Fraud and Investigation Management: User Manual

Fraud and Investigation Management
User Manual
Oct 2016
Version 1.0
Revision History
Brief Description Product Build Prepared By Approved By

Version Effective Date
of Change Version
1.0 Oct 2016 New 3.9 iNube Doc Shankar

Team Subramanian
Religare Internal Use Page 1

Table of Contents
Preface .......................................................................................................................................................... 7
Audience ................................................................................................................................................... 7
Acronyms .................................................................................................................................................. 8
Document Convention .............................................................................................................................. 8
Common Buttons ...................................................................................................................................... 8
1 Fraud and Investigation Management.................................................................................................. 9
1.1 Process Flow Chart – Doctor / Case Manager Triggered Cases .................................................... 9
1.2 Key Features................................................................................................................................ 10
1.3 Application User Login Details .................................................................................................... 10
1.4 Application User Logout Details .................................................................................................. 11
2 Triggered By Doctor / Case Manager .................................................................................................. 13
2.1 Investigation Supervisor ............................................................................................................. 13
2.2 Internal Investigator.................................................................................................................... 16
2.2.1 Reports Submitted – Internal Investigator ......................................................................... 22
2.3 External Investigation Agency Supervisor................................................................................... 24
2.4 External Investigator ................................................................................................................... 26
2.4.1 Reports Submitted – External Investigator ......................................................................... 32
2.5 External Investigation Agency Supervisor - Review and Submit Report..................................... 34
2.6 Investigation Supervisor - Reports Received .............................................................................. 36
2.7 Payment User – Pending Bills / Invoice....................................................................................... 38
2.8 Investigation Supervisor - External Investigator Payment Approval .......................................... 40
2.9 External Investigation Agency Supervisor - Payment Status ...................................................... 41
Appendix ..................................................................................................................................................... 43
2.10 Communication Matrix ............................................................................................................... 43
Index............................................................................................................................................................ 45

List of Figures
Figure 1: Process Flow Chart ......................................................................................................................... 9
Figure 2: Application Login.......................................................................................................................... 10
Figure 3: Investigation Supervisor Home .................................................................................................... 13
Figure 4: Assigned Cases Inbox ................................................................................................................... 13
Figure 5: Patient and Claim Information..................................................................................................... 14
Figure 6: Investigator Grid .......................................................................................................................... 16
Figure 7: Internal Investigator Home .......................................................................................................... 16
Figure 8: Investigation Cases Inbox - Internal ............................................................................................. 16
Figure 9: Investigation Details..................................................................................................................... 17
Figure 10: Patient Details ............................................................................................................................ 19
Figure 11: Internal Investigator Home – Reports Submitted ...................................................................... 22
Figure 12: Investigation Cases Inbox - Internal ........................................................................................... 22
Figure 13: Investigation Report Details....................................................................................................... 23
Figure 14: Internal Investigator Home ........................................................................................................ 24
Figure 15: Investigation Cases Inbox – External Investigation Agency Supervisor ..................................... 24
Figure 16: Investigation Details................................................................................................................... 25
Figure 17: Agency Supervisor Actions ......................................................................................................... 25
Figure 18: Investigator Grid – External Investigation Agency Supervisor ................................................... 26
Figure 19: External Investigator Home ....................................................................................................... 26
Figure 20: Investigation Cases Inbox - External .......................................................................................... 26
Figure 21: Investigation Details................................................................................................................... 27
Figure 22: Patient Details – External Investigator....................................................................................... 29
Figure 23: External Investigator Home – Reports Submitted ..................................................................... 32
Figure 24: Investigation Cases Inbox - External .......................................................................................... 32
Figure 25: Investigation Report Details - External ...................................................................................... 33
Figure 26: External Investigation Agency Supervisor Home – Review and Submit Report ........................ 34
Figure 27: Investigation Cases Inbox - External Investigation Agency Supervisor ...................................... 34
Figure 28: Investigation Report Details - External Investigation Agency Supervisor .................................. 35
Figure 29: Investigation Supervisor Home – Reports Received .................................................................. 36
Figure 30: Assigned Cases Inbox – Reports Received ................................................................................. 36
Figure 31: Patient and Claim Information – Reports Received ................................................................... 37
Figure 32: Payment User Home .................................................................................................................. 38
Figure 33: Payment Cases Inbox - External ................................................................................................. 38
Figure 34: Invoice Information.................................................................................................................... 39
Figure 35: Investigation Supervisor Home – External Investigator Payment Approval .............................. 40
Figure 36: Assigned Cases Inbox – External Investigator Payment Approval ............................................. 40
Figure 37: Invoice Information – External Investigator Payment Approval................................................ 40
Figure 38: External Investigation Agency Supervisor Home –Payment Status ........................................... 41
Figure 39: Payments Cases Inbox - External Investigation Agency Supervisor ........................................... 41

