Claims Processing Value Chain

1. Claims Origination

2. Claims Determination

3. Claims Litigation

4. Claims Finalisation

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. Documents management *

2.3. Direct claims

3.3. Internal law department (ILD)

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 20, 07 June 2013 * Report to Correspondence Manager

Symbols and Abbreviations Abbreviations

Symbols

On page reference

Off page reference

Action

Process

· · · · · · · · · · · · · · · · · · · · ·

Decision

Automated process

· · · · ·

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 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

Claims Processing Value Chain

1. Claims Origination

2. Claims Determination

3. Claims Litigation

4. Claims Finalisation

5. Post Claims Settlement

1.1. Hospital service centres

2.1. Medical

3.1. Summons administration

4.1. Capital payment

5.1. Post claims management

1.1. Community service centres

2.2. Represented claims

3.2. Writs management

4.2. Legal cost validation

1.2. Documents management

2.3. Direct claims

3.3. Internal law department (ILD)

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

1.1.1. HSC consultation process (Part 1 of 2)

A

HSC

HSC Check hospital register for MVA patients

Patient still alive?

Yes

MVA patient still in hospital?

No

No

1.1.1.1. Funeral expense origination process

Are there contact details available?

Yes

HSC

HSC

Visit patient in ward

1.1.1.2. First consultation process

No

End

Yes

A

Yes HSC Communicate expected timeframes to claimant

HSC Attempt to contact patient

HSC Forward claim to nearest region

Can the patient be contacted

No HSC

HSC

Record assessed claim on register

Follow up and SMS

End

End

Capture MVA victim/relative details on consultation register Patient to use ID number for RAF consultation reference number

B

1.1.1. HSC consultation process (Part 2 of 2)

HSC B

Complete a preliminary liability assessment

Template: 1. Is there a third party involved? 2. Is there damage or loss suffered? 3. Is the damage or loss suffered caused by or arising from the driving? 4. Was there any negligence or wrongful act? 5. Was it a motor vehicle accident? 6. Was the accident within the boarders of the Republic of South Africa?

Is the RAF liable?

Yes

No

Is an interim undertaking required?

Yes

HSC

HSC

Request a hospital case manager from the post claims settlement unit

Explain RAF claims initiation options to client

No

HSC Does the client opt to initiate claim with RAF? No

HSC

HSC

Inform client why the Fund is not liable and inform them of their right to continue with lodgement if they wish to

Inform client of process to initiate claim with attorney

End

End

Yes

1.1.1.3. Proceed to originate claim process

End

1.1.2. CSC consultation process

A

CSC

CSC

Capture MVA victim/relative details on consultation register

Inform & educate on RAF offerings & processes

CSC Complete a preliminary liability assessment Template: 1. Is there a third party involved? 2. Is there damage or loss suffered? 3. Is the damage or loss suffered caused by or arising from the driving? 4. Was there any negligence or wrongful act? 5. Was it a motor vehicle accident? 6. Was the accident within the boarders of the Republic of South Africa?

Is the RAF liable?

Yes

B

No CSC Inform client why the Fund is not liable and inform them of their right to continue with lodgement if they wish to

End

B

Is an interim undertaking required?

Yes

CSC

CSC

Request a hospital case manager from the post claims settlement unit

Explain RAF claims initiation options to client

No

CSC Does the client opt to initiate claim with RAF?

No CSC Inform client of process to initiate claim with attorney

End

Yes

1.1.1.3. Proceed to originate claim process

End

1.1.1.1. Funeral expense origination process

HSC/CSC

HSC/CSC Complete a preliminary liability assessment Template: 1. Is there a third party involved? 2. Is there damage or loss suffered? 3. Is the damage or loss suffered caused by or arising from the driving? 4. Was there any negligence or wrongful act? 5. Was it a motor vehicle accident? 6. Was the accident within the boarders of the Republic of South Africa?

Is the RAF liable? No HSC/CSC Inform client why the Fund is not liable and the right to continue with lodgement if they wish to

End

Yes

HSC collects all required documents and information

Template: - ID of claimant & deceased - Letter of cession (if parlour claiming) - Affidavit attested to by the parlour - Affidavit attested to by the family member - Death certificate - BI (Identification of body) forms - Embalming certificate (if applicable) - OAR - RAF 1 form - SMR/Medical Records - Funeral parlour voucher

HSC/CSC Does a funeral parlour need to be appointed?

