the damaged vehicle and the damage that occurred.

The call center agent assigns the claim to an adjuster who then reviews the claim and assigns part of the claim to other people or third parties as necessary. As part of the evaluation, the adjuster navigates to the ISO Database Search view to check whether the policy holder has already made a claim for the same vehicle with another insurance company.

The adjuster creates an activities plan based on the appropriate loss code in the Activities Plan view, then assigns an activity to a particular appraiser who appraises the damage. The adjuster creates claim elements and assigns them as necessary to third-party vendors, such as a repair shop to fix the damage, or a glass vendor to replace the car windshield.

The next step is to set up a reserve, which is a set amount of money that the insurer puts aside to make a claims payment. The adjuster navigates to the Loss Details - Auto view and creates reserves for the coverages that apply to the policy. He then navigates to the Reserves view and opens the reserves.

In due course, the adjuster receives the invoices associated with the claim and creates a record for each invoice in the Claims screen, then the Invoices view. In the Claims screen, then the Invoices view, he clicks the Generate Payment button to create a payment record for the invoices. The adjuster navigates to the Payments view and clicks the Submit Payment button to make the necessary payment and settle the claim.

Throughout the claims process, an adjuster can assign the claim to a specialist unit such as a subrogation unit or a fraud unit. The specialist unit then processes the claim in their area.

In this scenario, the end users are call center agents and claims adjusters. They enter information to:

Check that the claimant has a valid policy with the appropriate coverage
Create a loss claim and record details about it
Associate the loss with a contact and account
Record details about the damage to the vehicle
Check whether the claimant has filed a similar claim with another insurance company
Create an activities plan and assign activities to appraisers
Assign claim elements to appropriate third-party vendors
Create and open reserves
Record invoice details
Generate and submit payments

Process of Managing Claims

This topic details tasks performed by administrators and end users when managing claims. Your company might follow a different process according to its business requirements.

Administrator Procedures for Managing Claims

The following list shows tasks administrators typically perform to manage claims:

End-User Procedures for Managing Claims

The following list shows tasks call center agents typically perform to create the First Notice of Loss (FNOL):

The following list shows tasks claims adjusters typically perform to review and assign claims:

The following list shows tasks claims adjusters typically perform to create reserves and adjust claims:

The following list shows tasks claims adjusters typically perform to settle claims:

The following list shows tasks special unit investigators typically perform to investigate claims:

About Siebel Insurance eService Claims Center Locators

The Contact Us applet on the Siebel Insurance eService home page has a Locate Nearby Claims Centers hyperlink. When users with the role of Insurance Member click this link, an applet opens in which they can perform a parametric search using location attributes that they select from drop-down lists. For more information on Siebel Insurance eService, see Siebel eService Administration Guide Addendum for Industry Applications.

Setting up Siebel Insurance eService Claims Center Locators

This task is a step in Process of Managing Claims.

To set up Claims Centers Locator functionality, administrators must complete the following tasks:

Import the geocode data for their region
Enter claim center locations
Assign longitudes and latitudes to claim center locations

Geocode Data

The geocode data is used to reference your region. Geocode data for the U.S. geographical region is included in every licensed copy of Siebel Insurance. For information on importing geocode data, see Siebel Self Service Administration Guide.

Entering Claim Center Location

The claim center information is matched with locations entered by end users when they perform a search to locate a branch. Administrators can use the Sites screen to enter claim center location information.

To enter claim center location information

Navigate to the Site Map, Administration - Marketing, and then Sites.
In the Sites list, add a record.
In the Sites form:
1. In the Name field, enter the name of this claim center.
2. In the Type field, select Claim Center.
3. In the Address field, enter the address for this claim center.
4. Complete the necessary fields.
To add a service for a site, scroll down to the Site Services list, add a record and complete the necessary fields.
To add hours of operation, add a record in the Hours Of Operation list, and complete the necessary fields.

Assign a Longitude and a Latitude

The Siebel Insurance Claim Center Locator searches for claim centers using latitude and longitude. If you do not know the latitude and longitude, leave those fields blank. If the City, State, Zip Code, and Country fields are correct, the latitude and longitude values are automatically generated when you save the record.

Note: The latitude and longitude values will not generate if any one value in the City, State, Zip Code, or Country fields is incorrect. For example, if the ZIP Code is incorrect, you will receive an error message. To correct this problem, navigate to the Application Administration, ZIP Code Administration view and make sure the Geo values for that city, state, and ZIP Code combination has been loaded. For more information, see Siebel Self Service Administration Guide.

To add a new center to the Claim Center Locator

Navigate to the Site Map, Administration - Application, and then Branch Locator.
In the More Info form, add a record and complete the necessary fields.
In the Name field, enter a name for the branch.
In the Division field, select a site.
For more information on adding a site, see Entering Claim Center Location.
When the record is saved, the application automatically populates the Latitude and Longitude fields.

Activating the Workflow Processes

Siebel Claims uses many workflows processes, which, for example, are activated when a user clicks a particular button such as the Submit Payment button. You must activate these workflow processes before the user can use Siebel Claims.

For more information about the workflow processes, see Claims Workflows.

To activate the workflow processes

Navigate to the Administration - Business Process screen, then the Workflow Deployment view.
In the Repository Workflow Processes list, use a query to find all processes where the Name field contains the word claims.

Note: You can query on *Claims*.
Activate each workflow process that has a status of Inactive:
1. Select the workflow process record.
2. Click Activate.
The workflow processes are activated.

Administering Reserve Codes

You can define a reserve code for a particular reserve to determine how the reserve value is calculated. You can determine whether the reserve has a default value and whether that default value can be overridden. You use the reserve code in the Administration - Insurance screen, then the Loss Codes view as well as in the Loss Details - Auto, Loss Details - Property, and Reserves views in the Claims screen.

This task is a step in Process of Managing Claims.

To add a reserve code

Navigate to the Administration - Insurance screen, then the Reserve Codes view.

In the Reserve Code Administration list, create a new record, and complete the fields.

Some fields are described in the following table.

Field	Comments
Code	Enter a code.
Type	Select the type of reserve: Manual. The value is set at the time of creating the reserve code by the adjuster. Factor. The reserve has a default value. Calculated. The reserve value is computed in real-time by a business service. Note: The customer must develop this business service during implementation.
Factor Value	Enter the default value for a reserve of type Factor. The reserve will have this value when it is opened.
Allow Override?	Whether the adjuster can override a default reserve value.

Administering Loss Codes

You can define a loss code for a particular type of loss and associate a default activity plan template and default coverages with that loss code.

You use the activity plan association in the Claims screen, then the Activity Plans view. When the user enters a loss code and clicks the Default Plan button, the default activity plan for the loss code is created.

The default coverage association is used in the Claims screen, then the Loss Details - Auto and Loss Details - Property views to populate these views with default coverage data. From these views, the user can create appropriate reserves for each coverage.

This task is a step in Process of Managing Claims.

To add a loss code

Navigate to the Administration - Insurance screen, then the Loss Codes view.

In the Loss Code Administration list, create a new record, and complete the necessary fields.

Some fields are described in the following table.

Field	Comments
Code	Enter a loss code.
LOB	Select the line of business associated with the loss code: Auto or Property.
Active?	Whether the loss code is active.

In the Activity Plans list, add a record for the default activity plan for the loss code, and complete the Template and Description fields.
You must set up the activity plan in the Administration - Data screen, then the Activity Templates view.

In the Coverages list, add records for the required coverages, and complete the fields.

The coverages created in this coverages list are used to recommend the reserves to open for the particular loss code.

Some fields are described in the following table.

Field	Comments
Coverage	Select the coverage.
Rate State	Displays the rate state.
Type	Displays the type of coverage.
Reserve Code	Select the reserve code associated with the coverage.

Administering Adjusters’ Financial Limits

You can set financial limits for adjusters on both the reserves level and on the claims level.

You can set reserve and payment limits for each reserve code, and you can also set total reserve and total payment limits for a claim for the employee.

Reserve and payment limits are checked when the user clicks the Open Reserve button (in the Reserves view) and the Submit Payment button (in the Payments view) respectively. For more information, see Managing Reserves (End User) and About Issuing a Settlement Payment (End User).

This task is a step in Process of Managing Claims.

To set the adjusters financial limits

Navigate to the Administration - User screen, then the Employees view.
Select an employee record.
In the Employees list, enter the required values for:
- Total Reserves. The total reserve amount available to the employee for a claim.
- Total Payments. The total payment amount available to the employee for a claim.
Click the Claims Reserve Limits view tab.
For each reserve code, enter the required values for:
- Reserve Limit. The maximum value of reserve available to the employee for this reserve type.
- Payment Limit. The maximum payment value available to the employee for this reserve type.

Administering the Employee Hierarchy

When an adjuster clicks the Open Reserve button (in the Reserves view) and the Submit Payment button (in the Payments view), Siebel Insurance checks the reserve or payment limit for the coverage as well as for the total claim. If the limit is not enough, the adjuster’s supervisor is prompted to approve the reserve or payment.

It is therefore necessary to set the employee hierarchy to determine the supervisor for each adjuster. You set the employee hierarchy in the Administration – Group screen, then the Position view. For more information, see Siebel Applications Administration Guide.

Note: You must set the employee and supervisor as the primary for that position.