Preface
Religare Health Insurance Company Ltd. (RHICL) is a specialized Health Insurer offering health insurance
products to employees of corporates, individual customers and financial inclusion. It has opted to use
ClaimsLive as an aid for User Management, Provider Management, Cashless Pre Auth Claims
Management, Reimbursement Claims Management, Fraud and Investigation Management.
The Fraud and Investigation Management is envisaged to cover all the functionalities pertaining to
members. This document helps in visualization and understanding of all the activities carried out with
respect to members.
The Preface section provides information on the following:
 Audience
 Acronyms
 Document Convention
 Common Buttons
Audience
Role Responsibilities
Investigation  Receives Work item from Doctor (medical adjudication team), Auto
Supervisor triggered cases from Business Rule Engine.
 Selects any work-item (including Pre-Intimation work items) randomly
and conducts investigation
 Assigns the case for Investigator (Internal / External) based on Provider /
Member location.
 Monitors the Turn Around Time (TAT) of investigation process.
 Verifies the Investigation report received from investigator
 Reassigns the case for further investigation.
 Accepts / Rejects the report and submits it to Doctor / Case manager /
Both.
 Approves / Rejects the Physical bills submitted by External Investigator for
payment of investigation.
Internal Investigator  Accepts / Rejects the work item assigned by Supervisor for investigation.
 Performs investigation based on request received from Supervisor.
 Captures Investigation findings and submits Investigation Report.
External Investigation  Accepts / Rejects the work item assigned by Investigation Supervisor for
Agency Supervisor/ investigation.
Investigator  Performs Investigation based on request received.
 Captures Investigation findings and submits Investigation Report to
Investigation Supervisor.
 Monitors Investigation Turn Around Time (TAT).
 Raises Invoice for investigations done, and submits physical invoice / bills
for payment.
Payment User  Reviews physical bills and updates bill details.

 Uploads scanned copy of the bills / invoice.
 Updates corrected bill details for rejected bills.

Acronyms
This section lists all the terms or abbreviations formed from the initial letters of a phrase. Terms are
listed alphabetically by acronym and not by definition:
Convention Applied
Al Authorization Letter
DNF Data Not Found
DOA Date of Admission
DOD Date of Discharge
FIM Fraud and Investigation Management
FIR First Information Report
MLC Medical Legal Case
TAT Turn Around Time
TPA Third Party Administrator
Document Convention
This section provides information on the document conventions that are followed in this User Manual.
Conventions Applied
Bold  Menu Names

 Buttons
 Key Terms
Emphasis  Application Screen Names
 Important Information Specific to the Application
 Data Entered in the Screen Fields (if any)
You  Provider Inward User
 Provider DEO Maker
 Provider DEO Checker
 Provider Network Doctor
 Provider Network Supervisor
Note  Important Information
Common Buttons
This table lists the common buttons used in the PM application.
Conventions Applied
Cancel a task to clear the data entered.
Save the entered information and proceed.
Browse the file that needs to be uploaded.
Update the modified field details.
Page 8 Internal Use Religare

1 Fraud and Investigation Management

A Fraud Investigation determines whether a fraud has taken place and gathers evidence to protect the
victims involved. An insurance fraud investigation is a type of fraud investigation that centers on attempts
to benefit from deceitful claims. Seeking compensation for false or inflated claims is illegal, dangerous,
and raises the price of insurance for everyone. As such, this document gives a visualization and
understanding of all activities that would be carried by Fraud and Investigation Management Users.
This section provides information on the following:
 Key Features
 Application User Login Details
 Application User Logout Details
1.1 Process Flow Chart – Doctor / Case Manager Triggered

Cases
The Process Flow Chart for Doctor / Case Manager triggered cases is as displayed:
Figure 1: Process Flow Chart

