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Process documentationMapping of Accident Events

 

In health insurance claims, you can map accident events.

This means that in claims resulting from an accident you can take recourse against third parties. This is possible in the following situations, for example:

  • The insured was to blame for the accident

  • Legal requirements may mean that a third party has to take financial responsibility for the claim (such as an employers liability insurance association if the accident happened when the insured was on his/her way to work; or another insurance carrier if the insured has an accident insurance).

The check as to whether an accident actually happened is performed by means of an accident questionnaire that the insurance carrier sends to the insured.

Prerequisites

See Customizing Settings for Accident Event

Process

An accident event is processed as follows:

  1. During processing of the claim, you suspect that the claim might have resulted from an accident, meaning that you can trigger the recovery process.

    Indicators of an accident event:

    • Accident diagnoses

    • Accident indicators on a prescription

      During claims processing, you set the accident indicator manually on the prescription.

    As soon as there is indication of an accident, the system creates a task (in the sense of Activity Management) with the text 'Perform Search for Accident Questionnaires Already Sent Out'.

    Note Note

    You use the BRFplus to check whether such indications exist (see 'Customizing Settings for Accident Event', section 'Rules for Existence of Accident Indicators')

    End of the note.

  2. You check whether an accident questionnaire has already been sent to the insured.

    The following options are available for this:

    • In the list of pending tasks you click on the 'Perform Search for Accident Questionnaires Already Sent Out' task (see Step 1 above).

    • Choose Accident Event.

    The Change Claim Bundle: Accident Event Search screen appears. The system displays all accident events involving the insured on this screen.

    The options available to you for this check include:

    • You can navigate to the relevant accident event. To do so, click the relevant accident event number in the Claim Bundle column.

    • If a claim is already assigned to the accident event, you can navigate to the relevant claim. To do so, click the relevant claim number.

    • If there is an accident diagnosis for the accident event, you can navigate to this diagnosis. To do so, click the relevant diagnosis in the Primary Diagnosis column.

    If an accident questionnaire has already been sent out, assign the current claim to this accident event. To do so, choose Assign Claim Bundle to Claim (Assign Claim Bundle to Claim).

  3. If the accident event does not yet exist, create it.

    To do so, choose Create Accident Event.

    The system then performs the following activities:

    • It creates the accident event and automatically displays this new accident event in change mode.

    • It copies the existing data from claims processing and the entries on the screen for the accident event search.

    • It assigns the claim to the new accident event and displays it on the Assigned Claims/Subclaims screen.

  4. You send the accident questionnaire to the insured.

    To do so, on the Document Proposal List tab page, in the Form field, choose the document 'Request Accident Questionnaire' (for information about the prerequisites, see 'Customizing Settings for Accident Event, section 'Cover Letter for Accident Questionnaire'). This document is the cover letter for the accident questionnaire. You send the actual accident questionnaire as a hard copy, together with the cover letter, to the insured.

  5. Once the insured has filled in the accident questionnaire and returned it, you assign it to the accident event.

    You have the following options:

    • If you have the accident questionnaire in electronic form, you can assign it to the accident event and archive it in the Archived Documents section.

      For more information, see Archiving and Assignment of Documents

    • If you have the accident questionnaire as a hard copy, you must capture the replies in the Accident Questionnaire section by using a question sequence of structured facts capture (SFC) (for information about the prerequisites, see 'Customizing Settings for Accident Event', section 'SFC Question Sequence for Accident Questionnaire')

  6. You use the answers in the accident questionnaire to check whether the insurance carrier has a right of recourse over a third party.

  7. If such a right of recourse exists, you can trigger the subrogation/recovery process.

    To do so, on the Accident Event: Overview tab page, in the Claim Bundle Subtype field, choose the entry Accident w.Subro/Recovery . The system also displays the Settlements tab page.

    Thereafter, you can process the accident event like collective subrogation/recovery.

    For more information, see Mapping of Collective Subrogation/Recovery and the subsections of the documentation on collective subrogation/recovery, such as: