claimdirectorsm user guide overview

ClaimDirectorSM User Guide Overview

January 25, 2022

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ClaimDirector℠ User Guide - Overview January 25, 2022

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Table of Contents

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

ClaimDirector Expert Business Rules Scoring ............................................................................................ 1

ClaimDirector with Predictive Analytics .................................................................................................... 2

ClaimDirector Scoring Process .................................................................................................................. 2

Rules and Reason Codes ........................................................................................................................... 3

ClaimDirector Rules ............................................................................................................................................... 3

ClaimDirector Predictive Model Reason Codes ..................................................................................................... 3

ClaimDirector Features .......................................................................................................... 2

Visualized Analytics ................................................................................................................................... 2

Visualized ClaimSearch Match Report .................................................................................................................. 2

Claims Reporting Page .......................................................................................................................................... 4

SIU Triage .................................................................................................................................................. 5

SIU Triage and Disposition Flags ........................................................................................................................... 5

ClaimDirector Insights Dashboard ............................................................................................................ 7

Customizer ................................................................................................................................................ 9

Advisory List ............................................................................................................................................ 10

Operational Workflow ......................................................................................................... 11

Workflow Personas ................................................................................................................................. 11

Tips for Reporting Claims Data ............................................................................................. 13

Importance of Optional Fields ................................................................................................................ 13

Data Quality Considerations ................................................................................................................... 15

Manually Scoring Claims ......................................................................................................................... 16

Customer Service ................................................................................................................. 17


©2022 Verisk Analytics, Inc. All rights reserved. Page 1

ClaimDirector Introduction ClaimDirector is a powerful claim scoring system designed to help a user quickly distinguish between

questionable and meritorious claims. The solution offers three service levels: Claim Essentials Solution,

ClaimDirector, with expert business rules-based scoring, and ClaimDirector with Predictive Analytics, an

advanced machine learning model for fraud detection.

ClaimDirector Expert Business Rules Scoring The industry-based rules scoring engine provides deep insights into loss details to facilitate easier claim

assignment and fraud identification.

• Seamlessly integrated with 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, and other

data points.

• Individual rules are displayed in clear language which provides specific reasons supporting the score.

• Simple, interactive visualized match reports allow for a comprehensive understanding of party loss

history, loss locations, and claim details.

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

to ClaimSearch.

[Note: Claim Essentials Solution includes ClaimDirector expert business rules scoring.]



ClaimDirector with Predictive Analytics ClaimDirector with Predictive Analytics is a hybrid approach to scoring a claim. It combines ClaimDirector expert

business rules with predictive modeling and incorporates third party data sets, such as civil and criminal records.

Predictive modeling uses machine learning to surface anomalous claims using a combination of model reasons

enhanced with expert business rules.

ClaimDirector with Predictive Analytics processes claims using a unique predictive model which considers a

robust set of modeling variables, ultimately producing a claim score. Expert business rules are incorporated to

help provide additional facts and context to the reviewer. The model considers each of the modeling variables in

context of each individual claim to determine the value, or weight, of each variable on that claim. The result is

an increase in quality referrals through predictive modeling.

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

calculate claim scores in real time, a process that is repeated throughout the life cycle of the claim.

The Scoring Process

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

procedures and the claim is designated to be scored.

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

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

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

• ClaimDirector compares those attributes against proven industry indicators appropriate for the claim.

• A weight is assigned to each rule based on the type of claim and line of business.

• Sophisticated algorithms analyze all components and calculate the scores.

• The claim reviewer can use the score as a guideline to help determine if the claim can be processed

quickly or requires additional investigation. To reflect their decision, the reviewer uses the SIU Triage

function to set the SIU Triage status. (Note: Selected SIU Triage Status and Disposition are only visible to

the carrier company.)



