Claims Processing Value Chain - Home Road Accident Fund. RAF... · Claims Processing Value Chain 1.1. Hospital service centres ... · ICT - Information Communication ... Road Accident

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

3.3. Internal law department (ILD)

3.4. Magistrate, high & district court litigation

3.5. Panel attorney management

4.1. Capital payment

4.2. Legal cost validation

4.3. Legal cost payment

4.4. Writs payment

3.6. 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 14, 07 June 2013* Report to Correspondence Manager

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· FCM - Field Case Manager· 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 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 – 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

System intervention

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

3.3. Internal law department (ILD)

3.4. Magistrate, high & district court litigation

3.5. Panel attorney management

4.1. Capital payment

4.2. Legal cost validation

4.3. Legal cost payment

4.4. Writs payment

3.6. 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

5.1.1. Post claims management (Part 1 of 4)C

laim

s D

eter

min

atio

ns

Dep

artm

ent

Claims Officer

Claims Officer

Claims Officer

Claims Officer

Claims officer

Claims Officer

Claims Officer Claims officer

Claims officer

Is claimant still in hospital?

5.1.1.1. Hospital case management

5.1.1.2. Field case

management

Send certificate for senior review

Does senior approve the value

of the undertaking?

Issue undertaking and notify claimant

Revise certificate

Yes

B

Appoint a field case manager (FCM)

Appoint a hospital case manager

(HCM)

Is the Fund liable?

Does a new undertaking need

to be issued?

D

A

A

A

Receive undertaking request or retrieve

dormant undertaking

No

Yes

No

Yes

No

Draft undertaking certificate

Create File Copies with all

information required for undertakings

Yes

B

C

L

Direct or Represented

claimant?Direct

Consult claimants attorney prior to

issuing undertaking

RepresentedNo

D

5.1.1. Post claims management (Part 2 of 4)

Undertakings senior

Admin Assistant

Admin Assistant

Admin Assistant

Undertakings senior

Undertakings officer

Undertaking officer


Admin Assistant

Admin Assistant

Retrieve file

Is undertaking registered on U

system and does it have an excel file?

Check if undertaking is

registered on U system and if it has an excel file

Register undertaking on U

system

Is the file located? Yes

Create dummy file

Locate the claim file by checking on system who last had the file

and request accordingly

Receive undertakings

certificate from claims

department

No

DYes

No

DAllocate

Undertaking to undertakings officer

Is the claim a pre-authorisation

request or medical invoice?

Make initial assessment of

undertaking and create excel file

Capture invoice details on excel file

5.1.1.3. Determine clinical appropriateness and correctness

Invoice appropriate and

correct?

Is amount within mandate?

L

No No

Yes

E

E

Approve authorisation/

invoice

Yes

C

H

F

FL

No

Receive report from HCM & FCM indicating the

condition of the claimant

Check:1. If the claim is for the claimant2.After the date of inception3. Accident related 4. Reasonable5. Tariffs if applicable 6. Duplicate payment



Undertakings senior


Undertakings senior Manager

1.1.4. Prepare payment list

Notify claimant and service provider

Is there another payment request?

Yes

No

Print excel spreadsheet and attach invoice for

senior review

Approve authorisation/

invoice

G

Does the approval require

escalation

G

No

Escalate to relevant level for approval

Yes G

Approve excel spreadsheet and

invoice according to mandate

H

F

I




Undertakings Officer





Capital payment officer

Capital payment officer

LReject invoice/pre-

authorisation request

Notify claimant and service provider

Is the practice number

available?

Compare practice number to practice

numbers on the service provider table

Compare service provider details to

RAF accredited table

Is the service provider

accredited with the RAF?

J

K

Is service provider

registered?

Verify legal liability of valid service

provider

Send invalid service provider details for

senior/forensics review

Yes

No

J

K

Yes

No

Yes

No

Diarise and follow up in a week

I

Initiate payment of undertaking

EndValidate Invoice and check for duplicate

payments

End

I

5.1.1.1. Hospital case management (POP)

Hospital case manager











Hospital case manager Hospital case manager

Advise HSC on which claims are

serious and require undertakings

End

A

Visit the patient in the ward

Assess claimant situation, compile

detailed report

Educate claimant on undertaking

Compile detailed injury report

5.1.1.2.1. Plan treatment

Attach detailed report to claim to support an interim undertaking to

be issued

A

·Extent of RAF support and commitments·RAF liabilities and RAF policies·Pre-existing co-morbidities·Accident relatedness

·Communicate plan to all concerned·Pre-authorize procedures·Advocate for services·Procure services·Coordinate services·Train caregiver(if necessary)·Formulate report

Assess and implement

treatment planMonitor the case

·Status of the client·Continuous education on care·Equipment allocated to client

Revisit the case and determine goal accomplishment, timeliness client, client

satisfaction andcost – benefit analysis

Assess case and discharge from case management when

satisfied

·Client declines or no longer requires service·Goals have been achieved·No further service required·Client transferred to another case manager·Demise of client

Continue communicating with

client, caregiver, family and service provider

Discharge plan and communicate plan

to field case manager

B

B

Disengagement from client in the event:·Client declines or no longer requires service·Goals have been achieved·No further service required·Client transferred to another case manager·Demise of client

5.1.1.2. Field case management (POP)

Field case manager

Field case manager

Field case manager

Field case manager

Field case manager

Field case manager

Field case manager

Field case manager

Field case manager

Field case manager

Field case manager Field case manager

Field case manager

Field case manager

Review claimant history, check HCM

profile on SharePoint and on

file

Trace claimant

Schedule claimant home visit

Assess claimant situation, compile

detailed report

Educate claimant on undertaking

Compile detailed injury report

5.1.1.2.1. Plan treatment

A

Appoint caregiverA

B

Assess and implement

treatment plan

Can you contact the claimant

telephonically?Yes

No

Is the claimant dead?

