Implementing claim inquiry skills

Claims inquiry skills are implemented via the claims inquiry skills settings section in the System settings. Switching the skills on will enable the configured skills to be added to the inquiry. The setting also provides a maximum number of skills that can be assigned. This is used to support performance through the Get next action.

Note:If a work item has too many assigned skills, the amount reduces the likelihood of the item being retrieved for processing and increases the time needed to review the skills on the item and match them to the appropriate operator. As the claims inquiry can also contain skills from the associated claims, there could be a wide variety of skills identified from the selected claims.

Configuring claim inquiry skills

Claims inquiries can have two sets of skills associated with them: the skills associated with the core claims inquiry and the skills associated with the claims. These skills are configured using the settings described below.

The first table is the Claim inquiry skill type configuration found in the skills setting in the delegated rules on the portal.

The skill type configuration enables the reason code, channel and type identified during the creation of the claims inquiry to be used to define the skills. This table uses the Enable flag to identify if the type is to be used and the Collection name that is used to assign the actual skills based on the configuration.

The associated claim(s) skills can be assigned to the inquiry by setting the Add claim skills to be on. This is set in the Claims inquiry skill type in the system settings.

Inquiry channel skill

The inquiry channel skill adds the skill on the claim associated with the channel that the inquiry was received:

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the inquiry channel skill on the delegated rules. The SCE provides a skill for each of the OOTB channels that can be associated with the inquiry.

Inquiry reason code skill

The inquiry reason code skill adds the skill on the claim associated with the reason for the claim inquiry:

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the inquiry reason code skill on the delegated rules. The SCE provides a skill for each of the OOTB reason codes that can be associated with the inquiry.

Inquiry type skill

The inquiry type skill adds the skill on the claim associated with the type for the claim inquiry:

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the inquiry type skill on the delegated rules. The SCE provides a skill for each of the OOTB inquiry types that can be associated with the inquiry (Member, Provider and Other).

Overriding and adding claims skills

The SCE provides the ability to override claims skills that have been added to the inquiry skills list based on the associated claims. The addition of the claims skills is indicated when the Add claims skills flag is On in the system settings section detailed above.

The SCE will add the skills from each of the claims associated with the inquiry to the skill list for the claim inquiry. If the same skills are listed across multiple claims or through the core inquiry skill assignment, then the skill with the highest rating and a required flag of “Y” is assigned to the inquiry.

Examples:

• Two claims have required high dollar skills assigned, but one has a rating of 9 and the other a rating of 5, the high dollar skill with a rating of 9 will be added to the claim inquiry.
• A claim has an authorization skill rating of 6 and the inquiry reason is authorization with a rating of 5, then the claim inquiry will have an authorization skill rating of 6 assigned.

The ability to override these skills is available when the Override claims skills flag is On. The configuration for overriding specific claims skills is accomplished by the Override claims skills table in the delegated rules:

This table enables specific skills applied by the claims to be replaced by another skill name (if appropriate), a new Rating and whether that skill is Required. If the claims skills added meet the skill criteria in this table, then the rating, name and required flags will be updated. This configuration enables the claims skills to be applied as part of the review of the claims inquiry and will enable the override of skills that are just needed as part of claims resolution. For example: a member VIP skill might be required for both claims inquiry and claims resolution, but a line of business skill might only be required for claims resolution.

Maximum number of skills

The SCE provides the ability to limit the number of skills that can be added to the claim inquiry. When this is implemented, the skills from the inquiry and the claim(s) will be added to the claim inquiry until the cap is met.

Viewing claim inquiry skills

The skills assigned to the claims inquiry are visible when selecting the View skills item on the Actions menu. This will show the skills assigned to the inquiry, along with the required flag and operator required rating.