This task is a step in Process of Managing Claims.

Example of Setting up the Employee Hierarchy

This topic gives one example of setting up the employee hierarchy for approval of claims payments or reserves. You might use this feature differently, depending on your business model.

You have two employees Chacko and Chandra and you want to set up Chandra as the manager of Chacko using the positions Position1 and Position2. You must set up Position2 as the parent position of Parent1.

To set up the employee hierarchy

Navigate to the Administration – Group screen, then the Position view.
In the Parent Position field, set Position2 as the parent position of Position1.
Select the record for Position1 and enter Chacko in the Last Name field.
Select the record for Position2 and enter Chandra in the Last Name field.
Now if Chacko is an adjuster, and he tries to open a reserve that is over his limit, it is sent for approval to Chandra.

Integrating with the Insurance Services Office (ISO)

The ISO ClaimSearch database is an insurance fraud detection system owned by the Insurance Services Office (ISO), an organization that operates only in the U.S.

ISO is one of the largest private databases in the world. It contains detailed records of insurance premiums collected and losses paid from participating insurers. Insurance companies can become a member of ISO and they can send claims information to ISO to check whether similar claims have been filed with other insurance companies.

End users use the ISO Database Search view to check whether a similar claim has been filed by the claimant with another insurance company.

This task is a step in Process of Managing Claims.

Before an insurance company can integrate with the ISO, it must be an ISO member and pay the associated fees. The steps involved in integrating with the ISO include:

Setting the ISO System Preferences

You must configure the System Preferences shown in the following table using the Administration – Application screen. The values are available as seed data, but you must make sure that the ISO Connection Info, ISO CustLogInId, and ISO Pswd system preferences have the appropriate values assigned for the insurance provider.

Table ISO System Preferences

System Preference Name	System Preference Value
ISO ClientAppName	Client Application Name. The is XML_TEST for ISO ClaimSearch US customers.
ISO ClientAppVersion	Client Application Version. The value is 1.0 for ISO ClaimSearch U.S. customers.
ISO Connection Info	ISO Application URL.
ISO CustLogInId	Customer Login ID. The ISO assigns a unique user ID to each customer.
ISO Pswd	Clear text Password. The ISO assigns the password.

Note:

Checking the ISO Run-Time Event

You must verify the configuration of the run-time event that invokes the ISO Search Request workflow. You do this through the Administration – Runtime Events screen. The following table shows the data for the run-time event and the associated action set, ISO Integration.

This data is available as seed data in the Siebel Runtime Repository.

Table ISO Run-Time Event Data

Sequence	Object Type	Object Name	Event	Subevent	Action Set Name
1	BusComp	INS Claims ISO Search	InvokeMethod	EventMethodSubmit	ISO Integration

Checking the Validation Rules

The Validation Rule Set named INS Claims ISO Integration Validation specifies the validation rules that need to be applied before an ISO search request is submitted.

You can verify the configured rule set through the Administration – Data Validation screen.

The validation rule checks that some of the mandatory fields for the ISO search exist in the Claim record. The fields are Company Id, Policy Number, and Loss Date. The validation rule is available as seed data in the Siebel Runtime Repository. This rule is invoked as one of the initial steps in the FINS Claims ISO Search Request Workflow. The administrator has to make sure that the validation rule is present in the system.

Creating the Named Subsystem for the ISO Search Response

The Siebel system administrator must create a Named Subsystem called ProcessISOResponse and configure it with the inbound workflow, FINS Claims ISO Search Response. This is required for handling the results sent back by ISO after an ISO Database Search request is submitted.

For more information about creating a Named Subsystem, see Siebel System Administration Guide.

To create and configure the Named Subsystem

Start the Siebel Gateway and Siebel Server.
At a DOS prompt start the Siebel Server Manager (srvrmgr) and verify that the Siebel Server is running. For more information about the srvrmgr, see Systems Administration Guide.

Enter the following Siebel Server Manager command:

create named subsystem ProcessISOResponse for subsystem 
EAITransportDataHandlingSubsys with DispatchWorkflowProcess="FINS Claims ISO Search 
Response", DispatchMethod=RunProcess

Enter the following Siebel Server Manager command to validate that the Named Subsystem was properly created (an error would indicate that it was not created properly):
```
list parameters for named subsystem ProcessISOResponse
```
In the eai.cfg file in the {$SIEBEL_ROOT}\bin\enu (or appropriate language) directory, add the following entry.
```
[HTTP Services]

ProcessISOResponse=ProcessISOResponse
```
Enable the EAI component group.
Restart the Siebel Gateway and the Siebel Server.

Configuring the ISO Assigned Company ID

The ISO assigns unique company identifiers to member insurance companies. One company can have multiple IDs for different offices or divisions. The IDs are used during ISO database searches to check whether the company is an ISO member.

The Siebel system administrator must associate the ISO-assigned company ID with the Internal Division to which a user who performs an ISO database search belongs.

To configure the ISO-assigned company ID

Navigate to the Administration – Group screen, then the Internal Divisions view.
Select the Internal Division to which the employee belongs, or create a new Internal Division record as required.
In the Internal Division List applet, or Internal Division Entry applet, enter the ISO-assigned company ID in the Company ID field.
Save the record.

Integrating with the Office of Foreign Assets Control

The Office of Foreign Assets Control (OFAC) administers and enforces economic sanctions programs primarily against countries and groups of individuals, such as terrorists and narcotics traffickers. Siebel Insurance allows you to check claims payees against a blacklist of individuals and organizations provided by OFAC.

The blacklist is stored in the Siebel database and you must keep it up to date by importing data from an XML file, sdn.xml that you obtain from the OFAC site:

http://www.treasury.gov/offices/enforcement/ofac/sdn/sdn.xml.

You can schedule the FINS Claims OFAC Data Import Process workflow on a monthly basis to process the XML file and import the OFAC data.

The FINS Claims OFAC Data Import Process workflow has a process property for the Input File. You can set the default string of this process property to C:\TEMP\OFAC_SDN.xml, or whatever location you require.

Tip: Run the workflow after work hours to update the Siebel data; this minimizes the performance impact.

This task is a step in Process of Managing Claims.

Checking the Policy Validity and Coverage (End User)

When a call center agent receives a call about a claim, she must check that there is a valid policy associated with the claim and that there is appropriate coverage.

This task is a step in Process of Managing Claims.

To check policy validity

Navigate to the Contacts screen.
Search for the contact.
Drill down on the contact.
In the Summary view, select the appropriate policy.
Drill down on the policy and check whether:
- The contact has a valid policy.
- The contact has the right sort of coverage for the claim, for example, for an auto policy, the right coverage for driver and vehicle.
- Claims are already associated with the policy.

Creating First Notices of Loss (End User)

When end users create a first notice of loss, they add basic loss information and link a policy to the loss.

This task is a step in Process of Managing Claims.

To create a first notice of loss

Navigate to the Claims screen.
In the Claims list, add a record, and complete the necessary fields.
Drill down on the Claim # hyperlink.
Click the Loss Details, then the Loss Description view tab.
In the Claim Loss Description form, complete the necessary fields.

Recording Details of Involved Parties (End User)

As part of the first notice of loss process, a call center agent must record details of all parties involved in the claim. An involved party can be a contact or an organization. In the Involved Parties view, end users can see the relationship of all accounts and contacts related to the claim.

Each account and contact can have multiple roles. For example, a single party can be both the insured and the claimant; that is, insured with their own policy and a third party claimant on the other party's policy. As another example, a service provider can be the insured, claimant, or a witness.

In both the Contacts and Accounts forms, the On Behalf field records details of names and endorsement roles for the purpose of making payments. Because of legal requirements, it is necessary to capture all names and relationship correctly. The following table shows some examples of endorsement roles.

Table Contact Details and Endorsement Roles

Contact Payee	Endorsement Role	Claim Contacts
Bill Franklin	Attorney for	Todd Smith and Lisa Myers
Lisa Powers	Guardian of	Sandra Oh

In the examples in the table, the insurance company is making a single claims payment to Bill Franklin who is the attorney for Todd Smith and Lisa Myers and to Lisa Powers who is a guardian of Sandra Oh.

In the first example, the end user must:

Create three contact names: Bill Franklin, Todd Smith, and Lisa Myers.
In the record for Bill Franklin, select Todd Smith and Lisa Myers in the On Behalf field. Siebel Insurance concatenates the names in the On Behalf field.

When the adjuster later makes a payment in the Claims, Financials, and then the Payments view, he can select Bill Franklin as payee and Siebel Insurance will already have the information that Bill Franklin is the attorney on behalf of Todd Smith and Lisa Myers.

This task is a step in Process of Managing Claims.

To associate an involved party with a loss

Navigate to the Claims screen.
In the Claims list, drill down on the desired claim.
Click the Loss Details, then the Involved Parties view tab.
If the involved party is a person, add the required details for the contact.
1. If required, enter information in the On Behalf field.
2. If required, select Contact Detail, and enter detailed information for the contact.
If the involved party is an organization, scroll down to the Accounts form, and complete the necessary fields.
If required, select Account Detail, and enter detailed information for the account.
Repeat Step 4 through Step 5 for each involved party that you want to add to the claim.

