This content applies solely to Connected Claims, which must be purchased separately from the Appian base platform. This content was written for Appian 21.4 and may not reflect the interfaces or functionality of other Appian versions. |
The Connected Claims Fraud Management module allows you to manage fraud alerts and direct cases through Special Investigation Units (SIU). You can quickly view and take action on fraud alerts to ensure customers are supported, details are recorded, and cases are tracked efficiently.
This guide demonstrates the pages and views required to complete work within the Fraud Management module. Note that your specific implementation of the Connected Claims solution may have more or less functionality.
Martin works in the fraud detection unit of a large insurance company, updating and tracking fraud claims as they move throughout the Connected Claims system. Martin's responsibilities require him to perform the following actions:
Martin has a series of fraud alerts that require attention. From the Connected Claims home page, Martin clicks the FRAUD MANAGEMENT card.
Once within the Fraud Management module, the ALERTS dashboard displays by default. This screen provides Martin with a view of basic alert information like customer information, claim valuation, and status.
To filter the record table:
Clicking the hyperlink in the ALERT# column brings Martin to the Alert Summary page, which provides helpful information, like claim and alert details, and a checklist for fraud items.
Martin may have instances where suspicions of fraud are dispelled. In those instances, he needs to close the fraud alert.
To close an alert:
Fraud investigations include frequent communication. Entering notes on an alert is a key way for Martin to record his observations so that collaborating team members may become aware of emerging details.
To enter a note:
Note: Notes display in a drop-down section beneath the notes text box.
Once a note has been saved to the alert, it can be managed with the Reply, Edit, and Delete buttons.
A key element of a fraud alert is the Fraud Check-List Scorecard prominent at the bottom of the Alert Summary page. The checklist contains a series of different items with corresponding numeric values and comments. The checklist items contribute to an overall score.
Checklist items fall under two categories:
To annotate a fraud checklist:
Martin is working on an alert when he notices some conflicting details; this raises his suspicions. Martin decides that the suspicious activity should be reviewed by the Special Investigation Unit.
To create an SIU Case:
The following actions for viewing event graphs, managing communications and documentation, and viewing audits are available through the tabs located along the top of the Alert Summary page.
Martin is working a new alert and wants to do research on the customer in question. A good starting point for this research is by viewing the event graph. The event graph shows all of the alerts, claims, and supporting information linked to a primary account.
To view the event graph:
If Martin was required to manage documents through another application, it would add time and complexity to his routine tasks. Connected Claims simplifies document management by allowing Martin the ability to view a list of all pending and existing documents for each case, add new documents, and edit existing documents all from a single interface in the Alert record.
To upload a document:
Tip: The Add New Document link allows you to upload multiple documents at once.
At any point in the investigation process, you can drill down into a specific claim record, click the Documents tab and MANAGE DOCUMENTS to view all pending documents, view, download, and edit existing documents, or add new documents.
Communications items include automated messages and exchanges between customers and customer service representatives.
Note: Self-service items are communications that are automatically generated and sent to the customer as a result of a customer-performed action.
Selecting a communication item provides a detailed look at the message transmitted. The communications item screen shows the message, method, and details.
Creating new messages must be done via the SIU CASES dashboard, shown later.
Clicking on the Audits tab from the Alert Summary page will open the Audits page, showing all of the actions performed on a case.
Alerts that have been referred to the Special Investigation Unit are saved as SIU case records. Martin want to confirm that the alert from earlier was successfully generated as a new SIU case. Martin clicks SIU CASES from the navigation bar. The SIU CASES dashboard displays a record table of recent SIU Cases.
Clicking a hyperlink in the SIU CASE# column brings Martin to the SIU Case Summary page, which provides helpful information, like claim and alert details, and a checklist of fraud items.
Notes can be added to an SIU case to record relevant information that may become available.
To add notes:
From the SIU Case Summary page, click ADD CASE NOTE.
Managing evidence for an SIU case is done in the same way that documents are managed. See the Managing Documents section for steps.
As an SIU case moves through its life cycle, you may need to create and assign additional tasks and activity reminders to move the case through the process flow. You can create and schedule an On-Demand Task for this type of activity.
To create an On-Demand Task:
Note: On-Demand Tasks appear under the SIU Case Summary page as well as on the TASKS dashboard.
Now that you have walked through the various steps demonstrating the ways in which you can facilitate a fraud alert, you can start using the Fraud Management module to accurately track these activities.
How to Manage a Fraud Case