Rules and Reason Codes

ClaimDirector Rules

The ClaimDirector rules are comprised of a robust set of industry recognized indicators for potential fraud. Each

line of business has a designated set of rules tuned to optimize findings and improve scoring results. There are

thousands of rules and combinations conveniently categorized into subject areas. The ClaimDirector Insights

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

• Combo Rule

• Questionable Loss

Scenarios

ClaimDirector Predictive Model Reason Codes

ClaimDirector with Predictive Analytics reason codes cover many of the same categories as ClaimDirector rules

while also incorporating public records data, such as civil and criminal histories.

For more information regarding rules and reason codes, contact the Verisk Customer Support Center and ask to

be connected to the ClaimDirector Client Success team.



ClaimDirector Features The ClaimDirector platform contains several tools used to operationalize efficiencies during the claims handling

process.

Visualized Analytics ClaimDirector scoring results are displayed to the user in the Visualized ClaimSearch Match Report as well as

several dashboards, for when further analysis is needed. Scoring information is dependent on which

ClaimDirector service level process was used to score the claim.

Visualized ClaimSearch Match Report

The Visualized ClaimSearch Match Report contains the details for the currently selected claim as well as the

ClaimDirector rules and predictive alerts which generated the ClaimDirector score.

Sample Visualized Claim Scored using Expert Business Rules

This is an example of a scored claim using expert business rules. The score is noted in the upper left-hand corner along with a severity indicator. The alerts section is populated with the rules that contributed to the overall score.



ClaimDirector leverages a robust and dynamic set of industry-recognized indicators for potential fraud to score

each claim and the involved parties. These indicators, known as rules, are assigned weights based on their

severity. These weights are used to help determine the overall claim score, which can range from 0 to 999. The

higher the score, the greater propensity for fraud. Score ranges are assigned a color to allow you to quickly

identify a claim requiring review:

Green – Low Risk: Claim Scores ranging from 0 to 100

Yellow – Medium Risk: Claim Scores ranging from 101 to 649

Red – High Risk: Claim Scores ranging from 650 to 999

Sample Visualized Claim Scored with ClaimDirector with Predictive Analytics

This sample claim was scored using predictive analytics, as noted next to the score value. The Alerts section

contains a list of the reason codes from models and expert business rules that provide additional contextual

guidance.



Claims scored using ClaimDirector with Predictive Analytics leverage a predictive model to further assess rule

importance. The score ranges for ClaimDirector with Predictive Analytics are:

Green – Low Risk: Claim Scores ranging from 0 to 10

Yellow – Medium Risk: Claim Scores ranging from 11 to 66

Red – High Risk: Claim Scores ranging from 67 to 100

Claims Reporting Page

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

with a listing of claims submitted under their user ClaimSearch ID. This is also where the claim submission

process begins for those using manual claim entry.

To access Claims Reporting, select the Claims Reporting tile from the ClaimSearch homepage.

Columns on the page include ClaimSearch Indicators, Report Type, Date of Loss, Claim Number, ClaimDirector

Score and Viewed/Not Viewed indicator (blue dot). 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.

In Claims Reporting, the My Claim Reports link filters the list to show claims that you submitted in the last 90

days. My Office Reports link filters the list to show all the claims that your company submitted in the last 90

days. In both lists, the ClaimDirector Score column contains the score value calculated at the time the claim was

reported to the ClaimSearch database.



SIU Triage The ClaimDirector SIU Triage Page allows investigators and managers to review scored claims from the past 90

days. The triage listing includes links to access and review claims. SIU investigators with the ability to see the full

scoring details can utilize ClaimDirector’s scored claims and enter a triage status as well as a disposition status.

The triage feature helps prevent duplicate reviews of a claim and allows managers to quickly determine if claims

are being promptly reviewed by investigators and/or claim triage teams. It also allows companies to quantify

claim acceptance or rejection rates to help analyze performance.

SIU Triage and Disposition Flags

The SIU Triage flag appears in the upper right-hand corner of each visualized scored claim and next to each claim

listed on the SIU Triage page.