Yes

1.1.1.1.1. Appoint funeral parlour process

No HSC/CSC Assist claimant to complete RAF 1

HSC/CSC Record on register and deliver claim to nearest RAF branch for processing

HSC/CSC HSC to inform the claimant as to when they should expect communication from the Fund

End

Note: Follow up with the branch (via the call centre) on the progress of the claim when a claimant enquires about the progress of the claim

1.1.1.1.1. Appoint funeral parlour process

B

HSC/CSC Does the family have a parlour they want to use?

Yes

Contact funeral parlour and request services

HSC/CSC Funeral parlour should be instructed to deliver services and prepare invoice for RAF

HSC/CSC

HSC/CSC

HSC to assist parlour with completion of RAF 1 and supporting docs

Record on register and deliver to nearest RAF branch for processing

No A HSC/CSC Does the family allow the RAF to appoint a funeral parlour or related services?

Yes

Search for the nearest parlour to be appointed

Does the family agree with the appointment? No

No HSC/CSC End

Contact a different parlour and request services in line with family needs

A

Yes

B

End

1.1.3. Origination process

· · ·

Walk-in client MVA Patient Register Tip-off on MVA patient

Is this a repeat visit?

Yes

HSC/CSC

HSC/CSC

Retrieve client details from SharePoint

Assist client to complete RAF 1

HSC/CSC Has the SMR been provided?

No

Yes

HSC/CSC consultation process

HSC/CSC

A

Request all relevant supporting documentation

A HSC/CSC Bundle all RAF 1 documents & supporting documentation

HSC/CSC Record on register & deliver to nearest branch for processing

End

No

Make a note for V&V to initiate SMR acquisition

A

Claims Processing Value Chain

1. Claims Origination

2. Claims Determination

3. Claims Litigation

4. Claims Finalisation

5. Post Claims Settlement

1.1. Hospital service centres

2.1. Medical

3.1. Summons administration

4.1. Capital payment

5.1. Post claims management

1.1. Community service centres

2.2. Represented claims

3.2. Writs management

4.2. Legal cost validation

1.2. Documents management

2.3. Direct claims

3.3. Internal law department (ILD)

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

1.2.1. Document management - incoming (Part 1 of 2)

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Receive documents

Open mail

Stamp all documents with correct date “Lodgement date”

Sort documents according to category & priority

- Registered/normal post - Hand delivered - HSC’s - Docex - Fax - Mobile RAF

Mailroom assistant

Is it critical?

Critical documents: - Summons - Writs - BIF - Court order - Funeral Claims - Bill of Costs

No

Is it general?

Yes

Prioritise to deliver to relevant unit within 4 hours

A

Mailroom assistant Sort according to general correspondence & Yes deliver to relevant unit within 24 hours

A

No

Unidentified documents

End

B

A

Mailroom officer

Mailroom assistant

Mailroom assistant

Distribute to scanning assistants

Prep documents for scanning

Scan documents & perform quality checks “Knowledge lake”

Scanned page quality ok? No Mailroom assistant Rescan missing/ unclear page and archive accordingly

B

Yes

Mailroom assistant

Mailroom assistant

Mailroom assistant

Index scanned documents

Stamp all scanned pages

Place documents in allocated section for delivery

‘Big 6’ - Claimant & Injured Surname/ID - Vehicle registration - Date of accident - Sender details (e.g. Attorney name - Scanner details & Date

- New claims - Writs - Summons - General - Private

C

1.2.1. Document management - incoming (Part 2 of 2)

C

Mailroom assistant

Mailroom assistant

Record on register, batch and deliver to Registrations

Return signed copy of register

Mailroom assistant

Mailroom assistant

Record on register, batch and deliver to Writs unit

Return signed copy of register

Mailroom assistant

Mailroom assistant

Record on register, batch and deliver to Summons administration unit

Return signed copy of register

Mailroom assistant

Mailroom assistant

Register BIF

Record on register, batch and deliver to first verifier

Mailroom assistant

Mailroom assistant

Mailroom assistant

Sort general documents by department

Record on register, and batch for collection

Retain signed copy of register

Is it a new claim?

