Claims Processing Value Chain - Road Accident Fund. RAF... · · ICT - Information Communication ... · RAF 5 - Road Accident Fund Form 5 · RSA ... Claims Processing Value Chain

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 18, 30 May 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

System intervention





1.2. Document management


1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



4.1.1. Capital payment (Part 1 of 2)

B

Administrative assistant


Capital payment officer


Capital payment officer Capital payment

officer


Capital payment

officerCapital payment

officer







Receive payment request from Claims

Determination or Claims Litigation unit

Acknowledge receipt (register)

and stamp

Verify that the signatory of the payment request

document has the mandate to sign-off the

required amount

Check if the banking details and address

reflect current status which isn’t more than a

month old

A

Is the employee authorised to approve the

required amount?

Yes

No

AAre the

banking details current?

No

Verify amount payable against the invoice,

discharge or court order and supporting

documents supplied/attached

YesAre there issues

with the payment request?

Revert back to the employee or unit

senior and raise the matter

Yes

No

Retrieve file or supporting

documents from CAFS or requestor

NB: the system does allow above mandate – mandate authorisation

Payment to be made to a new

vendor/beneficiary?

Call procurement to liaise with vendor

and update banking details

No

A

Request the latest banking details

from the payment requestor

A

4.1.1.1. BIF Processes

Check for duplicate and prior payments

on the system

Any duplicate payment found?

Escalate duplicate matter to unit

seniorYes B

E

No

Yes

Update banking

details on address book

system

Does the payment request have an

expenditure authorisation

attached?

Yes

Load payment on the system

No

B

D

D

Resolve issues E

B

4.1.1. Capital payment (Part 2 of 2)


Capital payment team leader


Capital payment officer Capital payment

officerCapital payment

officer

Second officer checks payment as captured by assistant against

source documentation

Second officer approves payment, confirms payment

is due and correct and verifies signatures of prior

two officers

Request payment

End

E

Forward expenditure

authorisation and supporting

documents to finance

Receive payment confirmation from

finance

Forward payment confirmation to

claims file closure







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



4.2.1. Legal costs validation – Party/Party

Legal cost validation

officer



Legal cost validation officer



officer



Legal cost validation senior officer


senior/officer


senior/officerLegal cost validation

senior/officer



officer

Receive bill of cost from Documents

Management via email, fax or hand delivery


and stamp

Send instruction to panel attorney or cost consultant to attend settling/taxation

Forward the documentation for

approval and payment

EndRevert queries to officer

D

Receive settled/taxed bills from panel

attorney/cost consultant and distribute to officers.

(system to allocate)

Accept the offer on the system and print out the

Expenditure Authorisation and sign

Request file and assess the bill

Request approved?

Yes

No

4.2.1.1. Instruct panel attorney or cost

consultant to conduct block booking

The system-selected Senior/Officer

reviews the legal cost payment

request

C

Load the settled amount onto the

system. The system allocates the

approval to Senior/Officer with mandate

Can you settle the bill?

Senior to liaise with concerned parties and

negotiate

Is the matter resolved?

Yes C

No

A

Send bill for taxation or instruct

attorney / cost consultant

Create a legal cost query and raise the

matter with the senior when dispute

Are there any variances and/or

irregularities?Yes

No

C

D

A

Yes

No

If the file cannot be located, use the attorney’s file

4.2.2. Legal costs validation – Attorney/Client



senior



officer


officer



officer


officer



officer



and stamp

Request file from CAFS

Receive Assessors files/Advocates accounts/

correspondent bills/ out of town / experts accounts

B

Assess billNegotiate settlement

A

ARequest

approved?


senior and escalate the matter

No

Payment request is escalated to persons with

mandate

B


paymentEndYes

Load the settled amount onto the system. The system allocates the approval to Senior/

Officer with mandate

The system-selected Senior/Officer

reviews the legal cost payment

request

Accept the offer on the system and print out

the Expenditure Authorisation and sign

If the file cannot be located, use the attorney’s file

4.2.1.1. Block booking attorney/client (Part 1 of 3)






senior

Legal cost validation team

leader

Is the list received?