Once the claim reviewer determines the claim disposition, they update the SIU Triage status using the dropdown

list to indicate if the claim needs additional monitoring (Hold), should be investigated (Accept) or does not meet

criteria for SIU involvement (Reject). The SIU Triage status is available on the visualized claim and the SIU Triage

Page. The SIU Triage status is only visible to the carrier submitting the claim.



To access the SIU Triage Page, select the SIU Triage Page icon at the top of the visualized claim. Access to the SIU

Triage Page is also available from the ClaimSearch homepage by selecting the Dashboards tile and then selecting

ClaimDirector SIU Triage tile.

In the Filters section of the SIU Triage Page, use the Claim Score Type filter to toggle between viewing claims

scored with expert business rules and those scored with predictive analytics as applicable.

Detailed information regarding the SIU Triage feature is provided in the “ClaimDirector℠ User Guide – SIU

Triage” available in My Learning Center.



ClaimDirector Insights Dashboard The ClaimDirector Insights Dashboard is part of ClaimSearch Solutions Insights dashboard platform. The

dashboard facilitates transparency by providing valuable insight into:

• The overall scoring activity for your organization

• Trends by ClaimDirector Line of Business

• Claims by Rule Occurrences and Rule Categories

• Key Performance Indicator based statistics

• SIU Triage Status Breakdowns

• Location of Loss Distribution

Available filters will vary depending on your carrier’s subscription service. There are two levels of user access:

Viewer and Author.

• Viewer access is available to users with a valid ClaimSearch ID enabled to view Online Reports. Viewers

can set dashboard filters and download findings.

• Authors have the added ability to customize dashboards to meet the specific analytic needs of their

organizations. Functionality includes copying dashboards to save frequently used filter settings,

conducting new searches, and constructing new dashboards that can be shared with Viewers in their

organization.

The dashboard data is updated on a six-hour refresh cycle beginning at 3 AM Eastern. Data available for analysis

includes claims scored in the last five years.

To access the dashboards, select the ClaimSearch Insights tile from the ClaimSearch Landing Page.

Detailed information regarding the ClaimDirector Insights dashboard is provided in the “ClaimDirector℠ Insights

Viewer Guide” and “ClaimDirector Insights Author Guide” available in My Learning Center.



Customizer To meet individual company needs using business rule-based scoring, ClaimDirector offers the ability to adjust

the rules and tailor to specific lines of business within a carrier’s book of business. Administrative access to the

Customizer is limited to designated key decision makers in the SIU and/or Claims organizations. [Note:

Customizer is not included in the Claim Essentials Solution.]

Settings that can be changed include:

• Turning rules on or off by line of business

• Increasing or decreasing rule thresholds and weights

• Maintaining customer-defined advisory lists

For more information regarding other Customizer features, refer to the ClaimDirector Customizer User’s Guide

available in My Learning Center.

To access the Customizer:

1. Select the Anti-Fraud Solutions tile on the ClaimSearch homepage.

2. Then, select the ClaimDirector Customizer tile.



3. Use the options across the top of the window to select the appropriate features/function.

Advisory List The Advisory List feature is available to customers using business rules-based scoring and predictive scoring. It is

populated by the carrier and is only visible to that carrier. When a party or entity on the Advisory List matches a

party on a submitted claim, ClaimDirector provides a notification which impacts the claim score. This feature can

be used to generate alerts related to known entities of interest and for entities that require special handling.

Carriers who have integrated ClaimSearch into their claims processing system can also use the Customizer to

designate what ClaimDirector scoring information will be populated into their system.



Operational Workflow There are many different approaches to operationalizing ClaimDirector. The flowchart below illustrates how

Verisk Analytics products can be leveraged throughout the claim lifecycle. ClaimDirector is represented by the

red line and offers continuous claims scoring from first notice of loss to claim resolution.

Workflow Personas An organization’s application of ClaimDirector and access to scored claims depends on the needs of the

organization. Some organizations have a dedicated SIU team, while other’s have a single claims handler to cover

their investigations.