Recording Insured and Adverse Claimant Property Details (End User)

After they have created a claim, end users record details about the property involved in a claim using the following Claims views:

Insured Property. Track details about the insured property in a claim.
Adverse Claimant Property. Track details about claims or damages filed against the policy holder.

This task is a step in Process of Managing Claims.

To record insured property information

Navigate to the Claims screen.
In the Claims list, drill down on the desired claim.
Click the Loss Details, then the Insured Property view tab.
In the Insured Property list, add a record for each insured property involved in the claim.
In the Sequence # field, click the select button and select the insured property from the Pick Insured Property dialog box.
The type of property selected in the Insured Property list determines whether the application displays the Insured Vehicle Detail form or Insured Property Detail form.
In the Claim Elements # field, select a claim element, if applicable.
Many insurance companies break down claims into subcomponents called claim elements. By subdividing claims in this way, insurers can delegate the management of these subcomponents to specific groups within their company according to their business rules. For more information on claim elements, see Assigning a Claim Element (End User).
In the form that appears, complete the necessary fields.

Recording Adverse Claimant Property Information

Use the following procedure to record adverse claimant property information.

To record adverse claimant property information

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Loss Details, then the Adverse Claimant Property view tab.
In the Adverse Claimants list, add a record for each claimant.
In the Adverse Claimant Property list, add a record for each property.
In the Property Type field, select Auto or Property.
The Property Type you select determines whether the application displays the Vehicle Detail or Property Detail form.
In the Claim Elements # field, select a claim element, if applicable.
Many insurance companies break down claims into subcomponents called claim elements. By subdividing claims in this way, insurers can delegate the management of these subcomponents to specific groups within their company according to their business rules. For more information on claim elements, see Assigning a Claim Element (End User).
In the form that appears, complete the necessary fields.

Managing Claims Events (End User)

There are several circumstances in which a group of claims are associated with one event:

Catastrophic events. Events such as tornado or hurricane damage that result in claims under multiple policies. There can be multiple claims for one insured person under different policies.
Single loss involving multiple lines of business. Events where a single loss involving an insured person is covered under two different policies; for example, an insured person’s vehicle might be broken into and personal property stolen. In this case, the vehicle damage is covered under the auto policy, and the personal property is covered under the homeowner policy. A single incident occurs with the same loss date, description, and so on.
Single loss involving multiple people from the same company. Events, where, for example, two people insured with the same company are involved in a traffic accident. This is a single loss involving two insured people, on two separate auto policies. In this case, there are two claims, but a single incident with the same loss date, description, and so on.

The ability to record event details in one place reduces data duplication and the time required to collect claim information. It also provides the ability to track major catastrophic events and incorporate the statistics into risk-rating processes.

End users use the Claims Events screen to record details of claims events and to associate claims with an event.

This task is a step in Process of Managing Claims.

To record details of a claims event

Navigate to the Claims Events screen.
In the Claims Events list, add a record, and complete the necessary fields.

Associating a Claim with a Claims Event

Use the following procedure to associate a claim with a claims event.

To associate a claim with a claims event

Navigate to the Claims Events screen.
In the Claims Event list, select the event with which you want to associate the claim or group of claims.
In the Claims list applet, add a record or click the Associate button to display a picklist of claims, and select the appropriate claims.

Assigning a Claim to an Adjuster (End User)

There are two ways to assign a claim to an adjuster.

By entering the adjuster name in the Team field in the Claims header form applet.
By using Assignment Manager so that when the Call Center agent changes the status from Notice of loss to Open in the Status field in the Claims header form applet, it initiates an Assignment Manager function to assign the claim to an adjuster.

Note: This Assignment Manager function is not provided out-of-the-box.

For more information about using Assignment Manager, see Siebel Assignment Manager Administration Guide.

This task is a step in Process of Managing Claims.

Checking a Claim Against the ISO Database (End User)

The ISO ClaimSearch database is an insurance fraud detection system owned by the Insurance Services Office (ISO), a U.S. specific organization. This task is a step in Process of Managing Claims.

ISO is one of the largest private databases in the world and it contains detailed records of insurance premiums collected and losses paid from participating insurers. Insurance companies can become a member of ISO and they can send claims information to ISO to check whether similar claims have been filed with other insurance companies.

ISO Database search currently handles only Auto (Insured and Adverse Claimant) and Property (Insured only) searches.

End users use either the ISO Database Search view or the ISO Database Search Attachments view to check whether a similar claim has been filed by the claimant with another insurance company.

The ISO Database Search view displays the search records and, in the Claim Matches list applet, any matching records for that search that are returned by ISO.

The ISO Database Search Attachment view also displays the search records, and in the Attachments list applet, displays the actual search responses from ISO as XML data. Clicking the Attachment name opens the XML file in the default editor. The end user can also drill down to this view from the ISO Database Search view, through the Match Details field.

The claim data that must be sent to ISO for a database search is shown in the following table.

Table Required Data for ISO Database Search

Claims and Losses	Data Required
For each claim submitted	Report Type Insuring Company ID Policy Number Policy Type Claim Number Date of Loss Location of Loss State Loss Type
For each involved party	Role in the Claim Business Name (for accounts) First Name (for contacts) Last Name (for contacts Address Information Line 1 City State
For a casualty or third-party property damage loss	Alleged Injuries or Property Damage
For first-party property loss	Theft items

In the ISO Database Search view, the Report Type field specifies the type of search as follows:

Initial Search. Used when a claim is sent to ISO for the first time. The ISO ClaimSearch system writes the claim data to its database and then searches the database for claims that belong to the same claimant. This report type is used only for a first-time search or for resubmitting an initial search that had errors.
Replacement. Used to overwrite data sent in the initial search. The data is updated in the database and a new search is performed. To locate the initial claim in the database, the data must include the Insuring Company ID, Claim Number, Policy Number, and Date of Loss.

When the end user submits the search, the information displayed in the ISO database search list applet is shown in the following table.

Table Information Displayed in the ISO Database Search List Applet

Field	Comments
Date	The date when the search request was submitted.
Requested by	The ID of the person who submitted the request.
Status	The status of the request: Pending. The request is being created. Acknowledged. The request has been received by ISO. Error. The search is completed and there are errors. Complete. The search is completed and there are no errors.
# Matches	The number of matches returned.
Error Message	Any error messages returned. If the data sent is incomplete, or fields contain invalid data, an error is returned.
Match Details	A link that the end user can drill down on to see the details of matches.

To check a claim against the ISO database

Navigate to the Claims screen.
In the Claims list, drill down on the desired claim.
Click the Reports / Documents, then the ISO Database Search view tab.
Create a new record.
In the Report Type field, select Initial Search or Replacement.

Note: You can perform a replacement search only if at least one initial search has already been completed for the claim record.
Click Submit to send the claim data to ISO.

Creating an Activity Plan (End User)

An adjuster uses the Activity Plans view to manage the claims task to completion and assign activities to different individuals. When he clicks the Default Plans button, Siebel Insurance automatically creates an activity plan based on the loss code for the claim.

One of the adjuster’s jobs is to assign a field appraiser to appraise damage. Assigning an appraiser can be complex because the customer schedule and appraiser schedule must be optimized. In the activity plan, the user can drill down on an activity of type Field Appraisal to go to the Activities, then the Schedule view. The user can also drill down on the Status field in the activity plan, and if the status value is Unscheduled, the user is taken to the Dispatch Board view, which allows complex appraisal scheduling. For more information about scheduling with the Dispatch Board, see Siebel Field Service Guide.

This task is a step in Process of Managing Claims.

To create an activities plan

Navigate to the Claims screen.
In the Claims list, drill down on the desired claim.
Click the Diary Management, then the Activity Plans view tab.
Click the Default Plans button.
The default activities plan is created based on the loss code for the claim.

Assigning a Claim Element (End User)

Many insurance companies break down claims into subcomponents called claim elements. By subdividing claims in this way, insurers can delegate the management of these subcomponents to specific groups within their company according to their business rules.

You can also create a claim element and assign it to a third party. For example, you can assign a claim element to a service provider, such as Auto service, who then does the repair. The third party can see the claim element through the Partner Portal.

This task is a step in Process of Managing Claims.

To assign a claim element

Navigate to the Claims screen.
In the Claims list, drill down on the desired claim.
Click the Assignments view tab.
In the Claim Elements list, create a new record.

Adding Claim Element Details

Use the following procedure to add claim element details.

To add claim element details

Navigate to the Claim Elements screen.
In the Claim Elements list, drill down on the desired Line #.
Select the appropriate view tab to add details specific to the currently selected claim elements.

Note: The view tabs on the Claim Elements screen function identically to those on the Claims screen.

Assigning Claims to a Specialist Unit (End User)

The following buttons are available in the Claims List screen for evaluating the fraud and subrogation (that is, recovery) potential of a claim:

Evaluate Subrogation Potential. Evaluates the subrogation potential of the claim.
Evaluate SIU Potential. Evaluates the fraud potential of the claim.
Details. Captures the claims combined score details.

During implementation, the customer can write a business service or enable the Analytics application to drive the logic behind these evaluation buttons. When the user clicks either the Evaluate Subrogation Potential or Evaluate SIU Potential button, Siebel Insurance takes the value from the Details button, which captures the claims combined score details, and performs the calculation that determines the value in the Subro Potential or Suspicious Claims indicator in the Claims form respectively. Each indicator has ten bars each representing 10% and colors are displayed in the bars according to the value in the field to the right of the bars, which can have a value from 0 through 1.