1.2 Key Features
This section describes the details of the most important key features of Fraud and Investigation
Management:
 Capable of detecting Frauds.
 Gather enough evidence against the fraud detected.
 Assign the fraud work items to Internal / External investigation teams for investigation.
 Perform Investigation based on request received.
 Capture Investigation findings and submit Investigation Report to Investigation Supervisor.
 Raise Invoice for investigations done, and submit physical invoice / bills for payment.
1.3 Application User Login Details

This section helps you to login to FIM application.
To login to Fraud and Investigation Management application, do the following:
1. Click the URL link - http://10.216.9.202:98/ to navigate to Fraud and Investigation Management login
screen.
The Fraud and Investigation Management login screen is as displayed:
Figure 2: Application Login

2. Enter the login details in the respective fields as tabulated:
Field Field Name Description
User Name Enter the User Name The User Name and Password are validated
against the existing database.
Ensure that the Password entered is the

same as that provided during the
User Name creation.
Password Enter the Password for the User Note: Both the fields are mandatory and the
Name entered. password is case sensitive.
Remember Me Select the check box if you want to save the User name and password for future
logins.
Forgot Password? Click the link to navigate to Forgot Password screen. Enter your Date of Birth,
Email id, Mobile number and submit. The new password will be shared with you
through email, to update the new password.
Account Unlock Click the link to navigate to Account Unlock screen. Enter your Username, Date
of Birth, Current Password and submit. The Account shall be unlocked.
Note The Password Policies to be abided are as listed:
Password has to be changed for every 90 days.

Password should contain a minimum of 8 characters with at least 1 numeric, 1 capital letter and
1 special character. (Special characters that can be used are! @ # $ % ^ and * ( ).)
Post incorrect password entry for 3 times, account shall be locked.
Password cannot be the same as User ID.
Password cannot be the same as Previous three passwords.
3. Click Login to submit the login request.
On successful authentication of the login details, the home page is displayed.
Note All the User Roles integrated in the application are displayed in the homepage. Access to the
Individual Roles is determined by the Privileges.
1.4 Application User Logout Details

To logout from the application, do the following:
 Select Logout from Profile drop down option in home page.
The User is navigated back to main portal screen.
Successful Logout:

 The concerned flow will be saved in the system.
 Appropriate message will be displayed to the User
Unsuccessful Logout:
 The concerned flow will not be saved in the database.

 Appropriate message will be displayed to the User for confirmation.

2 Triggered By Doctor / Case Manager

Fraud and Investigation Management follows the following process flows:
 Triggered By Doctor / Case Manager – Investigation cases elicited by Doctor / Case Manager.
 Triggered By ClaimsLive - Investigation cases elicited by Business Rule / System.
 Pre Intimation Cases - Investigation cases elicited by Customer through call / email.
 Post Facto Cases - Investigation cases elicited post the approval of claims / payments.
Note The functionality for all the process flows remains the same.
However, “Triggered By Doctor / Case Manager” flow is explained in detail as an illustration.
This section provides information to process the investigation requests received by the Doctor / Case
Manager.
2.1 Investigation Supervisor

This section provides the information on the Investigation Supervisor activities where, the required details
are captured for investigating the assigned cases.
To perform the investigation activity, do the following:
1. Login as Investigation Supervisor to navigate to Investigation Supervisor screen.
The Investigation Supervisor screen is as displayed:
Figure 3: Investigation Supervisor Home
2. Click Triggered by Doctor / Case Manager dashboard to navigate to an inbox of assigned cases.
The Assigned Cases Inbox is as displayed:
Figure 4: Assigned Cases Inbox
3. Click the required Intimation Number to navigate to Patient and Claim Information screen.

The Patient and Claim Information screen is as displayed:
Figure 5: Patient and Claim Information

The Patient, Claim and Hospital details captured by the Doctor / Case Manager are displayed.
4. Enter the details as tabulated. (* - marked fields are to be filled mandatorily.)
Field Description
Supervisor Actions
Investigation Type Select from the options provided.
Note: Since we are looking at a positive flow. Field Investigation is

selected.
Assign To Select from the options provided.
Note: Refer Internal Investigator for more details.

Field Description
Refer External Investigation Agency Supervisor for more details.