Additionally, an individual’s use of ClaimDirector depends on their role within the claim processing workflow. If

required, access levels can be configured to control what view an individual has, based on their 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 examples illustrating how ClaimDirector can be incorporated into

a workflow.

• SIU Analysts or Investigators will generally review scored claims from the SIU Triage Page. This gives

them the ability to:

o Review a listing of scored claims for the last 90 days. Columns on the page include overall score

value and current SIU Triage status.

o 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.

o Save filters. Commonly used filter settings can be saved as bookmarks for easy reference. Claim

listings can be downloaded to conduct analysis related to operational performance.



• Claims Adjusters and Organizations without a dedicated SIU will generally review ClaimDirector results

at the individual claim level in the visualized ClaimSearch Match Report. This gives them the ability to:

o View ClaimDirector scores which are also listed on the Claims Reporting page.

o Designate Claims staff responsible for monitoring claim scoring activity through the SIU Triage

Page or Business Intelligence Dashboard.

• Organizations with their own claims handling system will generally view ClaimDirector results directly

in their claim system. This allows organizations to:

o Receive claim scores and key business rules directly in the own claim environment

o Select which business rules will populate into their claim system and even drive automated

workflows.



Tips for Reporting Claims Data

The ClaimDirector scoring process is dependent on the data entered on the claim and ultimately submitted to

ClaimSearch. Managing data quality and populating ClaimSearch optional fields significantly enhances the

effectiveness of ClaimDirector scoring. Our team is available to assist you with identifying opportunities to

enhance your data input. Contact the Verisk Customer Service Center and ask to be connected with a Client

Success team member.

Importance of Optional Fields Providing 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, including involved party Social

Security Numbers and/or Dates of Birth significantly increase the likelihood of finding matching claims for those

parties.

The Executive Analysis Report available in ClaimSearch contains a listing of key optional fields and how often

your organization populates these fields.

To access the report:

1. Select the Dashboard and Report tile on the ClaimSearch homepage.

2. Then select the Executive Analysis Report tile.



3. Select the Opt. Fields Trend hyperlink next to the desired Service Line.

4. Review the Optional Field analysis to look for fields that are under reported.



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

effectiveness of ClaimDirector. For example, entering a masked SSN could cause ClaimSearch to identify

matching claims that are not actually related to the involved party and could cause various ClaimDirector rules

to be applied, which might artificially inflate the ClaimDirector score.

Other data quality hurdles:

• Entering data in the wrong format

• Partially filling in fields

• Populating fields with filler data such as 12345678 or 999999999

To report any issues related to how data elements are entered in your claims or other carriers’ claims, contact

the Customer Support Center, and ask to be connected to an ClaimSearch Operations team member.



Manually Scoring Claims Claims can be configured to be scored automatically upon submission to ClaimSearch. If your company isn’t

turned on for automatic scoring, you have the option to manually score a claim at any time.

To score a new manually entered claim:

1. Select the Claims Reporting tile from the ClaimSearch homepage. 2. Select the Claims Submission link. 3. On the Claim Submission window:

a. Enter Office Code, Claim Number, Date of Loss, and Policy Number. b. Select the Next button.

4. Complete the step to add the claim and party information. 5. On the Claim Summary window, select the Generate ClaimDirector Score checkbox. 6. Select the Submit button.

To manually score an existing claim:

1. Select the Claims Reporting tile from the ClaimSearch homepage. 2. Select the Claims Submission link. 3. On the Claim Submission window:

a. Enter the ISO File Number of the claim to rescore in the Retrieve Existing Claim Using section. b. Select the Next button.

4. Optional - Complete the step to update the claim and party information. 5. On the Claim Summary window, select the Generate ClaimDirector Score checkbox. 6. Select the Submit button.

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



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 the Verisk Customer Support Center via email at [email protected], via phone at

800-888-4476, or through the Customer Service Live Chat feature located on the ClaimSearch title bar.

Additional ClaimDirector training resources are available from My Learning Center which is accessible from the

ClaimSearch homepage.

mailto:[email protected]

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