The following buttons are available for assigning claims to appropriate specialist units:

Notify SIU. Assigns the claim to the special investigation unit (SIU)
Notify Subro. Assigns the claim to the subrogation unit

After the Assignment Manager assigns the claim, an Alert applet in the Home page displays details of the claim. The user can then drill down on the alert to go to either the SIU dashboard view or the Recovery dashboard view, as appropriate.

Note: The Assignment Manager component must be running. To check that it is running, navigate to the Administration - Server Configuration, Servers, then Components screen, and check for Assignment Manager and Batch Assignment entries in the list.

For information about managing claims through the recovery process, see Managing Recovery Information (End User). For information about managing suspicious claims through the investigative process, see Managing Fraud Information (End User).

This task is a step in Process of Managing Claims.

To assign a claim to a subrogation unit

Navigate to the MyClaims screen.
Drill down on a claim.
Select a record, and click the Notify Subro button.
The claim is assigned to the subrogation unit.

Assigning a Claim to an SIU

Use the following procedure to assign a claim to an SIU.

To assign a claim to an SIU

Navigate to the MyClaims screen.
Drill down on a claim.
Select a record, and click the Notify SIU button.
The claim is assigned to the SIU.

Adding an Appraisal (End User)

End users use the Appraisals view to record a property's insurable value, or the amount of a loss.

A row in the view shows the total estimation value for all adjusters. End users can click the Check Reserves button to compare the total estimation value with the total reserve amount set for the claim. (The INS Reserve Estimation Check business service is invoked.)

If the reserve value is less than the total estimation value for all adjusters, Siebel Insurance notifies the end user that the reserve value must be adjusted.

This task is a step in Process of Managing Claims.

To add an appraisal

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Reports/Documents, then the Appraisals view tab.

In the Appraisals form, add a record, and complete the necessary fields.

Some fields are described in the following table.

Field	Comments
Type	The type of appraisal. Values include: Automobile, Home, RV.
Property Appraised	The property being appraised.
Amount	The amount of the appraisal.
Appraiser Type	The type of appraiser: Adjuster or Body Shop.
Appraiser Name	An employee chosen from a Select Appraiser applet.
Service Region	The service region applicable to the appraiser. This field is automatically prefilled when the appraiser name is selected.

Click Check Reserves to check that the total estimates do not exceed the available reserves.

Attaching Claims Documentation (End User)

Adjusters use the Claims screen, then the Attachments view to attach documents associated with a claim, for example:

All Claims. Statements, photographs, scene diagrams, state statutes, payments, estimates.
Auto Claims. Ticket disposition, uninsured: subrotech information.
Property Claims. Proof of loss.

This task is a step in Process of Managing Claims.

To attach claims documentation

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Reports/Documents, then the Attachments view tab.
In the Attachments list, create a new record, and complete the necessary fields.

Tracking Police and Fire Reports (End User)

End users can use the Police And Fire Reports view to collect and manage police and fire report information.

This task is a step in Process of Managing Claims.

To add police and fire report information

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Reports/Documents, then the Police And Fire Reports view tab.
In the Police/Fire Reports Detail list or form, add a record, and complete the necessary fields.

About Coverages and Reserves

When a customer purchases an insurance policy, the policy specifies which coverages are included in the policy. For example, for an auto policy there might be coverages for: towing and labor, rental car, collision, and bodily injury. Each of these coverages has an associated maximum amount covered and the deductible amount.

An adjuster must open a reserve for each coverage that applies to a claim. A reserve is an amount of money made available for payments in respect of claims. For example, if the claimant was involved in a collision accident, the adjuster must open a reserve for collision coverages. If the claimant was injured, the adjuster must open a bodily injury reserve.

The money that the insurance companies put aside cannot be used for anything else, therefore it is important to create the right amounts for reserves.

This task is a step in Process of Managing Claims.

Creating a Reserve (End User)

A claims adjuster uses the Loss Details - Auto and Loss Details - Property views to make sure that the customer has the right policy and coverage for a claim and to create a reserve for each coverage.

It is essential to capture policy information at the time that the claim is opened, because policy information might change over time. To do so, the end user must select the right policy for the customer in the Policy field in the Claims form header applet. In the case of the Loss Details - Auto view, the Driver, Vehicle and Coverages applets are then populated with the policy details.

Note: There is also a Get Policy button in the form applet that is disabled by default. The customer can enable this button by writing an appropriate business service to get the policy information from their policy system to populate the policy information in the claim.

The following table shows the information displayed in the Coverages applet.

Table Coverage Information in Loss Details Views

Field	Comments
Coverage	The name of the coverage, for example, collision, bodily injury and so on.
Individual Limit	The individual limit of the coverage.For example, for a bodily injury, the typical individual limit is $100,000, which means that the most the insurance company will pay for bodily injury for a particular person is only up to $100,000.
Total Limit	The total limit for a particular coverage. For example, for bodily injury, the typical total limit is $300,000, which means that the most the insurance company will pay for bodily injury for this claim is $300,000, regardless of how many persons are involved.
Deductible	The amount of loss paid by the policy holder.
Coverage Applies?	A flag to indicate that a reserve is opened based on the loss code for the claim.
Reserve Code	The reserve code.
Reserve	The name of the reserve.
Reserve Type	The type of reserve, which specifies how the reserve is set. Manual. The value is set at the time of reserve creation by the adjuster. Factor. The reserve has a default value Calculated. The reserve value is computed in real-time by a business service.
Reserve Amount	The amount of the reserve.

For each coverage, the Coverage Applies flag indicates whether a reserve must be created for the coverage. For example if the claim is for a car collision accident, the Collision coverage is flagged so that a reserve is created for that coverage. Coverages are flagged as applicable according to the default coverages for the loss code. For more information about loss codes, see Administering Loss Codes.

The adjuster clicks the Create Reserve button to create a reserve for all the coverages that have the Coverage Applies flag set. If you want to create a reserve from a coverage that does not have the Coverage Applies flag set, you can set the flag for that coverage and add the appropriate reserve code. Reserves are created according to the reserve code and reserve type that are associated with the coverage. For more information about reserve codes, see Administering Reserve Codes.

After a reserve is created, it can be viewed in the Claims, Financials, and then the Reserves view, see Managing Reserves (End User).

This task is a step in Process of Managing Claims.

To create a reserve for an auto policy claim

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Loss Details, then the Loss Details - Auto view tab.
Select the required policy in the Policy field in the Claim form header applet.
The policy information including details for Vehicles, Driver, and Coverages are copied into the view.
In the Coverages list, click the Create Reserve button.

About Managing Reserves

An adjuster uses the Claims, Financials, and then the Reserves view to:

Open reserves
Adjust reserves
Delete a reserve created using the Create Reserve button in the Loss Details - Auto or Loss Details - Property view
Create new reserves

Opening Reserves

To open a reserve, the adjuster enters the amount of reserve to open in the Reserve Amount field and clicks the Open Reserve button. Siebel Insurance then performs the following checks:

Reserve authority limit check. Siebel Insurance checks the user limit on a per reserve - per claims basis. For example, if adjuster A has a bodily injury limit of $20,000 and he would like to open bodily injury for contact 1 for $15,000 and bodily injury for contact 2 for $15,000, Siebel Insurance displays an error message since the $30,000 is more than the adjuster total bodily injury limit for the claims. The per reserve - per claim basis will apply at the supervisor level as well. That means if the claim goes to a supervisor, the amount will go against that supervisor limit even if he does not approve it. For example in, let’s say B (A’s supervisor) limit for bodily injury reserve is only $25,000. In this case, B can not approve it and Siebel Insurance will send the claim to C (B’s supervisor). The next time A would like to open another bodily injury reserve, B cannot approve it anymore since the total bodily injury for the claim is already more than $30,000 and this is more than B’s bodily injury $25,00 limit. A supervisor can click one of the reserves in the Inbox list to open a reserve, as long as his or her own limits are not exceeded. On the reserve applet, the approver only sees that associated reserve record. To see all of the reserve records, the approver can use the query button to show all reserves. From the inbox, a supervisor can change the reserve status to either approve or reject. Once a supervisor has changed the status of an Inbox item, the associated reserve status is changed and the item is moved to the completed inbox. Because the approval history is tracked by inbox items, administrators must not delete completed inbox items. For more information about using the Inbox, see Siebel Applications Administration Guide.
The reserve authority limit check
Split limit check. Siebel Insurance checks the individual policy limit and the total policy limit fields and does some comparison. If the reserve amount set for a contact or an account is more than the individual limit, Siebel Insurance displays an error message. Also, if the reserve amount set for a particular coverage is more than the total limit, Siebel Insurance displays an error message. For example, a Bodily Injury coverage can have a $100,000 individual limit and $300,000 total limit. Siebel Insurance checks that the reserve amount to be opened for each individual or account for the Bodily Injury reserve is no more than $100,000 and that the total reserves amount for bodily injury reserves for all individuals or accounts is no more than $300,000.

After the checks are performed, The Outstanding Reserve field is updated with the amount that was entered in the Reserve Amount field.

