Claims Processing Value Chain

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1. Claims Origination

2. Claims Determination

3. Claims Litigation

4. Claims Finalisation

Claims Processing Value Chain

1.1. Hospital service centres

1.1. Community service centres

1.2. Document Management *

1.3. Registration, validation &

verification

1.4. Mobile RAF

2.1. Medical

2.2. Represented claims

2.3. Direct claims

3.1. Summons administration

3.4. Internal law department

(ILD)

3.5. Magistrate, high & district

court litigation

3.6. Panel attorney management

4.1. Capital payment

4.2. Legal cost validation

4.3. Legal cost payment

4.4. Writs payment

3.7. Judgement monitoring

4.5. Claims file closure

5. Post Claims Settlement

5.1. Post claims management

1.5. Merits

3.2. Writs management

2.4. Supplier claims

Version 20, 06 June 2013 * Report to Correspondence Manager

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Symbols and Abbreviations

On page reference

Off page reference

Action

Process

Decision

Symbols

Abbreviations

·

AMA - American Medical Association

·

BI - Body Identification

·

BIF - Banking Indemnity Form

·

CAFS – Central Archiving Filing System

·

CC - Compensation Commissioner

·

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

·

EIL - Employer Individually 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

·

ICT - Information Communication

Technology

·

ID - Identity Document

·

ILD - Internal Law Department

·

IT - Information Technology

·

LCO - Legal Cost Officer

·

LoE - Loss of Earnings

·

LoS - Loss of Support

·

MMI - Maximum Medical Improvement

·

MVA - Motor Vehicle Accident

·

NB - Nota Bene (Important)

·

OAR - Official Accident Report

·

PA - Panel Attorney

·

POP - Patient Outreach Program

·

RAF - Road Accident Fund

·

RAF 1 - Road Accident Fund Form 1

·

RAF 4 - Road Accident Fund Form 4

·

RSA - Republic of South Africa

·

SAPS - South African Police Service

·

SMR - Statutory Medical Report

·

SMS – Summons Management System

·

SOP - Standard Operating Procedure

·

U number - Undertakings Number

·

U system - Undertakings System

·

UBC - Unabridged Birth Certificate

·

UO - Undertakings Officer

·

V&V - Validation and Verification

·

WCC - Workmen's Compensation Commission

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1. Claims Origination

1.2. Document Management

verification

1.4. Mobile RAF

2.1. Medical

2.3. Direct claims

3.4. Internal law department

(ILD)

court litigation

4.4. Writs payment

3.7. Judgement monitoring

1.5. Merits

3.2. Writs management

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2.1.1. Medical (Part 1 of 3)

Medical officer Medical officer Medical officer Medical officer Medical

officer Medical officer

Medical officer Medical administrative assistant Medical administrative

assitant Medical _officer Medical _officer

Medical officer Medical officer

Verify all files have been received &

acknowledge receipt

Check for duplicates Receive file from

merits/claims officer Is the claim a medical expense? Yes No End 2.1.2. Serious injury assessment Print template for medical bill assessment Any documentation outstanding for assessment? No Request documentation from claimant/ representative

Diarise for follow

up A A Duplicates found? Record on template for senior review &

continue with process Yes

Verify nexus between injuries, DOA & treatment

No B B Compare information on account against information on SMR, hospital records (diagnosis and procedure) Has nexus been established? Verify that treatment rendered is appropriate Yes Treatment verified? Yes Record on template for senior review &

continue with process

No

C

Record on template for senior review &

continue with process Yes

Peruse file

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2.1.1. Medical (Part 2 of 3)

Medical officer Medical officer Medical officer

Medical officer

Medical officer Medical officer Bill reviewer Medical officer

Medical officer Is the

information aligned?

Check for over/ under servicing (length of stay &

level of care) Yes No Over/under servicing identified? Yes No

Are there any pre-existing conditions? No Record on template for review Yes

Prepare file for review by bill review

assessor, date & sign file

2.1.1.1. Audit & review medical bills and notes made by officer Check drug utilisation (amount,

frequency, duplication of drugs

& drug interaction

Drug utilisation verified?

No

Check for pre-existing conditions

Yes D

D C

Does the bill reviewer agree? No Advise CO to make offer to claimant/ representative for medical expenses Yes End Advise CO to make a revised offer to claimant/ representative for medical expenses

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2.1.2. Serious injury assessment (Part 1 of 2)

Medical administrative assistant Medical administrative assistant Junior / medical officer Junior/ medical officer Junior / medical officer Junior / medical officer Junior / medical officer Junior / medical

officer Junior / medical

officer Junior / medical officer Receive files from

bill reviewer or CO

Verify that all files are available and

acknowledge receipt

Receive file from assistant and review

AMA assessment forms

Peruse of all relevant medical

documents

Are all the required documents available? Yes A A Information verified with the

expert?

Peruse and assess. Apply legal principles, subject

to approval by senior Yes

Has MMI been reached?