Yes

No

Is it a Writ?

Yes

No

Is it a Summons?

Yes

No

Is it a BIF?

Yes

End

End

End

1st verifier

1st verifier

Verify and approve BIF

Attach supporting docs and send to finance

No

End

End

1.2.2. Document management – Supplier Claim

Mailroom assistant Receive supplier claim via post/hand delivery/internal

Is it an internal receipt?

No

Mailroom assistant

Mailroom assistant

Mailroom assistant

Collect & acknowledge receipt

Stamp each page of the supplier claim form (RAF 2)

Return a stamped copy to delivery person

B

Mailroom assistant

Mailroom assistant

Bundle all new claims & attach registrations register

Deliver claims to registration department

Yes

1.2.2.1 Internal claims process

End

B

Mailroom assistant Split claims accordingly (Provincial, Private) (urgent, not urgent)

Mailroom assistant

Mailroom assistant

Record all claims on register, sort & bundle

Deliver bundled claims to registrations

Mailroom assistant Registrations to acknowledge receipt & stamp documents where required - Claimant Name, Surname & ID - Injured Name, Surname & ID - Vehicle registration - Date of accident

End

1.2.2.1. Internal claims process A

Mailroom assistant Verify against register that all claims have been received and acknowledge receipt

Are all the files available?

Yes

Mailroom assistant

Mailroom assistant

Mailroom assistant

Prepare documents to be scanned onto “Knowledge Lake”

Distribute files amongst scanning assistants

Scan documents and perform quality checks

Mailroom assistant Scanned page quality ok?

No

No

Mailroom assistant

Mailroom assistant

Contact claims department and request outstanding files

Rescan required page(s) and archive accordingly

A

B

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Stamp all scanned pages

Record all scanned files on register

Prepare file for CAFS barcoding and archiving

Deliver files to CAFS

End

Yes

Index scanned documents

‘Big 6' - Claimant & Injured Surname & ID - Vehicle registration - Date of accident - Sender details (e.g. attorney name) - Scanner details & date - Treatment

B

1.2.2. Document management - outgoing

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Collect/Receive documents from internal units

Sort mail and date stamp

Record on register for reference

Verify that lodgement/link number is displayed

Mailroom assistant Verified and correct?

Prepare for scanning

Yes

Mailroom assistant

Scan all documents

A

No

Mailroom assistant

A

Verify quality

Contact sender to verify and update where required

Mailroom assistant Scanned page quality ok? No Mailroom assistant

Rescan missing/ unclear page(s)

Yes

Index scanned documents

Mailroom assistant Are files to be transferred between regions?

Send a letter informing the claimant/representative and region that the claim is being transferred to another region

Yes

1.2.2.1. File transfer process

Yes

1.2.2.2. Docex process

End

Yes

1.2.2.3. Registered mail process

End

Yes

1.2.2.4. Normal mail process

End

Yes

1.2.2.5. Courier process

End

No

Is it for Docex?

No Is it registered mail? No Is it normal mail? No

Is it courier mail

No 1.4.1. Mobile RAF process

End

End

Claims Processing Value Chain

1. Claims Origination

2. Claims Determination

3. Claims Litigation

4. Claims Finalisation

5. Post Claims Settlement

1.1. Hospital service centres

2.1. Medical

3.1. Summons administration

4.1. Capital payment

5.1. Post claims management

1.1. Community service centres

2.2. Represented claims

3.2. Writs management

4.2. Legal cost validation

1.2. Documents management

2.3. Direct claims

3.3. Internal law department (ILD)

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

1.3.1. Registration

Registration officer

Registration officer

Receive documents from document management unit

Verify claims on register and sign copy of register

Registration officer

Is the claim for another region?

Yes

No

Is it an additional supplier claim?

