Let’s understand the claims journey. Here we will explain the claims workflow, masters to be set up for managing claims, claims documents list, TPA Master, and claims custom fields. Also, we will go through the intimation step, inward and outward steps, and all in between.

The first step is Claims Intimation. Once you are about to receive the documents from the customer, then you are at the Documents Inward step. When you are about to send the details to the claim processing team, then the status is Document Outward.

The next stage is Claim Processing Awaited. Here mainly three things can happen. Even though most of the claims get Approved, sometimes the claims get Queried or Repudiated. If it is Queried, then after getting the proper response it will be Closed and will again move to the Claim Processing Awaited stage. Then it will go the Approved or Repudated stages depends on various review criteria. If it is Approved, then after the final paper works, it will get Settled.

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Let’s start with Claim Executives. Go to Settings > Organization > Organization Master. Here after scrolling down to the bottom, you can see a drop down field called Claim Executive. You can enable this feature to activate Claim Executives.

The next masters to set up is Document Checklist. Click on Settings > Claims > Documents. Here you can see the list of policies that is linked to the Sibro insurance broking software. Click and expand on the respective policy that you want to create a document checklist. Here you can enter the required checklist items by clicking on Add More after adding one by one. Now click on Save to complete the process. This way you can prepare the document list for claims for any policy type.

The next master is TPA. Click on Settings → Claims → TPA Master → Add TPA. A pop up will be displayed where you can enter your TPA Name, Phone, Email Id and Address. Now click Add TPA button to complete the process.Now whenever we send an SMS, query, email etc, these details will be auto populated by the system as the TPA. When a new claim arrives and if the added TPA is the claim processor, then the system will auto populate the TPA details and instead of emailing the insurance company’s contact person, the system will email the TPA associated with that claim. Also the address of the TPA will be used for couriering the hard copies.

The next master is Claim Custom Fields. Click on Settings → Claims → Claim Custom → Custom Fields → Add Custom Field. A pop up will be displayed where you have to enter the position number, field name, field type, policies and also need to set whether this field needs to be mandatory or not. Now click Add button after entering all the above details and a new custom field will be created. When you do a claim intimation for a particular client who has a policy that has pre-assigned claim custom fields, these newly created fields will be populated in that claim intimation form.

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Firstly, we have to inform the claim processors that the accidental event has occurred. This intimation process is known as Claim Intimation. Meanwhile you can record the intimation in Sibro to keep track of it. In some cases, this intimation step is optional because your client would have directly informed the claim processors.

Click on Add (+) → Add Claim → Intimation. Select your client name and policy name from the drop down and the remaining details such as claim processor, claimant name etc will be auto populated by the system. Now select the claim intimation date, add documents (if any) and enter the remaining details. Now scroll down and check the documents list correctly and click Save to complete the process.

That’s it. You’ve added a claim and now the software will record this as Inward Awaited stage; meaning that you are waiting for the supporting documents to arrive.

Now click and expand on that particular client. Now scroll down and enter follow up details if you have any, and click on Add Follow up. Once we are about to receive the documents, click on Inward Awaited. Now you can cross check the auto-populated data here. Check the correct documents received with their corresponding dates and select the mode of receipt. If you want to upload any additional files, go to the top, click on the Add files button and updates the files. Now click Save to complete the process.

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After receiving the necessary documents from the customer, the status has to be changed to Outward Awaited. Click and expand on the particular claim. If you have still documents yet to receive, under the follow up section initiate another follow up.

Now when you receive all the necessary documents from the client and are about to send the same to the insurer, click on Outward Awaited.

Now scroll down and check all the list of documents that you are about to send to the insurer. Click Save to complete the process.

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As we have send the documents to the claim processing team, then the status become Claims Processing Awaited. Now click on the Claims Processing Awaited. Scroll down and put the date and choose the claims status from the drop down below and click on Save to complete the process. Now the status will be changed to Query Response Awaited.

When the customer responses to the queries, please click on Query Response Awaited button. Now scroll down, click on the Shortfall check button, enter the customer query response and click Save. Now it will again go to the status Claim Processing Awaited. Now again, as per the review, it can be either Accepted, Rejected or Queried again.

After you receive the final status, now click on the Claim Processing Awaited button. Scroll down below and enter the date as well as the final status and click on Save to complete the process.

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Go to the respective claim and click on the status Approved. Now scroll down and change the status Settled, enter the settled amount and click on Save. Now the claim status has been finally changed to Settled.

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