visualized claimdirector℠ user guide claimdirector overviewisocs-mlc.com/docs/claimdirector/cd...

©2019 Insurance Services Office, Inc. All rights reserved. ISO ClaimSearch is a registered trademark of Insurance Services Office, Inc.

Visualized ClaimDirector℠ User Guide ClaimDirector Overview

February 12, 2019

Copyright © ISO Services, Inc. 2019 All Rights Reserved

http://www.verisk.com/iso.html

Visualized ClaimDirector℠ User Guide – ClaimDirector Overview 2/12/19

Use of a term in this publication shall not be construed as granting any right, title, or interest in or to any patent, trademark,

copyright, or other right in or to the information. All information contained in this publication remains the property of ISO or

the applicable third party.

THE SYSTEM DECRIBED IN THIS DOCUMENT IS CONFIDENTIAL AND PROPRIETARY TO INSURANCE SERVICES OFFICE, INC. (ISO)

OR ITS LICENSORS. NO PART OF THIS PUBLICATION MAY BE REPRODUCED, COPIED, SOLD, DOWNLOADED, OR DISTRIBUTED IN

ANY MANNER OR BY ANY MEANS, WITHOUT THE EXPRESS WRITTEN PERMISSION FROM ISO.

The terms and conditions governing the licensing and use of ISO systems consist solely of those set forth in the written

contracts between ISO and its customers.

ISO makes no warranty of any kind regarding this material, including, but not limited to, the implied warranties of

merchantability and fitness for a particular purpose. ISO shall not be liable for errors contained herein or for damages in

connection with the furnishing, performance, or use of this material. Information in this publication is subject to change

without notice without notice.

NOTICE: © ISO Services, Inc. 2019. This Document includes proprietary trade secrets and confidential information of ISO. ISO

Services, Inc. 2019. This Document includes proprietary trade secrets and confidential information of ISO.

Use of a term in this publication shall not be construed as granting any right, title, or interest in or to any patent, trademark,

copyright, or other right in or to the information. All information contained in this publication remains the property of ISO or

the applicable third party.


i

Table of Contents

Visualized ClaimDirector Introduction .................................................................................... 1

Workflow Overview and Personas ......................................................................................... 2

ClaimDirector Scoring Process................................................................................................ 5

ClaimDirector Rules Overview ............................................................................................... 6

Customizer ............................................................................................................................ 6

Claims Data ........................................................................................................................... 6

Importance of Optional Fields .................................................................................................................. 6

Data Quality Considerations ..................................................................................................................... 7

Manually Scoring Claims ........................................................................................................................... 7

Reference Guides .................................................................................................................. 7

Customer Service ................................................................................................................... 8


©2019 Insurance Services Office, Inc. All rights reserved. ISO ClaimSearch is a registered trademark of Insurance Services Office, Inc. Page 1

Visualized ClaimDirector Introduction ClaimDirector℠ is a powerful claim scoring system designed to quickly distinguish between questionable and

meritorious claims. The industry-based rules engine provides deep insights into loss details to facilitate easier

claim assignment and fraud identification. Seamlessly integrated with ISO ClaimSearch®, the solution returns an

overall score based on the aggregation of business rules linked to the claim, relevant industry loss history related

to the loss parties, their addresses, social security numbers, phone numbers, service providers, NICB alerts (for

member companies), and other data points. Further, the individual rules are displayed in clear language that

provides specific reasons and for whom the rules applied. Additional visuals and drillable capabilities allow for a

comprehensive understanding of party loss history, party and loss locations and claim details. The score is used

to facilitate initial decisions around claim assignment, analysis, and identification of questionable claims. Scoring

occurs throughout the life of the claim each time information relevant to the claim is submitted to ISO

ClaimSearch.

In addition to the interactive visualization of the scored claim, the ClaimDirector platform contains several

components used to further operationalize efficiencies during the claims handling process:

• The SIU Triage Page provides a listing of all claim scores and dispositions for the last 30 days. User controlled filters and bookmarks are available to proactively review groupings of scored claims based on selected risk profiles. SIU Triage Page also enables SIU investigators to identify suspicious claims independently of the claims adjusting workflow.

• The Business Intelligence Dashboard provides a “top down” view and analytics of enterprise wide fraud risks based on up to two years of scored claim activity and associated rules. Rules are grouped into subject areas or rule categories design to facilitate fraud trend analysis. The Dashboard can also be used to evaluated individual rule performance.