For more information about financial limits for adjusters, see Administering Adjusters’ Financial Limits.

The following table shows the fields in the Reserves applet.

Table Reserve Fields

Field	Comments
Status	The status of the reserve. If the reserve status is Open, the reserve record is read only and the only way an adjuster can modify this record is by clicking the Reserve Adjustment button.
Reserve Code	The code of the reserve.
Reserve	The name of the reserve.
Reserve Amount	The reserve amount. The adjuster can enter the amount of reserve in this field. If the reserve type is Factor, this field is automatically prefilled.
Reserve Type	The type of the reserve such as Factor, Manual, or Calculated.
Reserve Open	The date the reserve is opened.
Reserve Closed	The date the reserve is closed.
Outstanding Reserve	The amount of reserve outstanding at a particular time. The value of this field is automatically decreased every time an adjuster makes an indemnity payment.
Last Name	The last name of the contact for which the reserve is opened.
First Name	The first name of the contact for which the reserve is opened.
Account	The name of the account in which the reserve is opened. A reserve can only be opened for either a contact or account and cannot be opened for both.
Individual limit	The individual limit for a particular reserve for a particular contact or account. The individual limits for reserves of the same reserve code must be the same. If, for example, you have two bodily injury reserves of the same code, one for person A, and you specify an individual limit of $100,000 and on the other bodily injury for person B you specify an individual limit of $150,000, Siebel Insurance displays an error message.
Total Limit	The total limit for a particular reserve. The total limits for reserves of the same reserve code must be the same.
Deductible	The deductible for the reserve. The deductibles for reserves of the same reserve code must be the same.
Adjuster	The name of the adjuster to which this particular reserve is assigned. Different reserves can be assigned to different adjusters and only the assigned adjuster can open that particular reserve, therefore it is necessary to enter the adjuster name.
Approver	The approver name. Siebel Insurance automatically populates the approver name with the adjuster’s supervisor name. For information about how the employee hierarchy is set to determine the supervisor for each adjuster, see Administering the Employee Hierarchy. The supervisor can then go to the Inbox screen, drill down on the claims that need approval, and select the claim to open the reserve. The supervisor can change the status to either approve or reject. Once the status of the inbox is changed, items move to the completed inbox. If this supervisor does not have enough reserve limit, Siebel Insurance fills in the supervisor’s supervisor name in the Approver field. Siebel Insurance then notifies that supervisor to go to the Inbox screen to approve the reserve.
Insured property	The insured property.
Total payment	The total amount of payment that has been made using this reserve.

Adjusting a Reserve

After a reserve is opened, the user can adjust only the reserve amount by selecting the reserve record and clicking the Reserve Adjustment button. The user can then change the reserve amount and reopen the reserve. The adjuster can make the adjustment even after the reserve is used to make payment.

When the adjuster makes a payment of type Indemnity, the value of the Outstanding Reserve field is decreased by the amount of the payment. If the Outstanding Reserve amount is 0, the adjuster cannot use this reserve to make other indemnity payments. If the adjuster wants to make indemnity payments, he must adjust the reserve amount by clicking the Reserve Adjustment button and entering the new reserve amount in the Reserve amount field. Siebel Insurance then updates the Reserve Outstanding field.

Only the adjuster that is assigned to a reserve can open or adjust that reserve.

An adjuster can assign a reserve to a different adjuster by changing the Adjuster field in the Reserves view.

Managing Reserves (End User)

After a reserve is created, an adjuster can open and adjust the reserve. You can also create new reserves and delete existing reserves.

This task is a step in Process of Managing Claims.

To open a reserve

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Financials, then the Reserves view tab.
In the Reserves list, select the required record.
Enter the required amount in the Reserve Amount field.
Click Open Reserve.

Adjusting a Reserve

Use the following procedure to adjust a reserve.

To adjust a reserve

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Financials, then the Reserves view tab.
In the Reserves list, select the required record.
Click Reserve Adjustment.
Enter the required amount in the Reserve Amount field.
Click Open Reserve.

Creating a New Reserve

Use the following procedure to create a new reserve.

To create a new reserve

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Financials, then the Reserves view tab.
In the Reserves list, create a new record and complete the necessary fields.
For information about the fields in a reserve, see the previous table.

Deleting a Reserve

Use the following procedure to delete a reserve.

To delete a reserve

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Financials, then the Reserves view tab.
In the Reserves list, select the required record.
Click Delete.

Tracking Demands for Payment (End User)

End users use the Bills view to record demands for payment associated with a claim.

Note: The Bills view was used in versions prior to Siebel Insurance 8.0. In Siebel Insurance 8.0, you can use either the Bills view or the Invoices view to capture information about bills.

This task is a step in Process of Managing Claims.

To record demands for payment

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Financials, then the Bills view tab.
In the Bills list, add a record, and complete the necessary fields.
For more information on claim elements, see Assigning a Claim Element (End User).
In the Attachments list, attach an electronic version or image of the bill.

Creating an Invoice Record (End User)

An adjuster uses the Claims, then the Invoices view to create a record of bills and invoices received from the claimant and third parties in respect of a claim. The view is also used to associate invoices with claims. If the adjuster wants to add additional line items for the invoice, or to attach an invoice image and note, the adjuster can drill down on the invoice number to go to the Invoices Screen.

For information about using the Invoices screen, see Siebel Communications Guide.

This task is a step in Process of Managing Claims.

To create invoice records

Navigate to the Claims, then the Invoices view.
In the Invoices list, add a new record, and complete the necessary fields.
Drill down on the invoice to go to the Invoices screen.
(Optional) In the Line Items list, add line items for the invoice.
(Optional) In the Attachments list, attach an electronic version or image of the invoice.
(Optional) In the Notes list, add any notes for the invoice.

Generating a Payment Record (End User)

An adjuster can use the Claims screen, then the Invoices view to create a record of invoices received from the claimant and third parties in respect of a claim, and to generate a payment record for invoices.

When the adjuster clicks the Generate Payment button, Siebel Insurance creates a payment record for one invoice or multiple invoice records.

Note: A similar view is in the Claims Element screen.

This task is a step in Process of Managing Claims.

To generate a payment record

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Financials, then the Invoices view tab.
In the Invoices list add records and complete the necessary fields.
Click Generate Payment.

Tracking Payments Related to Invoices (End User)

Adjusters can use the Invoices, then the Claim Payments view to track all of the payments for invoices.

This task is a step in Process of Managing Claims.

To view the payments for an invoice

Navigate to the Invoices screen.
In the Invoices list, drill down on an invoice.
Click the Claim Payments view tab.

About Issuing a Settlement Payment (End User)

End users use the Financials, then the Payments view tab to issue a settlement payment. This task is a step in Process of Managing Claims.

A payment can be associated with a single or multiple reserves. For example, an adjuster can make a payment of $10,000, and this payment can be drawn from a collision reserve and a towing-and-labor reserve.

Note: End users can associate a payment with reserves only if the payment type is indemnity. For other payment types, the Reserves list applet is a read-only applet.

The following table shows the fields in the Payment list applet.

Table Payment List Applet Fields

Field	Comments
Payment #	The system-generated payment number.
Payment Code	The code of the payment. Values include: After Full Payment, Full Payment, and Partial Payment
Payment Type	The type of payment. Values include: SIU Expenses, Subrogation Expenses, Expenses, Indemnity Payment, Loss, and Loss - Supplemental.
Payment Method	The method of payment. Values include: Check, Cash, Cashier Check, Third Party, Payroll Deposit.
Payee	The name of the contact to whom payment is made.
Vendor Payee	The name of the company to which payment is made.
Amount	The amount of the payment.
Cash Settlement	Whether the payment represents a cash settlement.
Claim Element #	The claim element associated with the payment.
Claim Element Coverage	The claim element coverage.
Invoice #	The invoice associated with the payment.
Issued	The date the payment is issued.
Check #	The number of the check issued for payment.
Paid By	The name of the adjuster making the payment.
Payment Status	The status of the payment. Pending. The default status and the status when the validation fails. On-Hold OFAC. The status when the OFAC check fails. On-Hold Limit. The status when the authority limit check fails. Approved Limit. The status when the supervisor approves. Rejected. The status when the supervisor rejects the payment. Payment Generated. The status when all the checks are good and the payment goes through. Void. The status when the payment is voided. Bulk Payment. The status when the payment is made through bulk payment.
From Date	For medical claim or bodily injury bills, the from date for the customer’s stay in hospital.
To Date	For medical claim or bodily injury bills, the to date for the customer’s stay in hospital.
Adjuster	Read only field populated with the login ID of the payment creator.
Approver	Read only field populated when the payment enters the approval process.

The following table shows the fields in the Reserve list applet.

Table Reserve List Applet Fields

Field	Comments
Reserve Code	The code of the reserve.
Reserve	The name of the reserve.
Reserve Amount	The reserve amount.
Outstanding Reserve	The amount of reserve outstanding at a particular time. The value of this field is automatically decreased every time an adjuster makes an indemnity payment.
Reserve Applied to Payment	The amount of the reserve that will be applied to the selected payment.
Deductible	The deductible for the reserve.
Apply Deductible?	Whether the deductible has been applied to the payment.
Individual limit	The individual limit for a particular reserve for a particular contact or account.
Total Limit	The total limit for a particular reserve.
Last Name	The name of the contact for which the reserve is opened.
First Name	The last name of the contact for which the reserve is opened.
Account	The name of the account in which the reserve is opened. A reserve can only be opened for either a contact or account and cannot be opened for both.
Reserve Open	The date the reserve is opened.
Reserve Closed	The date the reserve is closed.
Total Payment	The total amount of payment that has been made using this reserve.
Status	The status of the reserve.