Internal Investigator Select from the options provided.
Note: This field is enabled only if Assign To is selected as Internal

Investigator.
Select Location Select from the options provided.
Note: This field is enabled only if Assign To is selected as External

Investigator.
External Investigator Elect from the options provided.
Agency
Note: This field is enabled only if Assign To is selected as External

Investigator. The options are relative to the Location selected.
Billing Location Select from the options provided.
Note: By default, the only billing location available is New Delhi. This field
is enabled only if Assign To is selected as External Investigator.
Supervisor Remark Enter valid remarks.
5. Click Add Investigator to assign the investigation case to respective Investigator / Investigators and
view the same in the grid.
The Investigator Grid is as displayed:

Figure 6: Investigator Grid
1. Click Delete in Delete tab to delete the Investigator details from the grid.
2. Select Investigation not required if investigation is not required for the assigned case.
6. Click Submit to forward the case to the respective Investigator / Investigators for investigation.
Note The Internal / External Investigators login to process the investigation requests respectively.
2.2 Internal Investigator

This section provides the information on the Internal Investigator activities where, the required details
1. Login as Internal Investigator to navigate to Internal Investigator screen.
The Internal Investigator screen is as displayed:
Figure 7: Internal Investigator Home
2. Click Cases for Investigation dashboard to navigate to an inbox of assigned investigation cases.
The Investigation Cases Inbox is as displayed:
Figure 8: Investigation Cases Inbox - Internal
3. Click the required Investigation User ID to navigate to Investigation Details screen.

The Investigation Details screen is as displayed:
Figure 9: Investigation Details
4. Click Accept Investigation to accept the investigation case successfully and navigate to Patient
details screen.
1. Click Reject Investigation to reject the investigation case successfully. (if required).

The Patient Details screen is as displayed:

Figure 10: Patient Details
Field Description
Patient
Patient Name Enter the patient name.

Age Enter the patient age.

Field Description
Relationship With Insured Enter the relationship if the patient with the Insured Member.
Remarks Enter valid remarks.
Gender Select from the options provided.
Upload HealthCard ID Card Add attachment.

/ ID Card / Patient Photo
Note: Answer the rest of the Patient related details with Yes / No / NA.
Hospital
Patient Present In Hospital Select from the following options.

The Options are:
 Yes
 No
Room Number Enter the room number.
Room Category Enter the room category.
Treating Doctor Name Enter the treating Doctor’s name.
Pathologist Name Enter the Pathologist’s name.
Radiologist Name Enter the Radiologist’s name.
Reg No Of Hospital Enter the registration number of the hospital.
Nos. of Beds Enter the number of beds available.
Current Bill Enter the current bill amount.
Upload Other Documents Add attachments (if any).
Expected DOD Select a suitable date from the calendar.
Note: Answer the rest of the Hospital related details with Yes / No / NA.
Clinical
Reason for Admission Enter the reason for admission.

Duration of Illness Enter the duration of illness.
DOA Select a suitable date from the calendar.
DOD Select a suitable date from the calendar.
Provisional Diagnosis Enter the provisional diagnosis.
Is it Accident Case Select from the following options.
The Options are:
 Yes
 No
Accident Date and Time Select a suitable date from the calendar.
Note: This field is enabled only if it is an accident case.
Place Of Accident Enter the place of accident.
MLC Select from the following options.
The Options are:
 Yes
 No
MLC / FIR No MLC refers to Medical Case and FIR refers to First Information Report.
Enter MLC / FIR number.

Field Description

Upload MLC Docs Add attachments.
Name of Police Station Enter the name of the Police Station.
Alcohol Intake Select from the following options.
The Options are:
 Yes
 No
 NA
MLC / FIR Lodged Enter a brief description.
Clinical Evidence Add attachments.
Vicinity Check
Neighbour 1 Name and Enter the name and Contact number.

Contact
Contact
Contact
Contact
Contact
Note: Answer the rest of the Vicinity Check related details with Yes / No / NA.
Workplace Visit
Workplace Name and Enter Workplace name and address.

Address
Details of Corporate Enter brief details of Corporate Insurance.
Insurance
Note: Answer the rest of the Workplace Visit related details with Yes / No / NA.
Conclude
Signature of Relative / Add attachments.

Patient
Upload Evidence Add attachments.
Admissible Select from the following options.
The Options are:
 Yes
 No
Observation / Remark Enter valid remarks.
Investigator Signature Add attachments.
6. Click Save to save the details. (Saving the details helps you to submit the furnished details in
future.)
7. Click Submit to submit the investigation report to Investigation Supervisor.