No

Advise CO to diarise in line with expiry date and follow up

No

End

Record on template for senior review and continue with

process No Is a medico-legal assessment required? Yes Yes Request outstanding documentation No C Is it a valid GD claim? No B Notify CO of finding and reject GD claim

All files

available? Yes

Notify medical unit and request outstanding claims No C End Notify CO of finding and accept GD claim

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2.1.2. Serious injury assessment (Part 2 of 2)

D

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Claims Officer Claims Officer Claims Officer

Book appointment with expert

Diarise for follow up with expert on receipt of report

B Arrange transport & C

accommodation (where required)

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1. Claims Origination

1.1. Community service centres

verification

1.4. Mobile RAF

2.1. Medical

2.3. Direct claims

3.4. Internal law department

(ILD)

court litigation

4.3. Legal cost payment

4.4. Writs payment

1.5. Merits

3.2. Writs management

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2.2.1. Represented (Part 1 of 2)

Administrative assistant Administrative assistant Senior claims

officer Claims officer Claims officer

Claims officer

Claims officer Claims officer Receive files from

medical/merits unit Acknowledge receipt of files Senior to determine complexity of claim and distribute to claims officers

Assess and review documentation on file C Generate update sms to claimant/ representative A A

Are all the documents available for quantum determination? Assess claim documents (e.g. payslips, medico-legal, hospital records etc. Yes

Peruse file to determine if other departments have requested documents No Have documents been requested before? Follow up with Plaintiff Attorney (Represented) and diarise accordingly Yes C Contact plaintiff attorney and/or generate letter of request No Deliver letter to mailroom for delivery

Diarise for follow up, update notes on

claims view & book file back to CAFS

C B

Upon completion of the system development, the allocation of work/files will be done automatically by the system

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2.2.1. Represented (Part 2 of 2)

Claims officer Senior claims officer Claims officer Claims officer

Claims officer

Claims officer Claims officer Claims officer Claims officer Claims officer

Claims officer Claims officer Claims officer

Claims officer B Is an expert

required?

Senior to initiate expert payment and instruct

expert to quantify benefits e.g. actuary, industrial psychologist Quantify value of the benefits No Apply contingency deductions (apportionment and risk)

Consider any prior payments/interim payments/WCC/

social grants

Prepare an offer Is offer within mandate?

No

Load offer on system & generate update

sms to claimant/ representative

Yes Is the offer

accepted? Reject offer on system No D Accept offer on system, generate acceptance sms & request payment Yes

Prepare file & deliver to capital payment unit for

settlement

End Prepare memo for

mandate

Has memo been approved? Revise offer &

memo

No

Yes Prepare memo for

expert appointment Yes Does senior approve the memo? Yes Get secondary approval and make

offer to claimant No

Diarise for follow up and book file to

CAFS

Receive and review

expert reports D

F F

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1. Claims Origination

verification

1.4. Mobile RAF

2.1. Medical

2.3. Direct claims

3.4. Internal law department

(ILD)

court litigation

4.4. Writs payment

1.5. Merits

3.2. Writs management

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2.3.1. Direct (Part 1 of 2)

Direct administrative assistant Direct senior officer Direct administrative

assistant Claims officer Claims officer Claims officer

Claims officer Claims officer Claims officer Administrative assistant Claims officer Claims officer

Receive files from medical/merits unit Acknowledge receipt of files Senior to determine complexity of claim and distribute to claims officers

Assess and review documentation on

file

Are all the documents available for determination of quantum? Assess claim documents (e.g. payslips, medico-legal, hospital records etc. Yes

Peruse file to determine if other departments have requested documents No Have documents been requested before? Follow up with Mobile RAF or claimant and diarise

accordingly Yes C C No Generate update sms to claimant

A Did the claimant claim for GD

Can the injuries sustained be declared as serious?

Advise claimant to apply for GD as per regulation 3(2)(b) Yes

No

Contact direct claimant and generate letter of

request and task for Mobile RAF dispatcher

Deliver letter to mailroom or Mobile

RAF dispatcher

Diarise in line with Mobile RAF timeline for follow up, update claims view notes, and book file to CAFS

C Yes No A B B B Upon completion of the system development, the allocation of work/files will be done automatically by the system

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2.3.1. Direct (Part 2 of 2)

Claims officer Senior claims officer Claims officer Claims officer Claims officer

Claims officer

Claims officer Claims officer Claims officer Claims officer

Claims officer

Claims officer Claims officer Claims officer B Is an expert

required?

Senior to initiate expert payment and instruct

expert to quantify benefits e.g. actuary, industrial psychologist

Quantify value of the benefits

No

Prepare/revise memo for expert

appointment

Yes Does senior

approve memo? Yes

No

Diarise for follow up and book file to

CAFS

Receive and review

expert reports C Arrange transport/

accommodation for claimant if physical assessment is required

(via Mobile RAF)

D

Apply contingency deductions (apportionment

and risk)

Consider any prior payments/interim payments/WCC/

social grants

Prepare an offer Is offer within mandate?

