PD 16: Sample Procedures: Insurance Claims Processing

Sample Procedures: Insurance Claims Processing

16.1 Critical Business Function

WHAT

CS01 - Claims Processing (Less maturity and annuity payments)

16.1.1 Pre-Crisis

HOW

• Store Claim Schedules, medical-term dictionary, standard letter templates, policy contracts, and payment vouchers at the offsite office.
• Coordinate with IT to provide backup for the Claims Management System.

16.1.2 Within T+4 hours (RESUMPTION)

HOW

• Grab cheques and important system listings (pre-prepared) in the event of an evacuation.
• Require claimants who were informed before the crisis for cheque collection or demanding customers to provide documentary evidence to support their claims.

16.1.3 Within T+4 hours to T+8 hours (RECOVERY)

HOW

• Request from claimants who were informed before the crisis for cheque collection to provide documentary evidence to calculate claim amount, .g. Policy Document
• Demand that customers whose payments are due on the day of crisis submit documentary evidence.
• A policy copy will be extracted from the warehouse for cases without documentary evidence.
  • Provide manual Cheque Preparation by Finance.
  • Require claimants’ signatures on legal documents as valid discharge and declaration.

16.1.4 After T+8 hours (RECOVERY)

HOW

• Access E-Claims to identify cases, outgoing cheques and mail lost in the crisis
• Access Claims Tracking system to identify cases (not registered in E-Claims), outgoing cheques and mails lost in crisis
• Re-requisition for cheques lost in the crisis.
• Re-type letters which were lost in the crisis.
• Determine the need to resubmit claims that are in progress.
• Claims processing and payment.

16.1.5 RESTORATION

HOW

• Update the system with all data which were manually processed during the crisis.
• Reconcile claims processed manually during a crisis.
• Redirect claim submissions back to the office.
• Liaise with Finance on reconciliation of cheques issued during crisis.