End YesUpdate file and

send to the original undertakings officer

No

Are contact details

available?Yes

C

No

C

Send an SMS to the claimant and follow

up in 2 daysD

D

·Communicate plan to all (caregiver, service provider ,claims handler)·Pre-authorize procedures·Advocate for services·Procure services·Coordinate services·Formulate report

Monitor the treatment plan

physically or telephonically

·Status of the client·Caregiver(continuous education on care)·Assistive devices/equipment allocated to client e.g. check seating in wheelchair or if cushion is still proper.

Revisit the case and determine goal accomplishment, timeliness client, client

satisfaction andcost – benefit analysis

End

Caregiver required?

No

B

Yes

Assess case and discharge from case management when

satisfied

·Client declines or no longer requires service·Goals have been achieved·No further service required·Client transferred to another case manager·Demise of client

5.1.1.2.1. Plan treatment plan (POP)

Hospital/Field case manager




Assess clinical information

available

Clinical information adequate?

Obtain adequate clinical information

Create appropriate treatment plan

EndYes

No

Create clinical case record

· Identify medical interventions necessary

· Identify related needs of client & family

· Identify related needs of client & caregiver

· Identify relevant service providers for client

· State recommended interventions

· Identify barriers· Develop contingency

plan· Set target dates· Get buy-in of plan to

client & family· Get consent from all

concerned(client, caregiver & family)

·Comprehensive emergency·Psychological·Rehabilitation·Community based·Vocational·Educational needs·Financial needs·Identify medical interventions necessary·Identify related needs of client& family & caregiver·Identify relevant service providers for client ·State recommended interventions·Identify barriers·Develop contingency plan·Set target dates·Get buy in of pan to client & family ·Bet consent from all concerned(client, caregiver & family)

5.1.1.3. Determine clinical appropriateness and correctness











5.1.1.3.2. Apply payment

rule

Is invoice appropriate and

correct? Accept invoice End

5.1.1.3.1. Verify invoice against

pre–authorisation record

Has a pre-authorisation been issued

before?

Reject invoice

Amount reasonable?

No

Yes

Is it a medical invoice?

5.1.1.3.3. Verify clinical

detail

No

Yes

No

Accept invoiceContact service

provider/ claimant to negotiate

Agreement reached?

Adjust invoice / pre-authorisation

Yes

No

Yes End

Accept invoiceYes

No

End

End

Is invoice accepted?

End

No

Yes

Reject invoice

A

A

B

B

5.1.1.3.1. Verify invoice against pre–authorisation record














Assess authorisation record in terms of service rendered and authorised

Invoice different from pre-

authorisation record?

Record discrepancyDifference

substantiated?Accept invoice Last invoice? EndYes

No

Yes Yes

No

A

Clinical records substantiate

liability?

Interpret invoice and capture medical

evaluation results

Send medical feedback

Accept invoiceYes

B

A

Negotiate with service provider

Adjust and accept invoice

Reject invoiceAgreement reached?

Medical opinion required?

Distribute invoice to bill reviewer for interpretation

Yes

Record discrepancy

No

YesNo

B

No

Accept invoice

B

Reject invoice

No

BB

B

5.1.1.3.2. Apply payment rule





Check if the Fund is liable

Is date of service before undertaking acceptance date?

Duplicate invoice / pre-

authorisation?

Accept invoice

Reject invoice Last invoice? EndYes Yes

No

Yes

No

Last invoice? EndYes

No

No

A

AA

Is the Fund liable?

Yes

Reject offer

No

Last invoice? EndYes

No

A

5.1.1.3.3 Verify clinical detail



Undertakings senior officer

Undertakings senior officer






Evaluate diagnosis and treatment

codes

Senior medical opinion

required?

Invoice distributed to Senior bill reviewer for

interpretation

Interpret invoice and capture medical

evaluation results

Send medical feedback

Yes

No

B

A

ALast invoice

item?

Reject invoice

Clinical records substantiate

liability?

Invoice / pre-authorisation

acceptedEnd

Contact service provider/ claimant

to negotiate

Agreement reached?

Adjust invoice / pre-authorisation

Last invoice item?

End

Yes

YesNo

No

Yes

No

Yes

B

C

C

Yes

D

D

D

Update notes on Excel

5.1.1.4. Prepare payment list








Generate consolidated list of approved invoices

for payment

Send list to finance for approval and

payment

Finance approves?

Contact undertakings

department to resolve query

Query resolved?

Finance signs, payment is processed

End

Escalate matter and agree on resolution

Finance signs, payment is processed

End

Yes

No

Yes

No

Assistant makes copies of signed

excel and attaches invoices

Documents

Claims Processing Value Chain - Home Road Accident Fund. RAF... · Claims Processing Value Chain 1.1. Hospital service centres ... · ICT - Information Communication ... Road Accident