Note The submitted Investigation report cases plunge in Reports Submitted dashboard of Internal
Investigator.
2.2.1 Reports Submitted – Internal Investigator

This section provides information on the investigation report cases submitted by Internal Investigator to
To view the submitted investigation report cases, do the following:
1. Login as Internal Investigator to navigate to Internal Investigator screen.
The Internal Investigator screen is as displayed:
Figure 11: Internal Investigator Home – Reports Submitted
2. Click Reports Submitted dashboard to navigate to an inbox of investigation report cases.
The Investigation Reports Cases Inbox is as displayed:
Figure 12: Investigation Cases Inbox - Internal

Figure 13: Investigation Report Details

The Investigation details captured by Internal Investigator are displayed.
Note The Investigation details displayed will be in read only mode.
The Investigation Supervisor will login to process the received investigation report cases. Refer
Reports Received section for detailed information.
2.3 External Investigation Agency Supervisor

This section provides the information on the Internal Investigator activities where, the required details
1. Login as External Investigation Agency Supervisor to navigate to External Investigation Agency

Supervisor screen.
The External Investigation Agency Supervisor screen is as displayed:
Figure 14: Internal Investigator Home
Figure 15: Investigation Cases Inbox – External Investigation Agency Supervisor
3. Click the required Investigation ID to navigate to Investigation Details screen.

4. Click Accept Investigation to accept the investigation case successfully and navigate to Agency
Supervisor Actions screen.
1. Click Reject Investigation to reject the investigation case successfully.(if required)
The Agency Supervisor Actions screen is as displayed.
Figure 17: Agency Supervisor Actions
Field Description
Assign To Select from the options provided.
Agency Supervisor Remark Enter valid remarks.

6. Click Add Investigator to assign the investigation case to respective Investigator / Investigators and
view the same in the grid.
The Investigator Grid is as displayed:
Figure 18: Investigator Grid – External Investigation Agency Supervisor
2. Click Delete in Delete tab to delete the Investigator details from the grid.
7. Click Assign to forward the case to the respective Investigator / Investigators for investigation.
Note The External Investigator will login to process the assigned investigation case.
2.4 External Investigator

This section provides the information on the External Investigator activities where, the required details
1. Login as External Investigator to navigate to Internal Investigator screen.
The External Investigator screen is as displayed:
Figure 19: External Investigator Home
Figure 20: Investigation Cases Inbox - External

4. Click Accept Investigation to accept the investigation case successfully and navigate to Patient
details screen.
1. Click Reject Investigation to reject the investigation case successfully. (if required)

The Patient Details screen is as displayed:

Figure 22: Patient Details – External Investigator
Field Description
Patient
Patient Name Enter the patient name.

Age Enter the patient age.

Field Description
Relationship With Insured Enter the relationship if the patient with the Insured Member.
Remarks Enter valid remarks.
Gender Select from the options provided.
Upload HealthCard ID Card Add attachment.

/ ID Card / Patient Photo
Note: Answer the rest of the Patient related details with Yes / No / NA.
Hospital
Patient Present In Hospital Select from the following options.

The Options are:
 Yes
 No
Room Number Enter the room number.
Room Category Enter the room category.
Treating Doctor Name Enter the treating Doctor’s name.
Pathologist Name Enter the Pathologist’s name.
Radiologist Name Enter the Radiologist’s name.
Reg No Of Hospital Enter the registration number of the hospital.
Nos. of Beds Enter the number of beds available.
Current Bill Enter the current bill amount.
Upload Other Documents Add attachments (if any).
Expected DOD Select a suitable date from the calendar.
Note: Answer the rest of the Hospital related details with Yes / No / NA.
Clinical
Reason For Admission Enter the reason for admission.

Duration Of Illness Enter the duration of illness.
DOA Select a suitable date from the calendar.
DOD Select a suitable date from the calendar.
Provisional Diagnosis Enter the provisional diagnosis.
Is it Accident Case Select from the following options.
The Options are:
 Yes
 No
Accident Date and Time Select a suitable date from the calendar.
Place Of Accident Enter the place of accident.
MLC Select from the following options.
The Options are:
 Yes
 No
MLC / FIR No MLC refers to Medical Case and FIR refers to First Information Report.
Enter MLC / FIR number.

Field Description

Upload MLC Docs Add attachments.
Name of Police Station Enter the name of the Police Station.
Alcohol Intake Select from the following options.
The Options are:
 Yes
 No
 NA
MLC / FIR Lodged Enter a brief description.
Clinical Evidence Add attachments.
Vicinity Check

Contact
Contact
Contact
Contact
Contact
Note: Answer the rest of the Vicinity Check related details with Yes / No / NA.
Workplace Visit
Workplace Name and Enter Workplace name and address.

