Claims Processing Value Chain

Transcription

1 Claims Processing Value Chain 1. Claims Origination 2. Claims Determination 3. Claims Litigation 4. Claims Supplier claims 6. Post Claims Settlement 1.1. Hospital service centres 2.1. Medical 3.1. Summons administration 4.1. Capital payment 6.1. Post claims management 1.1. Community service centres 2.2. Represented claims 3.2. Writs management 4.2. Legal cost validation 1.2. Document management * 2.3. Direct claims 3.3. nternal law department (LD) 4.3. Legal cost payment 1.3. Registration, validation & verification 2.4. Supplier claims 3.4. Magistrate, high & district court litigation 4.4. Writs payment 1.4. Mobile RAF 3.5. Panel attorney management 4.5. Claims file closure 1.5. Merits 3.6. Judgement monitoring Version 8, 09 May 2013 * Report to Correspondence Manager

2 Symbols and Abbreviations Symbols On page reference Off page reference Action Process Decision AMA - American Medical Association B - Body dentification BF - Banking ndemnity Form CAFS Central Archiving Filing System CC - Compensation Commissioner CH - Claim Handler CLS - Legal and Compliance CO - Claims Officer COO - Chief Operations Officer CSC - Customer Service Consultant/Centre DM - Document Management DOA - Date of Accident DoB - Date of Birth EA - Expenditure Authorisation EL - Employer ndividually Liable ES - Executive Summary GD- General Damages GM - General Manager HCM - Hospital Case Manager HPCSA - Health Professions Council Of South Africa HSC - Hospital Service Consultant/Centre CT - nformation Communication Technology D - dentity Document LD - nternal Law Department T - nformation Technology LCO - Legal Cost Officer LoE - Loss of Earnings Abbreviations LoS - Loss of Support MM - Maximum Medical mpairment MVA - Motor Vehicle Accident NB - ta Bene (mportant) OAR - Official Accident Report PA - Panel Attorney POP - Patient Outreach Program RAF - Road Accident Fund RAF 1 - Road Accident Fund Form 1 RAF 2 - Road Accident Fund Form 2 RAF 3 - Road Accident Fund Form 3 RAF 4 - Road Accident Fund Form 4 RAF 5 - Road Accident Fund Form 5 RSA - Republic of South Africa SAPS - South African Police Service SMR - Statutory Medical Report sms - Short Message Service SMS Summons Management System SOP - Standard Operating Procedure U number - Undertakings Number U system - Undertakings System UBC - Unabridged Birth Certificate UCH - Undertakings Claims Handler V&V - Validation and Verification WCC - Workmen's Compensation Commission

3 Claims originations (Part 1 of 2) Hospital Service Centres and Community Service Centres Determine liability Assist the client to complete the RAF 1 form nitiate interim undertaking and funeral claim where applicable Request outstanding documents Send documents to the nearest branch A Document management A Receive documents Prioritise and scan documents Deliver documents to the relevant unit B Registration B Receive claim and capture claim s the claim an additional supplier invoice? Generate a ink number and a file Send to supplier claim unit D C

4 Claims originations (Part 2 of 2) Repudiate Validation and Verification C Determine substantial compliance Check documents and initiate SMR payment where applicable Verify and validate Object Branch transfer Request outstanding information E CAFS E Receive documents Barcode documents and register on CAFS system Send to merits F

5 Claims determination (Part 1 of 2) Repudiate Supplier claim D Merits F Perform merits assessment and request any other outstanding documents Affirm liability and inform the claimant Represented/Direct claim G G Assess the claim s a narrative assessor or bill reviewer needed? Send file to medical H Determine quantum s the claim litigious? s the claim a high court claim or outside jurisdiction? Send the file to magistrate, high and district court litigation K Represented / Direct Settle the matter Do experts need to be paid? Complete the trigger document and send to capital payment Send the file to LD J Load offer on the system and payment request with supporting documents send to finance L

6 Claims determination (Part 2 of 2) H Does the claim have narrative assessment only? Analyse documents Assess validity of claim and give opinion Send the file to direct/represented G Medical Assess the medical bill Record injuries Send the file to direct/represented G Supplier claims D Assess the claim Review the bill load and make an offer Print Expenditure Authorisation and forward the

7 Claims litigation (Part 1 of 2) Summons administration Receive and register summons s the summons from high court or outside jurisdiction? Forward summons to LD Appoint panel attorney Submit instruction to defend Forward summons to original determination officer G J J Receive file and draft pleadings where applicable Defend the matter Settle the case in/ out of court Load offer on system and print Expenditure Authorisation Do experts need to be paid? Complete the trigger document and send to capital payment L LD Send payment request

8 Title Phase Magistrate, high & district court litigation K Panel attorney attends to litigation process Ensure that the panel attorney is prepared for trail Settle the matter in/ out of court Load offer on system and print Expenditure Authorisation Do experts need to be paid? Send payment request Complete the trigger document and send to capital payment L Panel attorney management Receive and analyse complaint Engage with panel attorney Enforce penalties where applicable Compile a report End Judgement monitoring Receive and analyse judgement sample Compile a report Forward to corporate legal services End

9 Claims finalisations Capital payment L Receive payment trigger documents documents Conduct mandatory checks and load offer on system Accept offer on the system and print Expenditure Authorisation Send payment request Legal cost validation Receive legal costs from attorney Assess, load and make an offer Accept the offer on system and print Expenditure Authorisation Send payment request Writ payment Receive writ and supporting documents Conduct mandatory checks and load offer on system Accept the offer on system and print Expenditure Authorisation Send payment request Receive files Check all payments made Have all payments been made? Finalise file on the system End Claims file closure Request outstanding bills. Send bills to the relevant unit Diarise and follow up

10 Post claims settlement Undertaking Receive undertaking and register claim on the undertaking system Assess the invoice/ medical claim Send payment request to finance POP Review claim history Follow up with the claimant Adjust the treatment accordingly End