Yes

Branch transfer process

Send a letter informing the claimant/representative and region that the claim is being transferred to another region

Registration assistant

Registration assistant

Indicate on the file

Record on register and send file to supplier claims unit

End

End

No Registration assistant

A

B

Registration assistant

Registration assistant

Registration assistant

Capture new claim on system

Cross check information i.e. RAF1 & OAR

Register and submit new claim on system

Record report number on file and cover

Registration assistant

Registration assistant

Registration assistant

Registration senior

Submit to senior

Record new registrations on register (for V&V sign off)

Registration assistant

Registration assistant

Generate and print registration report

Ascertain link number from claims view using claim number or ID and update claim status as per V&V

Create colour coded file and record claim details on file

Registration senior

Registration senior

Registration senior

Batch files

Deliver batched files and register to validation & verification

Return signed copy of register to registrations

Date and sign off

End

A

B

1.3.2. Supplier Claims Registration (Part 1 of 2)

Administrative assistant

Registration senior officer

Receive new claims from document management unit

Acknowledge receipt of claims

Have all the claims as listed in register been received? No Registration senior officer

Yes

Registration senior officer

Registration officer

Senior to distribute new claims amongst officers

Acknowledge receipt of claims by signing register

Note: Upon system development completion, this allocation of work will be system driven

Registration officer Is the supplier claim a new claim?

Registration officer Indicate that the claim is an additional account on the file cover

Registration officer

A

Is the claim for another region?

Yes

Send a letter informing the claimant/representative and region that the claim is being transferred to another region

B

End

No Registration officer

Registration officer

Registration officer

Generate registration report and link number

Print & attach registration report to claim

Cross check and verify information captured

Registration officer Information captured correctly? No Registration officer

Rectify mistakes

Capture and register new claims on system

No

Notify documents management unit & request outstanding claims

Branch transfer process

Yes

Yes

Sign registration report as acknowledgement

B

A

1.3.2. Supplier Claims Registration (Part 2 of 2)

B

Registration officer

Registration senior officer

Deliver registered claims, reports and additional accounts to senior for review

Conduct spot checks on accuracy & quality of information captured on system

Quality & accuracy good? No Registration officer Send claim back to officer to rectify mistakes

Yes

Registration senior officer

Registration senior officer

Administrative assistant

Sign registration report as acknowledgement

Record all registered claims on register & bundle for delivery

Deliver registered claims to validation and verification

End

1.3.3. Validation and verification (Part 1 of 2)

Registration officer

V&V officer

Registrations delivers all new claims to V&V

Verify quantity of files with register (update where necessary)

All files available?

Yes

V&V officer

V&V officer

Sign and acknowledge receipt of claims

Distribute new claims equally amongst officers Note: Upon system development completion, this allocation of work will be system driven

No Senior V&V officer Request missing files from Registrations

V&V officer

A

Print generic template for validation and verification of claim

Has the claim prescribed?

A

V&V officer

Yes

Record on template for senior to review and continue with process

B

No V&V officer

B

Check for duplicates on claims view

V&V officer Duplicates found?

Yes

Record on template for senior to review and continue with process

C

No

C

V&V officer

V&V officer

Perform home affairs check, print report and place on file

Perform e-Natis checks if needs be

Due to costs, not every claim will be subjected to an eNatis check. Only matters where it is critical to obtain contact information may this validation be executed

D

1.3.3. Validation and verification (Part 2 of 2)

V&V officer D

Peruse documents to determine substantial compliance

V&V officer Is the claim substantially compliant?

Yes

Identify irregularities & trends for possible fraud

Fraud identified?

Yes

V&V officer

V&V officer

Record on template for senior to review and action

Refer identified files to Forensics accompanied with appropriate summary

No No V&V officer

V&V officer

Record on template for senior to review and list outstanding documents

Payment required for SMR?

Yes

1.3.2.1. SMR acquisition (payment) process

E

No V&V officer

E

Initial and stamp V&V template for senior to refer back to officer with queries if required

V&V officer Return validated & verified claim to senior For all repudiated and objected to claims

F

Senior V&V officer

Senior V&V officer

Review claims from officers

Take required action as noted by officer

1.3.2.2. Repudiation process

1.3.2.3. Objection process 1.3.2.4. Information request process

F

G

V&V administrator

V&V administrator

V&V administrator

Keep a copy of the fax/email/registered post confirmation in the file

Send the letter and confirmation for scanning

Batch new claims and deliver to CAFS/ Forensics (if needs be)

End

G

1.3.3.2. Repudiation process

B V&V officer Determine the grounds for repudiation

V&V officer Has the claim prescribed?