Address
Details of Corporate Enter brief details of Corporate Insurance.
Insurance
Note: Answer the rest of the Workplace Visit related details with Yes / No / NA.
Conclude
Signature of Relative / Add attachments.

Patient
Upload Evidence Add attachments.
Admissible Select from the following options.
The Options are:
 Yes
 No
Observation / Remark Enter valid remarks.
Investigator Signature Add attachments.
future.)
7. Click Submit to submit the investigation report to External Investigation Agency Supervisor.

Note The submitted Investigation report cases plunge in Reports Submitted dashboard of External
Investigator.
2.4.1 Reports Submitted – External Investigator

This section provides information on the investigation report cases submitted by External Investigator to
External Investigation Agency Supervisor.
1. Login as External Investigator to navigate to External Investigator screen.
The External Investigator screen is as displayed:
Figure 23: External Investigator Home – Reports Submitted
2. Click Reports Submitted dashboard to navigate to an inbox of investigation report cases.
Figure 24: Investigation Cases Inbox - External

Figure 25: Investigation Report Details - External

The Investigation details captured by External Investigator are displayed.
Note The Investigation details displayed will be in read only mode. The submitted report will plunge
in Review and Submit Report dashboard of the External Investigation Agency Supervisor.
The External Investigation Agency Supervisor will login to process the investigation reports.
2.5 External Investigation Agency Supervisor - Review and

Submit Report
This section provides information on the investigation report cases submitted by External Investigator to

Supervisor screen.
Figure 26: External Investigation Agency Supervisor Home – Review and Submit Report
2. Click Review and Submit Report dashboard to navigate to an inbox of investigation report cases.
Figure 27: Investigation Cases Inbox - External Investigation Agency Supervisor

Figure 28: Investigation Report Details - External Investigation Agency Supervisor

The Investigation details are displayed.
4. Click Edit to modify the required details. (if required)

5. Enter valid remarks in Remarks field.
6. Click Submit to submit the investigation report to Investigation Supervisor.

Note The Investigation Supervisor will login to process the received investigation report cases. Refer
Reports Received section for detailed information.
2.6 Investigation Supervisor - Reports Received

This section provides information on the investigation reports received from the Internal Investigator and
To view the reports received, do the following:
Figure 29: Investigation Supervisor Home – Reports Received
2. Click Reports Received dashboard to navigate to an inbox of assigned cases.
Figure 30: Assigned Cases Inbox – Reports Received
3. Click the required Investigation User ID to navigate to Patient and Claim Information screen.

The Patient and Claim Information screen is as displayed:
Figure 31: Patient and Claim Information – Reports Received

5. Click Reject Report to reject the received investigation report.(if required)
6. Click Accept Report to accept the received investigation report.
7. Click Raise Query to raise query to the respective Investigators and seek clarification.
Note Since we are looking at the positive flow, select Accept Report.
The completed investigation (external only) cases plunge in Pending Bills / Invoice dashboard of
the Payment User.
The Payment User will login to proceed with bills / invoice payment for the investigation carried
ou by the External Investigators.
2.7 Payment User – Pending Bills / Invoice

This section provides information on the bills / invoices that are due for payment by the Payment User for
the investigation carried out by External Investigators.
To proceed with bill payment activity, do the following:
1. Login as Payment User to navigate to Payment User screen.
The Payment User screen is as displayed:
Figure 32: Payment User Home
2. Click Pending Bills / Invoice dashboard to navigate to an inbox of assigned payment cases.
The Payment Cases Inbox is as displayed:
Figure 33: Payment Cases Inbox - External
3. Click the required Investigation User ID to navigate to Invoice Information screen.

The Invoice Information screen is as displayed:
Figure 34: Invoice Information
Field Description
Claim No Auto Fill.