• The Customizer allows an organization to control fraud indicators settings, claim characteristics, rules and thresholds to meet company specific needs plus manage company maintained advisory lists.



Workflow Overview and Personas There are many different approaches to operationalizing ClaimDirector. How an individual interacts with

ClaimDirector depends on the persona and roles they play in the claims processing workflow. The flowchart

below illustrates the inputs, output channels and potential personas involved in the process.

The major input channels are claims reported to ISO ClaimSearch and the rule and advisory list settings

maintained in the ClaimDirector Customizer. When a claim is submitted to ISO ClaimSearch, the

ClaimDirector Scoring engine uses the rules and threshold settings to evaluate the claim and assigns a score.

The scoring process is also applied when updates to the claim are submitted to ISO ClaimSearch.

How the reviewer accesses the scored claim depends on the workflow of the organization and the persona

of the reviewer. Reviewers may be in the SIU and/or Claims departments. Access levels can be configured

to control views based on individual roles and responsibilities. For example, some organizations limit scoring

information to SIU personnel only but allow all reviewers to see rule information without the scores. Below

are additional persona-based scenarios illustrating how ClaimDirector can incorporated in the workflow.

• SIU Triage Teams will generally review scored claims from the SIU Triage Page. This gives them the

ability to review a listing of scored claims for the last 30 days. Columns on the page include overall score

value and current SIU Triage status. From the listing, they can use filters to focus the list from different

perspectives such as high scoring claims for a selected policy type and loss location or claims that have

not been reviewed for a specified office. Commonly used filter setting can be saved as bookmarks for

easy reference. Listings can be downloaded to create reports related to operational performance.



• Claims Adjustors generally review ClaimDirector results at the individual claim level in the ISO

ClaimSearch visual format. ClaimDirector scores are also listed on the Claims Reporting page. In

organizations without a dedicated SIU, designated Claims staff may be responsible for monitoring claim

scoring activity through the SIU Triage Page and Business Intelligence Dashboard.

• Organizations that have Guidewire can also have the Claim Score and rule summaries populated directly

into the file in their claims system. Organizations can pick and choose which rules to populate into their

claim system and create tasks.

Once the claim reviewer determines the claim disposition, they update the SIU Triage Flag to indicate if the

claim needs additional research (Hold), should be investigated (Accept) or does not meet criteria for SIU

involvement (Reject).

SIU Analysts, SIU Triage Teams, and designated Claims staff will use the Business Intelligence Dashboard to

gain greater insight into ClaimDirector scoring activity and the rules driving those scores over time. The

ClaimDirector Dashboard facilitates transparency by providing valuable insight into: the overall scoring

activity for the organization, trends by line of business, rule occurrences (by individual rule number and rule

categories) and geography.

For SIU Case Manager subscribers (an optional product separate from ClaimDirector), there is a feature to

refer a scored claim to SIU Case Manager from the visualized claim or when the SIU Triage status is changed

to Accepted.

The Claims Reporting Page is the standard ISO ClaimSearch feature designed to provide an individual claim

reviewer with a listing of claims submitted under their user ISO ClaimSearch ID. Personas most likely to use

this page are Claim Handlers or Adjustors. Columns on the page include ClaimSearch Indictors, Report Type,

Date of Loss, Claim Number, ClaimDirector Score and Viewed/Not Viewed indicator. From this interactive

listing, claim reviewers can drill into selected claims to view details in the visualized claim format or use the

column headings to sort the listing.

Below are samples of the ClaimSearch pages containing ClaimDirector results. Details for each of these features are provided in separate guides. Claims Reporting



Visualized Claim

ClaimDirector SIU Triage

Business Intelligence Dashboard – Claims and Rules Tabs



ClaimDirector Scoring Process At the core of ClaimDirector is the robust scoring engine which uses the claims data and matching loss history to

calculate the scores. The flowchart below provides a high-level overview of the scoring process. This process is

repeated throughout the life cycle of the claim.

1. The process starts when claims data is reported to ISO ClaimSearch based on a company’s submission

procedures and the claim is designated to be scored. Scoring is processed in real time.

2. ClaimDirector analyzes the attributes of the submitted claim, along with information from any matching

claims in the ISO ClaimSearch database. Matches are based on relevant loss history related to the

involved parties, their addresses, phone numbers, vehicles and other data points.

3. ClaimDirector compares those attributes against proven fraud indicators appropriate for the claim.

These fraud indicators (or rules) are listed in the ClaimDirector Customizer.