No

Load offer on system & generate update

SMS to claimant/ representative Yes Is the offer accepted? Reject offer on system No D Accept offer on system, generate acceptance sms & request payment Yes

Prepare file & deliver to capital payment unit for

settlement

End Prepare memo

within mandate

Has memo been approved?

Revise offer & memo

No

Yes

Get secondary approval and make

offer to claimant

E E

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1. Claims Origination

verification

1.4. Mobile RAF

2.1. Medical

2.3. Direct claims

3.4. Internal law department

(ILD)

court litigation

4.4. Writs payment

1.5. Merits

3.2. Writs management

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2.4.1. Supplier claims (Part 1 of 2)

Administrative assistant

Supplier claims

senior officer Bill reviewer Bill reviewer Bill reviewer

Bill reviewer Bill reviewer

Bill reviewer _{Bill reviewer} Bill reviewer

Bill reviewer Bill reviewer Bill reviewer Bill reviewer

Receive new claims for assessment

Acknowledge receipt & verify all

claims received against register

All claims received?

Notify CH & request outstanding claims

No

Verify Date of Accident

Quantum Template: - Verify date of accident - Verify injured

- Verify nexus between injuries sustained & treatment

- Verify hospital/Ambulance records - Verify admission sheets

- Check duplicate: verification of payment made to supplier (phone & verify) - Verify that bill has not been settled in full

- Record schedule of med expenses

DoA verified?

Record on template and continue with

process No

A

Verify injured & details Yes

Injured verified?

process No Verify nexus between injuries sustained & treatment

Yes Nexus verified?

process No Verify hospital/ ambulance records Yes Hospital/ ambulance records verified? Record on template and continue with

process No Verify admission sheets Yes Admission sheets verified? B Yes Record on template and continue with

process No Assess bill

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2.4.1. Supplier claims (Part 2 of 2)

Bill reviewer

Bill reviewer Bill reviewer Bill reviewer _{Bill reviewer}

Bill reviewer Administrative assistant Administrative assistant Administrative assistant Bill reviewer Bill reviewer Bill reviewer B Check duplicate payments (to ensure that supplier

has not been paid already) No duplicates found? Record schedule of medical expenses Yes Record on template and continue with

process No

Record any relevant notes for senior to

view

Record assessed claims on register, bundle & deliver to senior for review

C Apply contingency

deductions (merits and risk) and load

offer Yes C Deliver file to finalisation End Does senior agree/approve? Repudiate claim No End Prepare claim to be delivered to DM for archiving

Cover claim & record link, ref, supplier name on

cover

Yes Generate EA to be

placed on file

Send to senior for approval

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2.4.2 Supplier finalisation

Supplier claims senior officer Supplier claims senior officer Supplier claims senior officer Supplier claims senior officer Supplier claims senior officer Supplier claims senior officer Receive batch payments from capital payment All payment requests correct and files available? Confirm on batch report and return to

capital payment for payment Yes

Investigate and make amendments

No

Check for paid claims on claims utility bulk Supplier

claims system

Change status of paid claims to “F”

Finalise and deliver

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Expert payment process

Claims Officer Claims Officer Claims Officer Claims Officer

Senior Officer

Senior Officer / Officer Prepare a memo to

address the situation

Is the expenditure within mandate? Forward to senior for approval Yes Memo / expenditure authorization to be forwarded to capital payment for payment

Diarise and follow up within 3 days Forward executive summary to persons with mandate No Is the executive summary approved? Yes

Revise the executive summary/expenditure

authorization No

Has payment

been made? Yes End

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Frequently asked questions in determination

What is the difference between the medical unit and the supplier unit aside from advice on narrative?

Both units process medical vouchers. The medical unit processes medical claims when they emanate from a non-supplier (i.e.

directly from a claimant/claimant attorney). Supplier units process medical vouchers from suppliers/agents

Should all medical claims go to the medical unit or only those referred by determination?

If we are going to capture all injuries then all files will need to be referred to medical unit if they contain past medical expenses. In

addition the supplier staff will need training on capturing injury information.

Do medical staff process interim payments or is this left to determination?

Medical staff should not process interim payments (unless in exceptional circumstances) for claims until the functionality to make

offers on medical claims independently is implemented. Payments should be made by the determination officer.

Will the type of injury be captured for every claim?

The type of injury will be captured for every medical claim when the system has been developed.

Will the direct/represented officers have access to the merits system?

Seniors and team leaders within Determination should have access to amend merits where no merits agreement has been reached

or input merits where merits have not been finalised.

When will files move to litigation?

The litigation criteria will be used for this. This varies from region to region.

What is the role of mobile RAF?

Mobile RAF will function as a courier company. They will be responsible for collecting documents and transporting claimants to

experts where necessary.

Who loads supplier claims and who approves them?

Bill reviewers load the claim and the senior approves

Who will finalise supplier files?