Investigator / Agency Name Auto Fill.
Date of Assignment Auto Fill.
Professional Fees Auto Fill.
Billing Location Auto Fill.
Conveyance Charges Select the Conveyance Charges if applicable.
Upload Conveyance Add attachments.
Documents Note: This field is enable only if Conveyance Charges are applicable.
Tax Auto Fill.
Total Auto Fill.
Invoice / Bill No Enter the Invoice / Bill number.
Date of Invoice/ Bill Select a suitable date from the calendar.
Invoice / Bill Received date Select a suitable date from the calendar.
Physical Investigation Select if physical investigation report is received.
Report Received
Physical Investigation Select a suitable date from the calendar.
Report Received Date
Upload Invoice / Add attachments if any.
Documents
Note In case of Data Not Found (DNF) cases, only Intimation numbers are generated.
Payment can be done successfully only for those cases with generated Claim numbers or
Authorization Letter numbers. Henceforth, for successful payment of DNF cases, they have to
be sent for Medical Adjudicator / Case Manager’s approval for the generation of Claim /
Authorization Letter numbers.
future.)
6. Click Submit to submit the payment report successfully.
Note The submitted payment reports will plunge in External Investigator Payment Approval
dashboard of the Investigation Supervisor.
The Investigation Supervisor will login to approve / reject the payment reports.

2.8 Investigation Supervisor - External Investigator Payment
Approval
This section provides information on the payment of investigation reports that are due to be approved by
To view the investigation report, do the following:
Figure 35: Investigation Supervisor Home – External Investigator Payment Approval
2. Click External Investigator Payment Approval dashboard to navigate to an inbox of assigned cases.
Figure 36: Assigned Cases Inbox – External Investigator Payment Approval
3. Click the required Investigation User ID to navigate to Invoice Information screen.
The Invoice Information screen is as displayed:
Figure 37: Invoice Information – External Investigator Payment Approval

The bill payment details captured by the Payment User are displayed.

5. Click Approve Bill / Invoice to approve the bill payment.
6. Click Reject to reject the bill payment. (if required).
Note The approved investigation reports plunge in Payment Status dashboard of External
Investigation Agency Supervisor.
2.9 External Investigation Agency Supervisor - Payment Status

This section provides information on the External Investigator payment reports approved by the
To view the External Investigator payment reports, do the following:

Supervisor screen.
Figure 38: External Investigation Agency Supervisor Home –Payment Status
2. Click Payment Status dashboard to navigate to an inbox of investigation report cases.
The Payment Reports Cases Inbox is as displayed:
Figure 39: Payments Cases Inbox - External Investigation Agency Supervisor

The Payment Status of the respective investigation case along with investigation report details are
displayed in the grid.
Note Scroll the navigation bar horizontally towards the bottom right corner to view the payment
status.

Appendix
The common functionality pertaining to all the Investigators has been covered in this section.
2.10 Communication Matrix

This section provides information on the communication alert that is triggered to notify the Investigators
on the investigation cases assigned to them.
The table elaborating the communication matrix is as displayed:
Communication Reference Number Trigger Mode

to be Shared
Assignment of claim to External Al / Claim / Pre Claim triggered for Mail and SMS
Agency Supervisor Intimation number. Investigation by
Investigation Supervisor
Assignment of claim for Al / Claim / Pre Claim assigned for Mail and SMS
investigation to External Field Intimation number. investigation by External
Investigator Agency Supervisor
Assignment of claim for Al / Claim / Pre Claim assigned for Mail and SMS
investigation to Internal Field Intimation number. investigation to Internal
Investigator field investigator
Claim acceptance by External Al / Claim / Pre Claim Acceptance for Mail and SMS
Investigation Agency Intimation number. Investigation by external
Supervisor for investigation Agency Supervisor
Claim acceptance by Internal Al / Claim / Pre Claim Acceptance for Mail and SMS
Field Investigator for Intimation number. Investigation by Internal
investigation Field Investigator
Claim acceptance by External Al / Claim / Pre Claim Acceptance for Mail and SMS
Field Investigator for Intimation number. Investigation by External
Claim Rejection by External Al / Claim / Pre Claim Rejected for Mail and SMS
Investigation Agency Intimation number. Investigation by External
Supervisor for investigation Agency Supervisor
Claim Rejection by internal Al / Claim / Pre Claim Rejected for Mail and SMS
Field Investigator for Intimation number. Investigation by Internal
Claim Rejection by External Al / Claim / Pre Claim Rejected for Mail and SMS
Field Investigator for Intimation number. Investigation by external
Investigation complete and Al / Claim / Pre Investigation/ Re - Mail and SMS
report submit notification by Intimation no investigation complete and
External Agency Supervisor number. report submitted
(For both investigation and Re -
investigation)
Investigation complete and Al / Claim / Pre Investigation/ Re - Mail and SMS
report submit notification by Intimation number. investigation complete and
External Field Investigator (For report submitted
both investigation and Re -
investigation)
Investigation complete and Al / Claim / Pre Investigation / Re - Mail and SMS
report submit notification by Intimation number. investigation complete and
Internal Field Investigator (For report submitted
both investigation and Re -
investigation)

