Summary: SIPOC For Insurance Reimbursement

SIPOC for Insurance Reimbursement Process Supplier | Input | Process | Output | Consumer | Hospitals | Send the claim forms along with requisite documents (original bills, documents and reports ) | Receive claims package | Filled claim form and attach required documents. | HCMT/TPA (Health Claims Management Team or Third Party Administrator) | Processing department | Date and time stampChecklist for completeness | Check for completeness | Send incomplete forms to hospitalsSend complete forms to authorization department | Hospital or Authorization department | Authorization department | Check patient's eligibility status, the medical necessity, or it is “covered under the claim” and determine whether the claim is paid or denied | Process
| Mark the completeness of the process | Consumer |

Metric for performance as seen from the SIPOC is

1) Average Time to Settle a Claim:
This metric measures the average amount of time to settle a claim. It's imperative to distinguish between different types of policies since different policies may vary greatly in terms of how long it takes to settle. A common example is the difference between regular commercial medical insurance claims or Auto accident claims or Personal Injury claims.

Swimlane Diagram for insurance process Hospital | Insurance provider | Consumer | Incomplete forms are received from the processing department.
Hospital sends the claim forms along with requisite documents (original bills, documents and reports) | Processing department receives claims date and time stamps and checks for completeness. Complete forms sent to authorization and incomplete back to hospital.
Customer service department generate confirmation email and mark completeness of the