Yes

Send to senior for approval

V&V officer

V&V officer Does the senior approve?

Yes

Advise merits to repudiate claim

Is the claim represented?

No

No V&V officer No A

Has the claimant passed away?

No

A

Yes

B

Consider revision of decision

Yes

Prepare file and continue with process (i.e. CAFS, merits, medical & quantum)

V&V officer Initial and stamp V&V template for senior to refer back to officer with queries if required

V&V officer

Start

Diarise file for 3 months to finalise if there is no response from claimant/represented

End

1.3.4. Supplier validation and verification (Part 1 of 2)

Administrative assistant

Validation and verification senior officer

Receive new claims from registrations

Acknowledge receipt of claims

Have all the claims as listed in register been received?

Yes

Validation and verification senior officer

Validation and verification officer

Validation and verification officer

Distribute claims amongst officers for validation & verification

Assess claim

Verify that RAF 2 is substantially compliant

V&V Template: - Verify RAF 2 (substantial compliance) - Verify itemised bill - Claimant details on claims view? - Verify locus standi (verify claim not settled by medical aid or injured) Duplicate checking: - Vehicle registration number - ID number - DoA & DoB - DoA & Surname - DoA & Supplier

No Validation and verification officer Notify registration senior and request outstanding claims

Validation and verification officer A

Peruse file for any invoices/vouchers, bills etc.

Verify that all claims have been special Yes branched to correct agent code

Have claims been special branched?

Yes

Verify that claim details have been captured correctly on system

Yes

A

No Validation and verification officer Record on template and initiate objection process

Validation and verification officer

Validation and verification officer Are there invoices available?

Is the claim substantially compliant?

Validation and verification officer Claim details verified?

No

No

No

Validation and verification officer

Validation and verification officer

Validation and verification officer

Record on template and initiate objection process

Record on template and continue with process

Record on template and initiate objection process

Yes

Verify locus standi

B

1.3.4. Supplier validation and verification (Part 2 of 2)

Validation and verification officer B

Locus standi verified?

Yes

Perform duplicate checks

Validation and verification officer Duplicates found?

No

No

Validation and verification officer

C

Record on template and continue with process

Yes

Record on template and initiate objection process

C

No

C

Is claim valid

Yes

Outstanding information?

No No

Validation and verification officer

1.3.2.2. Repudiation process

Record all validated and verified claims on register

Validation and verification officer

Validation and verification officer

Prepare claim to be delivered to DM for archiving

Bundle claims and deliver to merits for assessment

End

End

Yes

Validation and verification officer

Validation and verification officer

Object to the validity of the claim

Record information requested on template and continue with process

Verify all files on register and sign copy of register

Place a Metrofile barcode sticker on each new file

Capture file details on Metrofile database relating to the allocated barcode

Book file on Metrofile system to merits unit

Deliver new claim to claims merits unit

Merits unit to acknowledge receipt upon collection

End

Receive assessed files from merits officer

Book file to determination officer

Pre-Litigation Preparation

Receive assessed files from determination officer

Book file to litgation officer

Deliver new claim to claims litigation unit

End

Receive assessed files from determination /litigation officer

Book file to finalisation officer

Deliver new claim to claims finalisation unit

End

Pre - Determination Preparation

Receive register and batched files from validation & verification

Pre-Finalisation Preparation

Pre - Merits Preparation

1.3.5. CAFS - new claims only

A

Deliver new claim to claims determination unit

End

A

Claims Processing Value Chain

1. Claims Origination

2. Claims Determination

3. Claims Litigation

4. Claims Finalisation

5. Post Claims Settlement

1.1. Hospital service centres

2.1. Medical

3.1. Summons administration

4.1. Capital payment

5.1. Post claims management

1.1. Community service centres

2.2. Represented claims

3.2. Writs management

4.2. Legal cost validation

1.2. Documents management

2.3. Direct claims

3.3. Internal law department (ILD)

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

1.4.1. Mobile RAF process

A

Mobile RAF dispatcher

Mobile RAF dispatcher

Mobile RAF officer

Mobile RAF officer

Receive request to collect information (via senior/ dispatcher)

Obtain details of claim

Contact relevant authority to obtain details of the deceased/ funeral parlour

Interview & educate MVA victim/relative about RAF offerings & processes

Any fatalities?