When the user clicks the Submit Payment button, the following checks are performed:

Check whether some of the fields are entered correctly. Siebel Insurance checks:
1. That the Date From field is not null, and that it is before the date in the Date To field.
2. That the Date To field is not null, and that it is later than the date in the Date From field.
3. That the Payment Amount field is not 0.
4. That the Payment Status field is pending. Only a payment with status Pending is evaluated when the user clicks the Submit Payment button.
5. Whether the Mail To Flag is set for the Payee or Vendor Payee field. There must be only one payee among both the contact payees and the vendor payees that have the Mail Payment Flag checked.
Check whether the contact payee or account payee is in the OFAC database. Siebel Insurance checks whether the contact or account is in the OFAC database. If the payee or vendor payee is in the OFAC database, Siebel Insurance suspends the payment and changes the status of the payment to On Hold OFAC. For more information, see Checking a Claim Against the ISO Database (End User).
Check whether the per-coverage deductible has been applied to the payment amount. Siebel Insurance checks whether the deductible flag in the Reserve list applet is checked. This step is only applicable if the payment is associated with a reserve (that is, a payment of type Indemnity payment). If the deductible flag is not checked, Siebel Insurance displays a message prompting the adjuster to reduce the amount in the Reserve applied toward payment field by the deductible amount. When the flag is set to true, the deductible flag field becomes a read-only field and it applies to the reserve. So, the next time the adjuster associates the reserve to another payment, the deductible flag remains checked.
Check whether the payment amount is equal to the total of reserve applied to payment. Siebel Insurance checks whether the Total reserve applied toward payment field in the Reserve list applet is the same amount as in the Payment amount field in the Payment list applet. If the value is not the same, Siebel Insurance displays an error message prompting the user to adjust the amount to make it the same.
Check whether the reserve applied to payment is equal or less than outstanding reserve. Siebel Insurance checks whether there is enough outstanding reserve to make the payment. If there is not enough reserve left to make the payment, Siebel Insurance displays a message to adjust the Reserve Applied to Payment field in the Reserve list applet to be less or equal to the Outstanding Reserve field in the Reserve list applet.
Check if the payment authority limit is correct. Siebel Insurance checks whether the adjuster has enough payment limit to make this payment. The adjuster has a payment limit on the coverage level as well as on the total claim level (see Administering Adjusters’ Financial Limits). For every payment made by this adjuster, Siebel Insurance keeps track of how much payment has been made on the coverage level and on the claim level. Siebel Insurance then compares this with the adjuster payment limit for each coverage and for the claim. For example: Adjuster A has a bodily injury payment limit of $10,000, collision payment limit of $5,000, and a total indemnity payment limit of $20,000. If the adjuster receives an invoice, say for $12,000, and he wants to draw from the collision and bodily injury reserves to make this payment, the most he can pay from the bodily injury reserve is $10,000, and the most he can draw from the collision reserve is $5000. If he tries to pay more than his payment limit, Siebel Insurance displays a message and sends notification to the supervisor for approval.
Siebel Insurance keeps track of how much the user has paid from a particular limit. Suppose on this $12,000 payment, the user draws $10,000 from the bodily injury reserve and $2,000 from the collision reserve. The next time he wants to make a payment, he can not make a payment from bodily injury reserve without Siebel Insurance notifying his supervisor for approval, because he has already used up to his payment limit on bodily injury reserves.
Siebel Insurance keeps track of the adjuster payment limit on the per reserve - per claim level. For example, adjuster A might have a bodily injury payment limit of $10,000. Suppose he wants to make a payment, and wants to draw $6,000 from the bodily injury reserve 1 for Mary and $6,000 from bodily injury reserve 2 for Todd. In this case, Siebel Insurance displays an error message since the total of bodily injury payments is more than the adjuster A’s $10,000 limit. The per reserve - per claim basis will apply on the supervisor level as well.
If the adjuster does not have enough payment limit, Siebel Insurance creates an Inbox item for the supervisor’s approval. The supervisor can then go to the Inbox screen to approve the payment. The supervisor can drill down on the Inbox item to view the payment details. To see all of the payment records, the supervisor can use the query button. He can then return to the Inbox view and approve or reject the Inbox item. When the supervisor approves the payment, the payment status goes to Payment Generated. If the supervisor's limit is not enough, another Inbox item is created for the supervisor's supervisor. However, if the supervisor rejects the Inbox item, the payment status goes to Rejected. For more information about using the Inbox, see Siebel Applications Administration Guide.
Updating the reserve outstanding amount if all the above checks are passed. Siebel Insurance reduces the Outstanding Reserve field by the amount of payment made. For example, suppose an adjuster sets a $2,000 collision reserve for the claim, and the collision reserve has a $500 deductible. If the adjuster receives a bill from a glass vendor for $1,000, the adjuster applies the deductible for the collision reserve and pays the $500 from the $2,000 collision reserve. After he makes the payment, the outstanding reserve becomes $1,500. The adjuster can then use this $1,500 outstanding reserve to pay another bill related to collision coverage.

For more information about the financial limits for adjusters, see Administering Adjusters’ Financial Limits.

If the adjuster makes a mistake, the adjuster can select the Void button to reverse the transaction. When the user select the Void button, Siebel Insurance adds the payment amount back into the outstanding reserve amount. Furthermore, the user can modify the payment and reserve record accordingly.

Issuing a Settlement Payment (End User)

An adjuster issues a payment to settle a claim.

This task is a step in Process of Managing Claims.

To issue a settlement payment

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Financials, then the Payments view tab.
(Optional) If the payment type is Indemnity, in the Reserves list, associate one or more reserves with the payment.
In the Payments list, add a record and complete the necessary fields.

Note: You can configure your Siebel application to connect to the system your company uses to produce a draft or check to pay the claim. For more information, see Siebel Integration Messages.

Making a Bulk Payment (End User)

Insurance companies usually have a relationship with vendors such as car rental companies where the insurance company can make one large payment in a particular period, for example, every two weeks, or every month. For such bulk payments, Siebel Insurance allows the adjuster to query all the payments for the vendor, sum the payments, and generate one payment for the vendor.

To use the bulk payment capability, the user must first set the relevant account for bulk payment.

This task is a step in Process of Managing Claims.

To set an account for bulk payment

Navigate to the Accounts screen
Drill down on an account.
Click the Profiles, then the Customer Profiles view tab.
In the Pricing and Purchasing Information section of the form, select the Bulk Pay check box.
Bulk payment can now be used for the account.

Making Bulk Payments

Use the following procedure to make a bulk payment.

To make a bulk payment

Navigate to the Payments screen, then the Insurance Payments view.
Click the Generate Bulk Payment button.
In the Payments query box, select the appropriate Account, and select a From Date and To Date.
Siebel Insurance queries all payment record for the vendor for the specified period and generates a payment record for the vendor. The payments associated with that particular bulk payment are displayed in the Payment screen, Insurance Payment, and then the Bulk Payment view.

Note: For the query to work properly, make sure that the Issued field in the Claims, then the Payment view contains the payment issue date.

Viewing the Invoices and Claims for a Payment (End User)

Adjusters can use the Payments, then the Insurance Payments view to display all of the invoices and claims associated with a particular payment.

This task is a step in Process of Managing Claims.

To view the invoices and claims for a payment

Navigate to the Payments screen, then the Insurance Payments view.
Drill down on a payment.
The invoices and claims for the payment are displayed.

Managing Recovery Information (End User)

End users use the Claims screen, then the Recoveries view to record and track information regarding subrogation and salvage activities. This task is a step in Process of Managing Claims.

Subrogration refers to sections of a property insurance or liability insurance policies that give the insurer the right to take legal action against the third party who is responsible for the loss. For example, a customer’s car might be hit by another car and instead of waiting for the other car owner’s insurance to pay, the customer files a claim with his insurance company. The insurance company pays for the damage but contacts the other insurance company to get reimbursement for the payment. The process of getting reimbursement from the other insurance company is an example of subrogation.

Salvage occurs when the insurer takes ownership of the damaged property after the claim has been settled.

An adjuster can assign a claim to a subrogation unit if required. One or more investigators can then use the Recoveries dashboard to manage the subrogation activities and to recovery money from the third party.

A claim can be assigned to various investigators, for example, to arbitration or litigation specialists, or to people handling collection and salvage. The following table shows the primary fields in the Recovery dashboard.

