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The Insurance External Reporting ES bundle integrates SAP Claims Management with third-party service providers who manage reporting to regulatory agencies and insurance industry organizations such as NCCI and ISO. These service providers ensure that the data sent by insurance companies is reported to states, government agencies, and insurance industry organizations using the latest version of the correct forms. They also validate the data and send the forms on to the regulatory agencies and insurance industry organizations on behalf of the insurance companies.

Insurance companies need the third-parties because of the complexity of the reporting requirements. The reports that need to be provided:

  • are often large in number
  • contain generally different fields for different lines of business
  • must be delivered at well-defined events during the claims process, such as 5 days after the claim was opened or when a claim is closed

The Insurance External Reporting ES bundle helps automate this process by sending the necessary data to these third parties according to business rules (for example, 5 days after a claim is opened) or immediately when a claim is closed. Information about the reporting is shown in the SAP Claims Management user interface on the Regulatory Reporting tab. The resultant standardized platform enables insurance companies to comply with current government and industry rules and regulations by sending them stipulated claims information either manually or automatically, at measured, predetermined milestones.

Insurance External Reporting (click to enlarge)


The data provided to regulatory organizations enables them to monitor and control both the claims handling processes and the financial stability of individual insurance providers. For instance, since statistics that relate claims losses and expense payments to current premiums are among the data included in transmitted reports, regulatory agencies are continually able to determine balanced future policy rates.
This bundle addresses three main processes. These processes concern:

  • Processing claims for regulatory reporting
  • Closing claims that require regulatory reporting
  • Reopening claims that require regulatory reporting

The System Landscape

The Insurance External Reporting ES bundle leverages enterprise SOA through communications between SAP Claims Management and third-party software from regulatory agencies such as the state insurance commissioner and insurance industry organizations that include NCCI and ISO. This bundle follows the ACORD XML industry standard for messaging.

Processing Claims for Regulatory Reporting

Claims for regulatory reporting can be processed in two ways, automatically, via predefined business rules, or manually, per request.

On one hand, a business rule can trigger insurance claims to be flagged for reporting based on changes or additions to specific, predefined data elements. If a claims handler changes or deletes data in a field, for instance, the claim will be flagged for reporting and subsequently sent to the appropriate agency.

On the other hand, a business rule may dictate that claims be sent to agencies after a specified period of time has elapsed since a given event. For instance, depending on the agency, a rule may stipulate that all claims be sent to the agency seven days after the date a claim was submitted to an insurance provider (e.g., "If the jurisdiction region is Alabama, send the first report of injury to the regulatory reporting party seven days after date reported to carrier.").

The manual process is triggered when an agency submits a request for a report pertaining to a particular claim. For example, if the NCCI requests a detail claim information (DCI) report from an insurance provider, a clerk or claims handler will press the Send Report button on the Regulatory Reporting tab to send a relevant report.

Once received, the service provider validates the data. If errors are found, the respective regulatory reporting agency returns the error to SAP Claims Management. The errors are addressed and corrected and the report is resubmitted after appropriate changes are made to the claim.

Audience

Any business in the insurance industry, including those companies that provide for their own insurance, will benefit from the Insurance External Reporting ES bundle.

The roles in the insurance industry that will use this bundle include:

  • Clerk
  • Claims handler

    For details on Service Operations, Business Objects and Process Components, please check the ES Workplace.


How To Use This ES Bundle

The claims reports that today's insurance providers must submit to the vast array of regulatory reporting agencies now monitoring the insurance industry are large in number, contain multiple, various fields (depending on the types of business to which they refer), and must be delivered at well-defined events during the claims process. Because of this complexity, insurance providers need a means by which to ensure that reports are submitted to regulatory and insurance industry agencies accurately and in a timely fashion.

The Past: Pain Points without the Insurance External Reporting ES Bundle

Until now, regulatory reports have been generated by customer reports that contained hard coded structure mappings to third-party requirements. Systems were not integrated, and specialized personal with detailed knowledge were needed to execute the report submissions to regulatory agencies.

Today: The Benefits of Deploying the Insurance External Reporting ES bundle

Insurance companies that deploy the Insurance External Reporting ES bundle can further their cost savings, improve their efficiency, and increase their flexibility. For instance, most insurance companies today outsource their reporting to third-parties who specialize in regulatory reporting for the insurance industry.

The services in the Insurance External Reporting ES bundle are called directly from within SAP Claims Management, so there is no need for custom integration to send reports to regulatory agencies, and the reports themselves are fully customizable.

This following section will explore three use cases for the Insurance External Reporting ES bundle. Each use case provides concrete examples and shows how different outcomes can be achieved by using the enterprise services in different combinations. While these examples illustrate a few of the ways that this ES bundle could be used, the intention is to show the flexibility and reusability of these business objects and enterprise service operations so that you will have a clearer understanding of how to best deploy them in your own environment. This wiki is also a space for you to share knowledge and collaborate with others who are implementing the Insurance External Reporting ES bundle.

Use Case 1: Processing Claims for Regulatory Reporting

Johann, one of the claims handlers for Blue Sky Insurance has just completed a claim whose affiliated report must be submitted to NCCI. In the case of this report, a business rule has been established whereby all claims are sent to NCCI five days after they have been processed. Once Johann saves the claim, it proceeds by default to a submission queue, where it will wait for the allotted time to elapse. At that time, SAP Claims Management's A2A functionality activates the submission by invoking the Inform of Insurance Claim Created service operation, which uses the Insurance Claim business object.

As it happens, Johann failed to complete a crucial field in the report, so NCCI has returned it along with an error message by invoking the Change Insurance Claim based on Insurance Legal Reporting Error Notification, which also uses the Insurance Claim business object. When Johann opens the regulatory reporting error log, he can view the following fields:

  • Report Type: Name of the regulatory report
  • Send Receive: Indicates whether there is an acknowledgment that the report has been received
  • Date: Date of the error or acknowledgment
  • Feedback: Indicates the status of the report
  • Error Resolved?: Indicates whether there is an outstanding error that needs to be resolved
  • Error: provides a link to the error detail

Now that Johann has located and corrected the error, he can resubmit it by pressing the Send Report button, which invokes the Inform of Insurance Claim Change service operation.

Use Case 2: Closing Claims that Require Regulatory Reporting

After claims of a certain type are closed, regulatory agencies require reports on that claim. Johann has finished work on the current claim, so he closes it, which automatically triggers the Inform of Insurance Claim Closed service operation, which uses the Insurance Claim business object. This particular type of claim requires regulatory reporting when it is closed; a business rule has been executed here so that claims handlers need not be concerned about reporting requirements. Claims that require reporting upon closing can be triggered automatically in this fashion according to predefined business rules. This also ensures that reports are sent on a consistent basis, keeping the insurance company in full compliance with reporting requirements.

Use Case 3: Reopening Claims that Require Regulatory Reporting

Additional information has come to light about Johann's claim and it must be reopened. Since it was already reported as closed, Johann's reopening of the claim triggers the Inform of Insurance Claim Reopened service operation, which uses the Insurance Claim business object.

System Requirements

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