Claims Processing Value Chain - Road Accident Fund. RAF... · Claims Processing Value Chain 1.1. ... Information Communication Technology · ID - Identity Document ... 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. Documents 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

6. Post Claims Settlement

6.1. Post claims management

1.5. Merits

3.2. Writs management

2.4. Supplier claims

Version 20, 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· 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

Automated process





1.2. Documents management


1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



1.1.1. HSC consultation process (Part 1 of 2)

HSC HSC HSCHSC

HSC HSC

HSC

HSCHSC

Check hospital register for MVA

patients

Patient still alive?

YesMVA patient still

in hospital?

Attempt to contact patient

Can the patient be contacted

Yes

1.1.1.1. Funeral expense

origination process

End

No

Communicate expected

timeframes to claimant

Forward claim to nearest region

Record assessed claim on register

End

Are there contact details

available?

Yes

B

A

A

No No

Visit patient in wardYes

Patient to use ID number for RAF

consultation reference number

1.1.1.2. First consultation

process

Follow up and SMS

Capture MVA victim/relative

details on consultation

register

EndNo

1.1.1. HSC consultation process (Part 2 of 2)

HSC HSC

HSC

HSC

HSC

HSC

Complete a preliminary liability

assessment

Is the RAF liable?

Explain RAF claims initiation options to

client

Does the client opt to initiate

claim with RAF?

1.1.1.3. Proceed to

originate claim process

Yes End

Inform client why the Fund is not liable and inform them of

their right to continue with lodgement if they wish to

No

Inform client of process to initiate

claim with attorney

No

EndEnd

YesIs an interim undertaking

required?

Request a hospital case manager from

the post claims settlement unit

Yes

No

B

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?

1.1.2. CSC consultation process

CSCCSC

CSC

CSC CSC CSC

CSC

CSC

Inform & educate on RAF offerings &

processes

A


assessment

Is the RAF liable?

Inform client why the Fund is not liable and inform them of

their right to continue with lodgement if they wish to

End

Yes

Is an interim undertaking

required?

Request a hospital case manager from

the post claims settlement unit

Yes

No

Explain RAF claims initiation options to

client

Does the client opt to initiate

claim with RAF?

1.1.1.3. Proceed to

originate claim process

Yes End

Inform client of process to initiate

claim with attorney

No

End

B

B


Capture MVA victim/relative

details on consultation

register

No

1.1.1.1. Funeral expense origination process

HSC/CSC HSC/CSC HSC/CSC

HSC/CSCHSC/CSC

HSC/CSC

HSC/CSC

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

Does a funeral parlour need to be appointed?

1.1.1.1.1. Appoint

funeral parlour process

Yes

Assist claimant to complete RAF 1

No

Record on register and deliver claim to nearest RAF branch

for processing

End

HSC to inform the claimant as to when they

should expect communication from the

Fund

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


assessment


Inform client why the Fund is not liable and the right to continue with lodgement if

they wish to

End

Is the RAF liable?

Yes

No

1.1.1.1.1. Appoint funeral parlour process

HSC/CSCHSC/CSC

HSC/CSC HSC/CSC

HSC/CSC

HSC/CSC

Does the family have a parlour they want to

use?

Search for the nearest parlour to

be appointed

Does the family allow the RAF to appoint a

funeral parlour or related services?

Yes

End

No

Does the family agree with the appointment?

No

Yes

Contact a different parlour and request services in line with

family needs

A

ANo

Contact funeral parlour and request

services

Funeral parlour should be instructed

to deliver services and prepare invoice

for RAF

HSC to assist parlour with completion of

RAF 1 and supporting docs

Record on register and deliver to

nearest RAF branch for processing

EndYes

B

B

1.1.3. Origination process

HSC/CSC HSC/CSC

HSC/CSC

HSC/CSC

HSC/CSC

HSC/CSC

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

Is this a repeat visit?

HSC/CSC consultation

process

No

Assist client to complete RAF 1

Has the SMR been provided?

No A

Request all relevant supporting

documentation

Yes

Bundle all RAF 1 documents &

supporting documentation

Record on register & deliver to nearest

branch for processing

End

A

A

Retrieve client details

from SharePoint

YesMake a note for

V&V to initiate SMR acquisition







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



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

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant Mailroom assistant

Mailroom assistant

Mailroom officer

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Receive documents

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

Open mail

Stamp all documents with

correct date“Lodgement date”

Sort documents according to

category & priorityIs it critical?

Prioritise to deliver to relevant unit within 4

hoursYes

No

Is it general?

Sort according to general correspondence &

deliver to relevant unit within 24 hours

Yes

A

A

Unidentified documents

No

End

A

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

Distribute to scanning assistants

Prep documents for scanning

“Knowledge lake”

Scanned page quality ok?