Table Recovery Dashboard Fields

Field	Comments
Subro Referral	Indicates whether the claim has been referred to subrogation.
Referral Source	Identifies how the case was referred to subrogation: System. The case was referred automatically due to the subrogation potential score. Manual - adjuster. An adjuster referred the case manually. Manual - Reassignment. The case was reassigned.
Assignment Date	Displays the time and date on which the subrogation file was opened.
Closed Date	Displays the time and date on which the subrogation file was closed.
Subro Potential	Displays the combined subrogation potential score. This field is updated by the Evaluate Subrogation Potential button in the Claims List applet.
Overall Fault %	Displays the theory of liability value for the claim. This field is set through the Update Theory of Liability task.
Status	Select the status of the subrogation case. Values include: Assigned, Accepted, Initial Review, Negotiations, Decision Pending, Closed, and Re-opened.
Disposition	Select the final status of the subrogation case after processing. Values include: Partial Recovery, Full Recovery, Collections Handoff, Arbitration Handoff, Litigation Handoff, and Abandoned.

The following table shows the fields in the dashboard that display the key financial information.

Table Recovery Dashboard Key Financials Fields

Field	Comments
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.
Total Expenses	Displays the total subrogation expenses incurred to date.This field is updated by the Update Expenses task. Note: The value in this field comes from the Claims, then the Payment view for payments with a type of Subrogation Expense.
Recovery Potential	Displays the recovery potential for the claim. The default value is (Theory of Liability % * Total Claim Payment), that is the theory of liability percentage multiplied by the total claim payment amount.This field is updated by the Update Recovery potential task.

The following table shows the fields in the dashboard used for arbitration or litigation referrals.

Table Recovery Dashboard Arbitration/Litigation Referral Fields

Field	Comments
Arb./Lit. 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 arbitration or litigation for further pursuit.
Counsel/Arb. Board	Select the arbitration board or the external counsel handling the case. If the organization is a business unit, it is added to the claims Service Provider list with a role of Subro Arb./Lit. Provider.
Settlement Amount	Enter the settlement amount for the subrogation case.
Status	Select the status of the arbitration or litigation process. Values include: Assigned, Accepted, Initial Review, Filed Arbitration, Under Litigation - Internal, Under Litigation - External, Decision Pending, Closed, and Re-opened.
Disposition	Select the final status of the arbitration or litigation case. Values include: Settled - Full Recovery, Settled - Partial Recovery, Collections Handoff, and Abandoned.

The following table shows the fields in the dashboard that display the final outcome of the recovery processing

Table Recovery Dashboard Outcome Fields

Field	Comments
Recovery Amount	Enter the total recovery amount on the claim.
Debt Schedule	Select the debt schedule for the subrogation recovery. Values include Installments and Single Payment.
Deductible Return	Displays the deductible return amount for the subrogation case.This field is updated by the Calculate Deductible Return task.

The following table shows the fields in the dashboard used for collections referrals.

Table Recovery Dashboard Collections Referral Fields

Field	Comments
Collections Referral	Indicates whether the claim has been assigned to collections.
Assignment Date	Displays the date and time when the case was assigned to collection for further pursuit.
Collection Agency	Select the collection agency handling the case. If the organizations is a business unit, it is added to the claims Service Provider list with a role of Subrogation Collection Agency.
Collection Amount	The collection amount for the subrogation case.
Collection Status	Select the status of the collection process. Values include: Assigned, Accepted, Negotiating, Closed, and Re-opened.
Disposition	Select the final status of the collection process. Values include: Full Recovery, Partial Recovery, and Abandoned.

The following table shows the fields in the dashboard used for salvage processing.

Table Recovery Dashboard Salvage Potential Fields

Field	Comments
Notify Salvage	Indicates whether salvage potential has been notified.
Recovered Date	Enter the date recovery took place.
Amount Recovered	Enter the amount salvaged.

Using the Common Task Links

In the Recovery dashboard, task links allow the user to update information in the dashboard or to reassign the case to a different person.

The following table shows the tasks in the recovery dashboard.

Table Tasks in the Recovery Dashboard

Action	Description
Check State Statutes	Checks the state statutes. During implementation, the customer can extend the business service for this task to implement statute of limitations logic specific to the states in which they operate.
Update Theory of Liability	Displays a dialog box with the following fields: New Theory of Liability %. Enter a new value with which to update the Overall Fault % field in the dashboard. Reason for Change. Enter the reason for adjusting the theory of liability to create a new note of type Subro Liability Assessment with the text you enter. Update Recovery Potential flag. Select this check box to update the Subro Potential field with the calculated value (New Theory of Liability % * Total Claim Payment Amount).
Update Recovery Potential	Displays a dialog box with the following fields: New Recovery Potential Amount. Enter a new value with which to update the Subro Potential field in the dashboard. Reason for Change. Enter the reason for changing the recovery potential to create a new note of type Subro Recovery Potential with the text you enter.
Recalculate Payment	Recalculates the total claim payment and updates the Total Claims Payment in the dashboard.
Update Expenses	Recalculates the total subrogation expenses and updates the Total Expenses field in the dashboard.
Calculate Deductible Return	Calculates the amount of the deductible that must be returned to the insured party and updates the Deductible Return field in the dashboard.
Notify Salvage	Updates the Notify Salvage flag.
Reassign Claim	Displays a dialog box with the following fields: Assign To. Select the User ID of the person to whom you want to assign the claim. Leave the field blank if you require Assignment Manager to assign the claim automatically. Reason for Reassignment. Enter the reason for reassigning the case to create a new note of type Subro Reassignment with the text you enter.
Refer to Arbitration / Litigation	Displays a dialog box with the following fields: Assign To. Select the User ID of the person to which you want to assign the claim. Leave the field blank if you require Assignment Manager to assign the claim automatically. Referral Notes. Enter any referral notes to create a new note of type Subro Litigation Referral with the text you enter.
Refer to Collections	Displays a dialog box with the following fields: Assign To. Select the User ID of the person to which you want to assign the claim. Leave the field blank if you require Assignment Manager to assign the claim automatically. Referral Notes. Enter any referral notes to create a new note of type Subro Collection Referral with the text you enter.

Creating a Recovery Payment Record (End User)

A subrogation or SIU specialist uses the Financials, then the Recoveries view to create a record of invoices related to recoveries from third parties. This view is used to capture recoveries payment as well as to keep track of invoices that you send to third parties to collect the money. It is similar to the Claims screen, then the Invoices view but has a filter to show only invoices and payments related to the SIU and subrogation unit.

This task is a step in Process of Managing Claims.

To create recovery payment records

Navigate to the Claims screen.
In the Claims list, drill down on a claim.
Click the Financials, then the Recoveries view tab.
In the Invoices list, add records, and complete the necessary fields.

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. The following table shows the primary fields in the SIU dashboard.

Table SIU Dashboard Fields

Field	Comments
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.
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.

The following table shows the fields in the dashboard that display the key financial information.

Table SIU Dashboard Key Financials

Field	Comments
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.
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.
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.

The following table shows the fields in the dashboard that display the final outcome of SIU investigation.

Table SIU Dashboard Outcome Fields

Field	Comments
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.

The following table shows the fields in the dashboard used for arbitration or litigation referrals.

Table SIU Dashboard Litigation Referral Fields

Field	Comments
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.

Using the Common Task Links

In the SIU dashboard, task links allow the user to update information in the dashboard or to reassign the case to a different person.

The following table shows tasks in the SIU dashboard.

Table Tasks in SIU Dashboard

Action	Description
Recalculate Payment	Recalculates the total claim payment and updates the Total Claim Payments field in the dashboard.
Update SIU Expenses	Recalculates the total SIU expenses and updates the Total Expenses field in the dashboard.
Update Recovery Potential	Displays a dialog box with the following fields: New Recovery Potential Amount. Enter a new value with which to update the Recovery Potential field in the dashboard. Reason for Change. Enter the reason for changing the recovery potential to create a new note of type Fraud Recovery Potential with the text you enter.
Update Probability of Resolution	Displays a dialog box with the following fields: New Theory of Liability %. Enter a new value with which to update the Prob. of Resolution field in the dashboard. Reason for Change. Enter the reason for adjusting the theory of liability to create a new note of type SIU Liability Assessment with the text you enter. Update Recovery Potential flag. Select this check box to update the Recovery Potential field with the calculated value (New Theory of Liability % * Total Claim Payment Amount).
Recalculate Conservation	Recalculates the conservation amount and updates the Conservation Amount field in the dashboard.
http://www.nicb.org	Goes to the National Insurance Crime Bureau (NICB) Web site to allow you to enter information for investigation by NICB. The NICB is a nonprofit organization that analyzes and investigates insurance fraud cases.
Reassign Claim	Displays a dialog box with the following fields: Assign To. Select the User ID of the person to which you want to assign the claim. Leave the field blank if you require Assignment Manager to assign the claim automatically. Reason for Reassignment. Enter the reason for reassigning the case to create a new note of type SIU Reassignment with the text you enter.
Refer to Arbitration / Litigation	Displays a dialog box with the following fields: Assign To. Select the User ID of the person to which to assign the claim, or leave the field blank if you require Assignment Manager to assign automatically. Referral Notes. Enter any referral notes to create a new note of type SIU Litigation Referral with the text you enter.

About the Business Rules Processor and Claims Logic

Much of the logic for Siebel Insurance is implemented using the Business Rules Processor (BRP) business service. The BRP is appropriate for business logic that can be modified, and you can modify claims business logic independent of modifying Siebel Runtime Repository objects. Because BRP is a business service, it can be called from workflow processes. For more information about using the BRP, see Business Rule Processor.

The following table shows the BRP business rules processes for claims.

