Business Process Modelling: Lodging a Health Insurance Claim - A Case Study of Bupa Insurance Company

This report focuses on the health insurance claim process of Bupa Insurance Company through business process modelling. The report includes a textual description of the process, a BPMN model, and assumptions made. The process involves the customer filing a claim request, which is then passed onto the claims handler, who checks the validity of the policy. The claim request is then forwarded to the Assessor in the service centre for investigation. If the claim is under coverage, the Assessor approves a preliminary estimate of the amount. The claim request is then passed onto the Senior Assessor if the estimate exceeds the range fixed for the insurance policy. After verification of the claims case by Senior Assessor, data is being entered into the management system for processing of payment and the claims handler processes payment to the customer.

Running head: BUSINESS PROCESS MODELLING
Business process modelling: Lodging a health insurance claim
A Case Study of Bupa Insurance Company
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1BUSINESS PROCESS MODELLING
Table of Contents
Background of the Organization......................................................................................................2
Textual description of the chosen process.......................................................................................2
BPMN model of the chosen process................................................................................................5
Overview and explanation of assumptions......................................................................................6
Bibliography....................................................................................................................................8

2BUSINESS PROCESS MODELLING
Background of the Organization
Bupa is a leading healthcare organization that provides health and care services over
Australia and New Zealand. The organization helps the members to lead a long, healthy and
happy life. It offers both healthcare and insurance services for the customers to ensure good
health of their family and wellness. The company has to follow a standard procedure for every
activity whether it is enrolment of insurance policies or handling of insurance claims. In this
report, the focus is particularly on describing the process of claims handling within the
organization. A model is designed to illustrate on the flow of activities that is being followed by
the company when a health insurance claim is lodged by customer.
Textual description of the chosen process
The process that has been chosen for this report in health insurance claim handling that
depicts the process that is being followed by Bupa insurance to handle claim requests from
customers. The process that has been undertaken in this particular study is one of the activities
that is being carried out in the business operations of the company. This process helps the
customers to live a long, healthy and happier lives with support of the company. The process of
claims handling comprises of two cases that is the claim amount may or may not exceed the
range covered by the insurance policy being enrolled by the customer. The claiming of the health
insurance amount can be processed by the customer as per their requirement whether hospital
treatment, health issues or accidental incident but the receivable amount depends on the value of
the enrolled insurance policy.
In the chosen process, first step is taken by the customer who files a claim request to the
company against their insurance policy. It is assumed that the customer is a member and has an

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insurance policy enrolled within the company. Then the request is being passed onto the claims
handler who is responsible for handling the claims processing within the company. The claims
handler after receiving the claim request from the customer checks whether the policy is valid or
not. Now, if the claims handler finds the policy to be valid then he/she will enter the data into
system so that it can be processed further or else the claim will be reject as there is no valid
policy as mentioned by the customer. After the data is being entered into the system, the claim
request is being forwarded to the Assessor in the service centre for investigating the case. The
Assessor handling the case will then check whether the claim being requested in under the policy
coverage or not.
If the assessor finds that the claim is being under coverage then he/she approves for
preliminary estimate of the amount that can be given against the policy. The approved estimate
may or may not exceed the range fixed for the insurance policy so if the estimate is found to
exceed the range then the request is being passed onto the Assessor present in the Headquarter
and if it does not exceeds the range then the claim request will be passed to the Senior Assessor.
The Assessor present in headquarter is then requested to conduct an investigation on the case that
has been put forward by the customer. After checking the requirements of the customer, the
Headquarter assessor identifies whether the mentioned cause for claim is under the coverage of
enrolled policy by the customer. If the Headquarter assessor finds that it is under coverage then
he/she processes further to determine the actual expense and approves the case but forwards to
the Senior Assessor to check the case for the claim request which is again connected indirectly
with the Assessor in service centre remains as if the estimate does not exceeds the range. Now
after verification of the claims case by Senior Assessor, data is being entered into the
management system for processing of payment and the claims handler is being informed about

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the payment being processed. The claims handler then processes payment to the customer and at
the time of payment processing the system has to perform two operations. The system after
processing claim amount for the customer closes the case and files the claim being processed
against the requested claim on behalf of the particular customer. Finally, the customer can fulfill
the requirements with the claim amount being processed from the health insurance claim process.
BPMN model of the chosen process
Figure 1: BPMN model for Health Insurance Claim process
(Source: Created by Author)

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Overview and explanation of assumptions
The assumptions that has been considered for designing the business process model in
context to the health insurance claim process are listed as below:
The type of claim being made is one that can be lodged online, and does not require the
policy holder to phone, mail in a claim, or visit a claim branch in order to lodge the claim.
The health insurance claim is logged online by the policyholder prior to the claim being
received by the Health Insurance Company (presumably via a support portal).
The health insurance claim being lodged includes specific details about the claim
including the claimant’s details, the practitioner they are claiming services for, and the item
codes for the individual services they are claiming for.
The health insurance claim contains photos or scanned copies of receipts for the health
service as a verification method for the health insurance company.
The conditions of the policy being valid (indicated in an early step in the process) also
include the assumption that the policy has surpassed all waiting periods associated with type of
claim being made against the policy.
The health insurance claim being made is that of general dental, as to not need to
differentiate the different types of claims being made and ways that they can be made.
The health insurance company has a system that calculate the refund amount, and no
manual intervention to calculate the amount needing to be refunded is needing to be made by the
finance team.

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The system used by the health insurance company stores all previous claim requests that
are able to be reassessed and reopened should the circumstances require it.
Once the claim is finalized on the end of the insurance company, no intervention is
needed by the claimant in order for the claim to be marked as closed.

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Welcome. (2018). Bupa - a global healthcare company. Retrieved 29 March 2018, from
https://www.bupa.com/