Rescan missing/unclear page and

archive accordingly

B

Index scanned documents

Yes

B

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

Stamp all scanned pages

Place documents in allocated section for

delivery

- New claims- Writs- Summons- General- Private

C

Scan documents &

perform quality checks

No

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

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

1st verifier 1st verifier

Mailroom assistant

Is it a new claim?

Record on register, batch and deliver to

RegistrationsYes

Return signed copy of register

End

Is it a Writ?

No


Writs unit


EndYes

Is it a Summons?

No


Summons administration unit


EndYes

Is it a BIF?

No

Yes

Sort general documents by department

Record on register, and batch for

collection

Retain signed copy of register

End

No

C


first verifierRegister BIF

Verify and approve BIF

Attach supporting docs and send to

financeEnd

1.2.2. Document management – Supplier Claim

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Receive supplier claim via post/hand

delivery/internal

Is it an internal receipt?

Yes

Collect & acknowledge

receipt

Stamp each page of the supplier claim

form (RAF 2)

Return a stamped copy to delivery

person

Split claims accordingly

(Provincial, Private) (urgent, not urgent)

BRecord all claims on

register, sort & bundle

Deliver bundled claims to

registrations

Registrations to acknowledge

receipt & stamp documents where

required

Bundle all new claims & attach

registrations register

Deliver claims to registration department

End

- Claimant Name, Surname & ID- Injured Name, Surname & ID- Vehicle registration- Date of accident

BNo

1.2.2.1 Internal claims process

End

1.2.2.1. Internal claims process

Mailroom assistant Mailroom

assistantMailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Prepare documents to be scanned onto “Knowledge Lake”

Verify against register that all

claims have been received and acknowledge

receipt

Are all the files available?

Contact claims department and

request outstanding files

No

YesDistribute files

amongst scanning assistants

Scan documents and perform quality

checks

Scanned page quality ok?

Index scanned documents

Yes B

Rescan required page(s) and archive

accordingly

No

A

A

B

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

Stamp all scanned pages

Record all scanned files on register

Prepare file for CAFS barcoding and

archivingDeliver files to CAFS End

1.2.2. Document management - outgoing

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

Mailroom assistant

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

Verified and correct?

Prepare for scanning

Yes

Contact sender to verify and update where required

No

A

A Verify qualityScanned page

quality ok?Index scanned

documentsYes

No

Are files to be transferred

between regions?

1.2.2.1. File transfer process

Yes

Is it for Docex?

No

1.2.2.2. Docex process

Yes

End

End

Is it registered mail?

No

1.2.2.3. Registered

mail processYes End

Is it normal mail?

No

1.2.2.4. Normal mail

processYes End

Is it courier mail

No

1.2.2.5. Courier process

Yes End

1.4.1. Mobile RAF process

No

End

Scan all documents

Rescan missing/unclear page(s)

Send a letter informing the claimant/representative

and region that the claim is being transferred to

another region







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



1.3.1. Registration

Registration assistant




Registration officer




Registration senior

Registration senior

Registration senior

Registration senior







Receive documents from document

management unit

Verify claims on register and sign copy of register

Cross check information

i.e. RAF1 & OAR

Record report number on file and

coverA

Capture new claim on system

Register and submit new claim

on system

No

Is it an additional

supplier claim?

Indicate on the fileRecord on register

and send file to supplier claims unit

Yes End

A

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 fileDate and sign off Submit to senior

Record new registrations on

register (for V&V sign off)

B

B Batch files

Deliver batched files and register to

validation & verification

Return signed copy of register to registrations

End

Generate and print

registration report

Is the claim for another region?

No

Branch transfer process

Yes End



another region

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?

Senior to distribute new claims amongst

officersYes

Acknowledge receipt of claims by

signing register

Capture and register new claims on

system

A

A

Notify documents management unit & request outstanding

claims

No

Generate registration report and link number

Print & attach registration report

to claim

Cross check and verify information

captured

Information captured correctly?

Sign registration report as

acknowledgementYes

Rectify mistakes

No

Is the supplier claim a new

claim?Yes

Indicate that the claim is an

additional account on the file cover

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

Branch transfer process

End



another region

Is the claim for another region?

No

Yes

B

B

1.3.2. Supplier Claims Registration (Part 2 of 2)







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?

Yes

Send claim back to officer to rectify

mistakes

No

Sign registration report as

acknowledgement

Record all registered claims on

register & bundle for delivery

Deliver registered claims to validation

and verificationEnd

B

1.3.3. Validation and verification (Part 1 of 2)

Registration officer V&V officer

Senior V&V officer

V&V officerV&V officer

V&V officer

V&V officer

V&V officer

V&V officer

V&V officer V&V officer

Registrations delivers all new claims to V&V

Verify quantity of files with register

(update where necessary)

All files available?