Table BRP Business Rules Processes for Claims

BRP Name	Description	Used In
FINS Claims Evaluate Subrogation Potential	Calculates the Subrogation Real Time score.	Evaluate Subrogation Potential button in MyClaims view
FINS Claims Calculate Combined Score	Calculates the Subrogation Combined score.	Field that drives the subrogation indicator in MyClaims view
FINS Claims Calculate Fraud Score	Calculates the combined Fraud Potential score based on the Real time Rule score, Real time Predictive Model score, and Batch Predictive Model score.	Field that drives the fraud indicator in MyClaims view
FINS Claims Evaluate Fraud Potential	Evaluates the Fraud Potential score.	Evaluate SIU Potential button in MyClaims view
FINS Claims Reserve Estimation Check BRP	Compares the Total Estimation amount with the Total Reserve amount.	Claims, then the Appraisals view
FINS Claims Authority Limit Check	Performs the authority limit check before the reserve is opened.	Open Reserve button in Claims, then the Reserves view
FINS Claims Split Limit Check	Performs checks on the limits for reserve claims.	Open Reserve button in Claims, then the Reserves view
FINS Claims Calculate SIU Expenses	Calculates the SIU Total Expenses.	Task link in SIU dashboard view
FINS Claims Calculate Total Conservation Amount	Calculates the Conservation Amount.	Task link in SIU dashboard view
FINS Claims Calculate Total Payment Amount	Calculates the Total Claim Payments amount.	Task link in SIU dashboard view
FINS Claims Create Fraud Case Assignment Alert	Creates an alert for a fraud case assignment.	Task link in SIU dashboard view
FINS Claims Calculate Subrogation Expenses	Calculates the Subrogation Total Expenses.	Task link in Recovery view
FINS Claims Calculate Deductible Return	Calculates the Subrogation Deductible Return amount.	Task link in Recovery view
FINS Claims Create Subrogation Case Assignment Alert	Creates a subrogation case assignment alert.	Task link in Recovery view
FINS Claims Set Notify Salvage	Sets the Notify Salvage flag.	Notify Salvage flag in Recovery view
FINS Claims Subrogation Reassignment	Reassigns the claim to a subrogation specialist.	Task link in Recovery view
FINS Claims Subrogation Update BC Fields	Updates the subrogation fields for Recovery Potential or Update Theory of Liability tasks.	Task link in Recovery view
FINS Claims Fraud Litigation Assignment	Performs the Claims fraud Arbitration Litigation assignment.	Task link in Recovery view
FINS Claims SIU Reassignment	Reassigns the claim to a fraud specialist.	Task link in SIU dashboard view
FINS Claims Fraud Update BC Fields	Updates business component fields when the Update Recovery Potential or Update Probability Of Resolution link is clicked.	Task link in SIU dashboard view
FINS Claims Subrogation Arbitration Litigation Assignment	Assigns the claim to a subrogation arbitration or litigation unit.	Task link in Recovery view
FINS Claims Subrogation Collections Assignment	Assigns the claim to a subrogation collections unit.	Task link in Recovery view
FINS Claims Subrogation Check State Statutes	Checks the State Statutes.	Task link in Recovery view
FINS Claims Assign SIU Opportunity	Assigns the claims to the SIU unit when the user clicks the Notify SIU button.	Notify SIU button in MyClaims view
FINS Claims Assign Subrogation Opportunity	Assigns the claims to the subrogation unit when the user clicks the Notify Subro button.	Notify Subro button in MyClaims view
FINS Claims Invoke Assignment Manager	Invokes the Assignment Manager component.	All assignment buttons and assignment links.
FINS Claims Check OFAC Status For Contact Payees	Checks and updates the OFAC-related fields for the Contact payees during the Submit Payment processing.	Submit Payment button in Claims, then the Payments view
FINS Claims Check OFAC Status For Vendor Payees	Checks and updates the OFAC-related fields for the Vendor payees during the Submit Payment processing.	Submit Payment button in Claims, then the Payments view
FINS Claims Payment Update Reserves	Updates the Reserve fields during the Submit Payment processing.	Submit Payment button in Claims, then the Payments view
FINS Claims Payment Validate Reserves	Validates the Reserve fields during the Submit Payment processing.	Submit Payment button in Claims, then the Payments view
FINS Claims Reserve Adjustment	Changes the Status from Pending - Open to Open when a user clicks the Reserve Adjustment button.	Reserve Adjustment button in Claims, then the Reserves view
FINS Claims Add Reserve Position to Claim Team	Adds the Reserve position to the Claim team.	Open Reserve button in Claims, then the Reserves view
FINS Claims Manual Override Flag	Sets the Manual Override flag. If the reserve is of type Factor and the Allow Override flag is set, and if the reserve amount is changed, the Manual Override flag is set to true.	Claims, then the Reserves view
FINS Claims Void Payment Reserves Process	Cancels the submitted payment.	Void payment button in Claims, then the Payments view
FINS Claims Apply Deductible For Reserve	Applies the deductible flag for the reserve across payments.	Apply Deductibles flag in Claims, then the Payments view

Claims Workflows

Siebel Claims uses many workflows processes, which, for example, are activated when a user clicks a particular button, such as the Submit Payment button in the Payments view.

The following table shows the workflows for Siebel Claims.

Table Workflows for Siebel Claims

Workflow Name	Description	Used In
FINS Claims Add Reserve Position to Claim Team	Adds an adjuster position to a claim. For each adjuster for the current reserve, it checks if the position is part of the claim team, and if not, it adds the position to the claim team.	Adjuster field in the Claims, then the Reserves view
FINS Claims Call Evaluate SIU Potential Process	Calls the FINS Claims Evaluate Fraud Potential and FINS Claims Calculate Fraud Score BRPs and displays a popup message.	Evaluate SIU Potential button in MyClaims view
FINS Claims Call Evaluate Subrogation Potential Process	Calls the FINS Claims Evaluate Subrogation Potential and FINS Claims Calculate Combined Score BRPs to initialize the real-time rule score and calculate the subrogation combined score.	Evaluate Subrogation Potential button in MyClaims view
FINS Claims Get Policy Details Process	Creates a new revision of the policy and returns the new policy ID.	Get Policy button in Claims, then the Loss Details -Auto view
FINS Claims ISO Search Request	Sends a search request to the ISO database.	Submit button in ISO Database Search view
FINS Claims ISO Search Response	Updates Siebel Insurance with the results from the ISO database search.	Submit button in ISO Database Search view
FINS Claims OFAC Data Import Process	Imports the OFAC XML data to the Siebel database.	Submit Payment button in Claims, then the Payments view
FINS Claims Open Reserve Process	Opens the reserve for a claim.	Open Reserve button in Claims, then the Reserves view
FINS Claims Payment Create Activity Alert Sub Process	Creates an activity of type Alert, and assigns it to the subrogation or fraud unit.	Submit Payment button in Claims, then the Payments view
FINS Claims Payment Validation Sub Process	Validates the payment record (Submit Payment Validation Ruleset) and also checks that it is not a duplicate payment.	Submit Payment button in Claims, then the Payments view
FINS Claims Approval Manager Process	Checks whether the Inbox item is approved. If so, updates the proper Status value in the original request.	Submit Payment button in Claims, then the Payments view
FINS Claims Payments Create Payments Process	Creates the bundled Payment record based on the selected invoice records.	Generate Payment button in Claims, then the Invoices view
FINS Claims Payments Inbox Action SubProcess	Checks whether additional approvals are required when a user approves an Inbox item.	Inbox screen for payment approval
FINS Claims Payments Inbox Drilldown Process	Fetches the proper payment when the user clicks on the Inbox item and invokes a view navigation subprocess.	Inbox screen for payment approval
FINS Claims Payments Inbox GotoView SubProcess	Navigates to the Claim Payments view with the given payment information.	Inbox screen for payment approval
FINS Claims Payments Status Update SubProcess	Checks whether the Inbox item is approved. If so, updates the proper Status value in the original request.	Inbox screen for payment approval
FINS Claims Payments Query Payments GotoView SubProcess	Navigates to the Claims Payments view.	Submit Payment button in Claims, then the Payments view
FINS Claims Submit Payment Check Draft Authority Limits SubProcess	Checks whether the payment limits for the user are exceeded. If so, sends the item to the appropriate supervisor’s Inbox for approval.	Submit Payment button in Claims, then the Payments view
FINS Claims Submit Payment Check OFAC Status SubProcess	Checks the imported OFAC data for the payee.	Submit Payment button in Claims, then the Payments view
FINS Claims Submit Payment Process	Invokes the main submit payment process.	Submit Payment button in Claims, then the Payments view
FINS Claims Submit Payment Updated Reserves	Updates the Claims Reserve totals during the processing of a claims payment.	Submit Payment button in Claims, then the Payments view
FINS Claims Submit Payment Validate Reserves SubProcess	Checks to verify that there is enough reserve in the Claims Reserve totals before allowing the workflow to process a claims payment.	Submit Payment button in Claims, then the Payments view
FINS Claims Void Payment Process	Cancels a payment that was generated successfully during the Submit Payment process. Sets the payment status to void and reverses the reserve outstanding made during the Submit Payment process. Also, creates an activity for the logged in user indicating that a payment has been cancelled.	Void button in Claims, then the Payments view