Communication Reference Number Trigger Mode
to be Shared
Assignment of claim for re- Al / Claim / Pre Investigation report Mail and SMS
investigation to External Intimation number. rejected by Investigation
Agency Supervisor Supervisor
investigation to External Field Intimation number. rejected by External
Investigator Agency Supervisor
investigation to Internal Field Intimation number. rejected by investigation
investigator Supervisor

Index
Acronyms Investigation Supervisor .............................. 38

Preface ........................................................... 6 Internal Investigator
Application User Login Details Triggered By Doctor / Case Manager .......... 14
Fraud and Investigation Management........... 8 Investigation Supervisor
Application User Logout Details Triggered By Doctor / Case Manager .......... 11
Fraud and Investigation Management........... 9 Investigation User ID
Audience Internal Investigator .................................... 20
Preface ........................................................... 5 Key Features
Common Buttons Fraud and Investigation Management .......... 8
Preface ........................................................... 6 Payment Status
Communication Matrix External Investigation Agency Supervisor ... 39
Appendix ...................................................... 41 Pending Bills / Invoice
Conveyance Charges Payment User .............................................. 36
Payment User ............................................... 37 Reports Received
Document Convention Investigation Supervisor .............................. 34
Preface ........................................................... 6 Reports Submitted
External Investigation Agency Supervisor External Investigator.................................... 30
Triggered By Doctor / Case Manager ........... 22 Reports Submitted – Internal Investigator
External Investigator Triggered by Doctor / Case Manager........... 20
Triggered By Doctor / Case Manager ........... 24 Review and Submit Report
External Investigator Payment Approval External Investigation Agency Supervisor ... 32

You are now successfully well informed of Fraud and Investigation Management
Module.
Management Module.

Fraud and Investigation Management: User Manual

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Fraud and Investigation Management

Brief Description Product Build Prepared By Approved By

1.0 Oct 2016 New 3.9 iNube Doc Shankar

Religare Internal Use Page 1

Religare Internal Use Page 3

Religare Internal Use Page 5

Payment User  Reviews physical bills and updates bill details.

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Bold  Menu Names

Cancel a task to clear the data entered.

Save the entered information and proceed.

Browse the file that needs to be uploaded.

Update the modified field details.

Page 8 Internal Use Religare

1 Fraud and Investigation Management

1.1 Process Flow Chart – Doctor / Case Manager Triggered

Figure 1: Process Flow Chart

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1.3 Application User Login Details

The Fraud and Investigation Management login screen is as displayed:

Figure 2: Application Login

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Field Field Name Description

Ensure that the Password entered is the

Note The Password Policies to be abided are as listed:

Password has to be changed for every 90 days.

3. Click Login to submit the login request.

On successful authentication of the login details, the home page is displayed.

1.4 Application User Logout Details

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 The concerned flow will not be saved in the database.

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2 Triggered By Doctor / Case Manager

However, “Triggered By Doctor / Case Manager” flow is explained in detail as an illustration.

2.1 Investigation Supervisor

1. Login as Investigation Supervisor to navigate to Investigation Supervisor screen.

The Investigation Supervisor screen is as displayed:

Figure 3: Investigation Supervisor Home

The Assigned Cases Inbox is as displayed:

Figure 4: Assigned Cases Inbox

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Figure 5: Patient and Claim Information

4. Enter the details as tabulated. (* - marked fields are to be filled mandatorily.)

Investigation Type Select from the options provided.

Note: Since we are looking at a positive flow. Field Investigation is

Note: Refer Internal Investigator for more details.

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Refer External Investigation Agency Supervisor for more details.

Note: This field is enabled only if Assign To is selected as Internal

Note: This field is enabled only if Assign To is selected as External

Note: This field is enabled only if Assign To is selected as External

The Investigator Grid is as displayed:

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Figure 6: Investigator Grid

2.2 Internal Investigator

1. Login as Internal Investigator to navigate to Internal Investigator screen.

The Internal Investigator screen is as displayed:

Figure 7: Internal Investigator Home

The Investigation Cases Inbox is as displayed:

Figure 8: Investigation Cases Inbox - Internal

3. Click the required Investigation User ID to navigate to Investigation Details screen.

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