Yes

Contact made?

No

B

No

Mobile RAF officer

Mobile RAF officer Notify dispatcher & update task on SharePoint for follow up within 1 week

Arrange and hold meeting with client Mobile RAF officer Documents available?

Yes

Yes

Arrange meeting for document collection

A

D

D

No Mobile RAF officer Notify dispatcher & update task on SharePoint for follow up within 1 week E

F Mobile RAF officer

Mobile RAF officer

B

Request consent from client/relative

Consent obtained?

Yes

No Mobile RAF officer Inform client of process to initiate claim with attorney

End

Request required documents

Checklist: - OAR - SMR - UBC - Substantial compliance documents

All required merits documents obtained?

Yes

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Return all obtained document information to the requesting branch for capturing

Update task on SharePoint as finalised

Complete report on SharePoint

No Mobile RAF officer Notify dispatcher & update task on SharePoint for follow up within 1 week

End

F

1.4.2. Mobile RAF - origination

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Receive request from HSC via senior mobile RAF dispatcher

Obtain all relevant information relating to the potential claim

Contact client to arrange meeting

Is the client available?

Yes

Mobile RAF officer

Mobile RAF officer

Visit client to educate on RAF processes and offerings

Assist client to complete RAF 1 and collecting all required supporting documents

A

No Mobile RAF officer Diarise for 3 days and follow up Yes

Is the client available? No Mobile RAF officer Follow up with an SMS notification to claimant

Mobile RAF officer

A

Submit in duplicate to nearest RAF branch for processing and return stamped copy to claimant

Mobile RAF officer

Mobile RAF officer

Update task on SharePoint as completed

Complete report on SharePoint

End

Mobile RAF officer

Mobile RAF officer

Update task on SharePoint as completed

Complete report on SharePoint

End

Claims Processing Value Chain

1. Claims Origination

2. Claims Determination

3. Claims Litigation

4. Claims Finalisation

5. Post Claims Settlement

1.1. Hospital service centres

2.1. Medical

3.1. Summons administration

4.1. Capital payment

5.1. Post claims management

1.1. Community service centres

2.2. Represented claims

3.2. Writs management

4.2. Legal cost validation

1.2. Documents management

2.3. Direct claims

3.3. Internal law department (ILD)

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

1.5.1. Merits assessment (Part 1 of 2)

D Merits officer Merits assistant

Merits assistant Verify all files on register and acknowledge receipt

Receive new claims from V&V

Generate update SMS to claimant & conduct merits investigation

Info outstanding?

Yes

Merits officer

Merits officer

Determine documentation / information required

Peruse file to check if other departments have requested the information & whether there are linked files with required information

Is outstanding information available?

No

No

B

A

C Merits officer

Information requested?

A

Yes

Is it a direct claimant?

Yes

Is Mobile RAF timeline due?

Yes

Follow up with Mobile RAF (senior mobile officer)

No No

No No

Merits officer 1.5.1.1. Appoint assessor process

Yes

Assessor/ expert Required?

Follow up with Plaintiff Attorney/ Claimant/Mailroom

No Merits officer

Deliver letter to mailroom (distribution) or Mobile RAF for collection

Merits officer Can the process continue?

Yes

B

Diarise for follow up

No C

Generate letter of request for information to claimant/ representative

Merits officer

Information collected?

Diarise follow up with Mobile RAF

Merits officer Diarise for follow up within 1 week

D

Merits officer

D

D

Yes

D

Yes

B

1.5.1. Merits assessment (Part 2 of 2)

Merits officer

B

Merits apportionment using available information & case law

Is the RAF liable?

Yes

Merits officer

Merits officer

Prepare merits assessment summary

Notify claimant/ representative of merits apportionment

Merits officer Is the claim a medical expense claim only?

Yes

Prepare file and deliver to medical unit

End

No

No

Merits officer

Merits officer

4.2.1. Repudiation process

Is the claimant represented?