Request missing files from

Registrations

No

Sign and acknowledge

receipt of claimsYes

Distribute new claims equally

amongst officersA

APrint generic template

for validation and verification of claim

Has the claim prescribed?

Record on template for senior to review and continue with

process

Yes

No

Check for duplicates on claims view

Duplicates found?

Record on template for senior to review and continue with

process

Yes

Perform home affairs check, print

report and place on file

No

Perform e-Natis checks if needs be

D

C

B

B

C

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

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

1.3.3. Validation and verification (Part 2 of 2)

V&V officer V&V officer V&V officer V&V officer

V&V officer V&V officer


Senior V&V officer

Senior V&V officer

V&V administrator

V&V administrator

V&V administrator

Peruse documents to determine substantial compliance

Is the claim substantially compliant?

Identify irregularities &

trends for possible fraud

Yes

Record on template for senior to review and list outstanding

documents

No

Fraud identified?

Record on template for senior to review

and actionYes

Initial and stamp V&V template for

senior to refer back to officer with

queries if required

Return validated & verified claim to

seniorF

FReview claims from

officers

Take required action as noted by

officer

Payment required for

SMR?

1.3.2.1. SMR acquisition (payment)

process

Yes

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

the file

Send the letter and confirmation for

scanning

Refer identified files to Forensics

accompanied with appropriate summary

Batch new claims and deliver to CAFS/

Forensics (if needs be)

End

No

D

1.3.2.3. Objection process

1.3.2.4. Information

request process

1.3.2.2. Repudiation

process

E

E

G

G

No

For all repudiated and objected to claims

1.3.3.2. Repudiation process

V&V officer V&V officer V&V officerV&V officer


V&V officer

Determine the grounds for repudiation

Has the claim prescribed?

Has the claimant passed away?

No

No

Advise merits to repudiate claim

Diarise file for 3 months to finalise if there is no

response from claimant/represented

Is the claim represented?

No

Prepare file and continue with

process (i.e. CAFS, merits, medical &

quantum)

Yes

End

Does the senior approve?

Send to senior for approval

Yes Yes

Yes

Consider revision of decision

Initial and stamp V&V template for

senior to refer back to officer with

queries if required

StartA

B

B

A

No

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


Validation and verification

senior officer


senior officer


officer


officer


officer


officer


officer


officer


officer


officer


officer


officer


officer

Receive new claims from registrations


Have all the claims as listed in register been

received?

Notify registration senior and request outstanding claims

No

Distribute claims amongst officers for


Yes Assess claim

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

Verify that RAF 2 is substantially

compliant

Is the claim substantially compliant?

AYes

Record on template and initiate

objection process

No

APeruse file for any invoices/vouchers,

bills etc.

Are there invoices

available?

Verify that all claims have been special

branched to correct agent code

Yes


objection process

No

Have claims been special branched?

Record on template and continue with

process

No

Verify that claim details have been captured correctly

on system

YesClaim details

verified?Verify locus standiYes


objection process

No

B

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


officer


officer


officer


officer


officer


officer


officer

Validation and verification officer

Locus standi verified?

Record on template and continue with

process

No

Perform duplicate checks

YesDuplicates

found?


objection process Yes

No

B

Is claim validOutstanding information?

Yes

No

Record all validated and verified claims

on register

No

Bundle claims and deliver to merits for

assessment

End

Yes

End

Object to the validity of the claim

Prepare claim to be delivered to DM for

archiving

C

C

Record information requested on template

and continue with process

1.3.2.2. Repudiation

process

No

C

1.3.5. CAFS - new claims onlyP

re -

Mer

its

Pre

par

atio

nP

re -

Det

erm

inat

ion

P

rep

arat

ion

Pre

-Lit

igat

ion

P

rep

arat

ion

Pre

-Fin

alis

atio

n

Pre

par

atio

n

Receive register and batched files from


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

A

Receive assessed files from merits

officer

Deliver new claim to claims determination

unit

Book file to determination

officerEnd

End

Deliver new claim to claims merits unit

Book file on Metrofile system to

merits unitA

Merits unit to acknowledge receipt

upon collection End

Receive assessed files from

determination officer

Deliver new claim to claims litigation unit

Book file to litgation officer

End

Receive assessed files from

determination/litigation officer

Deliver new claim to claims finalisation unit

Book file to finalisation officer







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



1.4.1. Mobile RAF process

Mobile RAF dispatcher

Mobile RAF dispatcher Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Receive request to collect information

(via senior/dispatcher)

Obtain details of claim

Any fatalities?