4. A weight is assigned to each characteristic per the type of claim, line of business, loss date, and loss

type.

5. Sophisticated algorithms analyze all components and calculate the scores. The scores reflect the

organization’s customized values and thresholds maintained in the Customizer feature.

6. The claim reviewer uses the score as a guideline to help determine if the claim can be processed quickly

or requires additional investigation. The reviewer sets the SIU Triage flag to reflect their disposition

decision. (Note: Selected SIU Triage Status and Disposition are only visible to the carrier company.)



ClaimDirector Rules Overview The ClaimDirector rules are comprised of a robust set of industry recognized fraud indicators. Each line of

business has a designated set of rules tuned to optimize findings and reduce false positive scores. There are

hundreds of rules and thousands of rule combinations. To gain a clearer picture of how rules impact scoring,

many of the rules have been categorized based on subject areas. The ClaimDirector Dashboard provides the

capability to analyze the rule activity in these categories. Current rule categories include:

• Advisory Rules

• Auto Fire Rules

• Auto Theft Rules

• Coverage Rules

• Injury Rules

• NICB Rules

• Prev. SIU Rules

• Property Fire Rules

• Property Theft Rules

• SSN Rules

• VIN Rules

• Weather Rules

Customizer To meet individual company needs, ClaimDirector offers the ability to adjust the rules to more closely reflect

unique claims landscapes based on books of business. Administrative access to the Customizer is limited to

several key decision makers in the SIU and/or Claims organizations. Settings that can be changed include:

• Turning rules on or off

• Increasing or decreasing rule thresholds and weights

• Maintaining customer defined advisory lists

Carrier’s with third party claims systems such as Guidewire, can also use the Customizer to designate what

ClaimDirector scoring information will be populated into their claims system. For more information regarding to

other Customizer features, refer to the ClaimDirector Customizer User’s Guide.

Claims Data The ClaimDirector scoring process is highly dependent on the data entered on the claim.

Importance of Optional Fields Completing as many of the ClaimDirector important optional fields as possible greatly impacts the likelihood of

triggering rules and impacting the overall quality of the claims score. For example, not including involved party

SSNs and Dates of Birth decreases the likelihood of finding matching claims for those parties. Also, possible

issues identified by SSN based ClaimDirector rules will not be found (such as “the involved party’s SSN was

issued prior to the involved party’s Date of Birth” and “the involved party is linked to two or more SSNs in the

ClaimSearch database). The Executive Analysis Report available in ISO ClaimSearch contains a listing of the

optional fields and how often your organization populates these fields. The ClaimDirector team is available to

assist you with identifying opportunities to leverage optional fields. Contact NJ Support and ask to be connected

with a member of the ClaimDirector team.



Data Quality Considerations It is just as important to populate the fields with quality data. Improper data entry practices can degrade the

effectiveness of ClaimDirector. Damaging practices include data entered in the wrong format, partially filled

fields, manually masked data such as SSN = XXX-XX-123, and fields populated with filler data such as 12345678

or 999999999. For example, entering a manually masked SSN could cause ClaimSearch to identify matching

claims that are not actually related to the involved party. Plus, this data could cause various ClaimDirector rules

to fire which artificially inflate the ClaimDirector score. If you notice issues with how data elements are entered

in your claims or other carriers’ claims, contact NJ Support and ask to be connected to an Operations team

member to report the issues.

Manually Scoring Claims A carrier can configure claims to be scored automatically when submitted to ISO ClaimSearch via System-to-

System and/or claims can be submitted manually via the Claims Submission feature of Claims Reporting. To

generate a ClaimDirector score when manually submitting claims or updates, be sure to select the “Generate

ClaimDirector Score” checkbox prior to pressing the Submit button on the Claim Summary screen. For more

information on the claim submission process, please refer to the ISO ClaimSearch User Guide.

Reference Guides This reference guide provides a high-level overview of ClaimDirector. The following additional reference guides

are available with more detail information for each component:

• SIU Triage Feature

• Claim Result Report

• Dashboard Overview

• Customizer Overview

• Frequently Asked Questions



Customer Service We hope you find this guide useful and we look forward to hearing your feedback. If you have any questions or

comments, please contact us at [email protected] or call 800-888-4476.

mailto:[email protected]

visualized claimdirector℠ user guide claimdirector overviewisocs-mlc.com/docs/claimdirector/cd...

Documents