This message allows the sharing of a current electronic version of a single claim. It can be sent in two ways from carrier to agency: (1) as an immediate response when a ClaimDownloadRq (claim download request) is received or (2) automatically when there’s an update to the claim. These updates may include notifications about a new claim, changes in claim details (such as claim adjuster, claim status, or reserve amounts), or claim payments.

Example:

Imagine an insurance company receives a new car accident claim. The system can send a message with the electronic version of this claim, including the claim number, adjuster information, status (“under review”), and reserve amount ($5,000). If the adjuster changes or the claim is approved for payment, the updated details are sent automatically to the interested parties.

This process ensures all parties have the latest claim information without needing to request it manually. It improves efficiency and ensures transparency in the claims process.

Lifecycle of ClaimsDownloadRS

ClaimsDownloadRs refers to the structured messages used in claim management to provide updates at different stages of a claim’s lifecycle. Each stage represents a key milestone or event in handling the claim. Below is a detailed explanation of each event:

1. CLN – Claim Number Assignment

• Description: A unique claim number is assigned to a new claim. This number is used to identify and track the claim throughout its lifecycle.
• Example: A policyholder reports a car accident, and the system generates the claim number “CLM83749.” This information is shared with all relevant parties.

XML PATH of Claim Number

<ClaimsOccurrence>
   <ItemIdInfo>
      <InsurerId>CLM83749</InsurerId>
   </ItemIdInfo>
</ClaimsOccurrence>

2. CLI – Claim Information

Description:
CLI (Claim Information) refers to the detailed data about a claim, including core details like the policyholder’s information, date of loss, cause of loss, coverage details, and any related parties or incidents. It is essential for properly documenting and processing a claim.

3. ADJ – Adjuster Assignment

• Description:
  An adjuster is assigned to investigate and manage the claim. This stage includes the adjuster’s name, contact details, and assignment date.

• Example:
  Adjuster Party Assigned
  AssignedDate

4. RES – Claim Reserve

• Description:
  A reserve is an estimate of the potential financial liability for the claim. Changes to reserve amounts are communicated as the claim progresses.

• Example:
  The initial reserve is set at $10,000. Later, after further investigation, the reserve was updated to $15,000.

5. CLS – Claim Status Update

• Description:
  It communicates the status changes in the claim, such as C = Closed, D = Declined,
  O = Open, OT = Other, R = Reopened, S = Subrogation – Claim Open Pending Subrogation.

6. PMT – Payment

• Description:
  Payments made toward the claim are recorded and communicated. This may include details like payment date, amount, payee, and payment method.

Mandatory Elements of Transaction Codes:

Transaction Code	Mandatory Information
CLN	This transaction should contain the Company Claim Number. XML PATH: /ClaimsOccurrence/ItemIdInfo/InsurerId This “InsurerId” is the Claim number.
CLI	This transaction should contain all the aggregates of ClaimsDownloadRS. Aggregates include: ClaimsDownloadInfo, Producer, InsuredOrPrincipal, ClaimsOccurrence, ClaimsParty, AdjusterParty etc.
ADJ	This transaction should contain at least all the requirements of the AdjusterParty aggregate.
RES	This transaction should contain at least all the requirements of the ClaimsPayment aggregate with a PaymentTypeCd=”LossResv”.
CLS	This transaction should contain at least ClaimStatusCd and ClaimStatusDt.
PMT	This transaction should contain at least all the requirements of the ClaimsPayment aggregate.

Summary:
The ClaimsDownloadRs lifecycle ensures that all stakeholders are kept informed at each stage of the claim process, from claim creation to resolution. This structured communication improves transparency, accuracy, and efficiency in handling claims.