Contact relevant authority to obtain

details of the deceased/funeral parlour

Yes Contact made?

Interview & educate MVA victim/relative about RAF offerings

& processes

Yes B

Arrange and hold meeting with client

No

A

Notify dispatcher & update task on SharePoint

for follow up within 1 week

No

A

BRequest consent

from client/relativeConsent

obtained?Request required

documents Yes

Inform client of process to initiate claim with

attorney

No

End

E

All required merits documents obtained?

No

F

F

Return all obtained document

information to the requesting branch

for capturing

Yes

Documents available?

Arrange meeting for document collection

Yes

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

Notify dispatcher & update task on SharePoint

for follow up within 1 week

No

D D

Complete report on SharePoint

Update task on SharePoint as

finalised

Notify dispatcher & update task on

SharePoint for follow up within 1

week

End

1.4.2. Mobile RAF - origination

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

Mobile RAF officer

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?

Visit client to educate on RAF processes and

offerings

Yes

Diarise for 3 days and follow up

No

Assist client to complete RAF 1 and

collecting all required supporting documents

Submit in duplicate to nearest RAF branch for processing and return

stamped copy to claimant

Is the client available?

A

A End

Yes

Follow up with an SMS notification to

claimant

No

EndUpdate task on SharePoint as

completed

Update task on SharePoint as completed

Complete report on SharePoint

Complete report on

SharePoint







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



1.5.1. Merits assessment (Part 1 of 2)

Merits assistant Merits assistantMerits officer

Merits officer Merits officer

Merits officer

Merits officerMerits officer



Receive new claims from V&V

Verify all files on register and

acknowledge receipt

Info outstanding?

Determine documentation /

information required

Yes

No

AInformation requested?

Is it a direct claimant?

YesIs Mobile RAF timeline due?

Yes

Follow up with Plaintiff Attorney/

Claimant/Mailroom

No

Can the process continue?

No

Follow up with Mobile RAF (senior

mobile officer)Yes

Information collected?

No

D

DYes

C

C

Assessor/ expert Required?

No

1.5.1.1. Appoint assessor process

Yes Yes

Diarise follow up with Mobile RAF

No

D

Generate letter of request for

information to claimant/

representative

No

Deliver letter to mailroom

(distribution) or Mobile RAF for

collection

Diarise for follow up within 1 week

D

Diarise for follow up

D

B

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

required information

Is outstanding information available?

Yes

A

No

B

B

Generate update SMS to claimant & conduct merits

investigation

1.5.1. Merits assessment (Part 2 of 2)

Merits officerMerits officer Merits officerMerits officer


Merits officer

Merits apportionment using available

information & case law

Is the RAF liable?

YesPrepare merits

assessment summary

4.2.1. Repudiation

processEnd

Notify claimant/representative of

merits apportionment

No

Is the claim a medical expense

claim only?

Prepare file and deliver to medical

unitYes End

No

Is the claimant represented?

Prepare file for quantum

investigation with represented unit

YesDeliver file to

relevant unit, and notify CAFS

End

Prepare file for quantum

investigation with direct unit

No

B

1.5.2. Merits (Part 1 of 2)


Merits senior officer

Merits senior officer Merits officer

Merits officer

Merits senior officer

Merits officer Merits officer

Merits officer

Merits officer


Merits officer

A

Receive new claims from V&V

Check that all the files have been

received against the register

Have all the claims been received?

Notify Senior V&V and request

outstanding claims

No


Yes

Check whether enough information

is available to determine merits

Sufficient information available?

Has information been requested

by V&V?

No

No

AYes

Merits apportionment using available information &

case law

Is the RAF liable?

Repudiate claim

No

Yes

End

Prepare claim to be delivered to DM for

archiving

Determine if claim is Pre or Post and

record on template

Determine whether injured was a

passenger/driver/pedestrian and

record on template

OAR/Affidavit

Has the information

been receivedYes AYes

Is a phone number of the

injured/claimant available?

Call the injured/claimant and

acquire outstanding information

Yes

C

No

Request outstanding information

DC

B

Record on template and follow up within

2 weeksE

E

F

No

1.5.2. Merits (Part 2 of 2)

Merits officer Merits officer Merits officer Merits officer

Merits officer

Merits officer

Merits officer

Prepare merits summary

Record assessed claims on register

and bundle for delivery to quantum

B

DCan you get hold

of the injured/claimant?

Leave a message requesting

outstanding information

No

Acquire outstanding information

Yes

F

A

Deliver to senior/office for review

YesSenior/officer

approves recommendation?

Amend recommendations

accordingly

No

Deliver claims to quantum for assessment

End

B

A

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.