Prepare file for quantum investigation with represented unit

Deliver file to relevant unit, and notify CAFS

End

No Merits officer Prepare file for quantum investigation with direct unit

Yes

End

1.5.2. Merits (Part 1 of 2)

Administrative assistant

Merits senior officer

Receive new claims from V&V

Check that all the files have been received against the register

Merits senior officer Have all the claims been received?

Yes

Acknowledge receipt of claims

Merits officer Check whether enough information is available to determine merits

No

Sufficient information available?

Yes

A

OAR/Affidavit

E

No

Merits senior officer Notify Senior V&V and request outstanding claims

Has information been requested by V&V?

Yes

Has the information been received

Yes

A

No

Merits officer A

Determine if claim is Pre or Post and record on template

Merits officer

Merits officer

Determine whether injured was a passenger/driver/ pedestrian and record on template

Merits apportionment using available information & case law

C

No Is the RAF liable?

B

Yes

Merits officer No Merits officer

C

Is a phone number of the injured/claimant available?

Yes

Call the injured/ claimant and acquire outstanding information

Repudiate claim No Merits officer

Merits officer

Request outstanding information

Prepare claim to be delivered to DM for archiving

Merits officer

End

F

Record on template and follow up within 2 weeks

E

D

1.5.2. Merits (Part 2 of 2)

B

Merits officer

Merits officer

Merits officer

Prepare merits summary

Record assessed claims on register and bundle for delivery to quantum

Deliver to senior/ office for review

Merits officer Senior/officer approves recommendation?

No

Merits officer Merits officer D

Can you get hold of the injured/ claimant?

Yes

Acquire outstanding information

A

Amend recommendations accordingly

No B Merits officer Leave a message requesting outstanding information

F

Yes

Deliver claims to quantum for assessment

End

Frequently asked questions in originations Who should provide support for HSCs/CSCs decision making? The direct senior/team leader should be responsible for supporting HSC staff. Do HSCs/CSCs perform a merits assessment? No, they only perform a liability assessment. This means that they will determine e if the Fund is liable or not. How do HSCs/CSCs help suppliers lodge their claims? HSCs/CSCs should help suppliers lodge the claim and inform them about the necessary documents needed to make their claim successful. Do we have guidelines on how much funeral parlours should charge for their services? Yes, the Fund has provided guidelines on tariffs/margins funeral parlour should use. Who will initiate the SMR payment process? V&V should initiate the payment of SMR. 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. Can merits offers be communicated to represented claimants only? Merits offers should be communicated to all claimants. What is the maximum time a claim should be with the HSC staff? Claims should not stay with the HSC staff for more than 3 months (to prevent prescription). Who will be responsible for registering BIFs? Document management officers. Who is the 1st verifier for BIFs? Documents management senior What should happen to additional accounts sent by suppliers in the supplier claims process? Officers should flag the accounts as additional accounts and send them to the V&V. After V&V these claims can bypass merits and be sent straight to the Supplier Unit. Who will be responsible for updating incorrect or outstanding information once the correct information is received? V&V staff should have access to correct information on the system if it has been incorrectly registered. Seniors in the rest of the units should be responsible for updating outstanding and incorrect information on file. Officers and junior officers should alert their seniors when information needs to be updated. Can bar-coding of files happen in V&V rather than files being transferred to CAFS? A CAFS member should allocate a portion of their time to V&V to barcode all files and send them directly to merits. This works in PTA and assists with timelines. This will help to stop files being bottlenecked at CAFS. Should merits officers get all the information for supplier claims before assessing supplier claims merits? Merits officers should treat all merits assessment equally. The fact that the Fund reserves its rights to revisit the merits should be indicated on the supplier merits offer should. How do we address urgent undertakings? Urgent undertakings go through the same process but they are fast tracked through the process by the originator. Should all supplier claims go through V&V and Merits units? Yes, except for additional supplier claims – these should bypass merits. What should happen to additional accounts sent by suppliers in the supplier claims process? Registration staff should flag the accounts as additional accounts and send them to the V&V. After V&V these claims can bypass merits and be sent straight to the Supplier Unit.