Yes

Did the attorney respond to the

invite?

No

Yes

B

No

C

C

Is the list and bill received before block booking

date?

Yes

B

A

D

No

Follow up with attorney

Invite attorneys and cost consultants to take part in block

bookings

Request and receive a list of matters with the

bills 7 days before block booking date. Scanning process implemented

Follow up with attorney/ set up new date

Request files from CAFS according to

the list from attorney

Team leader decides on

attorney’s to invite for block booking

Did the attorney accept the

invite?

End

No

BYes



junior officer

Legal cost validation junior

officer


junior officer


officer

Legal cost validationofficer


junior officer


officer

Files received? Yes

Are files available at

CAFS?

No

Yes

Request file contents from

attorney

No

Have previous bills been received?

Printout any previous payments made for

previous bills to avoid duplicate payments

Yes

No

A

D

Have block settlement on arranged day

F

E

E


officer

Check on system if previous bills

have been received

Allocate file on Legal Cost

system

Scan and file settlement

document on Legal Cost system to be allocated to

officer who settled

Load settled amount onto

system. To allocate approval to Senior/Officer

with mandate

H


officer

Create a legal cost query and raise

matter with seniorAssess bill

Any variances and/or

irregularities?Yes

Senior to liaise with concerned parties and

negotiate

G

J

F

F



Is matter resolved?

Yes

No


officer


Send bill for taxation -set down

by Plaintiffs attorney

G

H

Load the settled amount onto the

system. The system allocates the

approval to Senior/Officer with mandate

Receive settled/taxed bills from panel

attorney/cost consultant and distribute to officers




officer


System-selected Senior/Officer reviews the legal cost payment

request

Request approved?

Yes

Revert queries to officer

No

J


approval and payment

End

Accept offer on system, print and sign Expenditure

Authorisation

H

H







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



4.3.1. Legal costs payment (Part 1 of 2)


Legal cost payment officer



Legal cost payment

officer





Receive legal costs payment request from

‘Legal Costs Validation’

Check if banking details and address

reflect current status

Are the banking details

current?

No

Request latest banking detailsfrom payment

requestor

Verify amount payable against the settled or taxed bill

of costs

YesAny issues with

payment request?

A


senior and raise the matter

Yes

No

Any duplicate payment found?

Escalate duplicate matter to the unit

seniorYes

No

C

Check for duplicate and

prior payments on the system

A

Is the issue resolved?

CYes

B

B

D

Follow up with senior

No

DRefer the details to procurement

4.3.1. Legal costs payment (Part 2 of 2)






Second officer checks all aspects of payment as captured by assistant

against the source documentation

Second officer approves payment, confirms that

payment is due and correct and verifies signatures of the

prior two officers

Forward expenditure authorisation and

documents to financeEnd

C

Receive legal cost payment

confirmation from finance

Forward payment confirmation to

claims file closure







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



4.4.1. Writs payment process

Writ payment officer



Is the writ amount within

mandate?

Request payment, forward writ with supporting

documents to finance for verification & payment

Yes


Diarise follow up in 1 day & verify that payment has been

processed

Has payment been processed?

Treasury

Notify relevant stakeholders, print

confirmation & forward to sheriff

Yes

No

Prepare ES in line with relevant

senior’s mandate

No

Submit ES to senior for approval

ES approved?

No


Send payment confirmation to Writ

Management unit and claims file closure

End


Receive writ with supporting documents

from Writ Management unit

A

Yes

A







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



4.5.1. File finalisation

Claims finalisation team leader


Claims finalisation

officer

Claims finalisation

officer

Claims finalisation

officer

Claims finalisation

officer

Claims finalisation

senior officer

Claims finalisation

officer


AAny outstanding

payments?

A

Check against the following:Has capital been paid?Have plaintiff’s costs been paid?Have RAF costs been paid?Have assessors been paid?Have medicolegal experts been paid?Have actuaries been paid?Have sheriff's costs been paid? (If applicable)Has Interest been paid? (if applicable)

No

Send file for archiving

End

Escalate matter to unit senior

Yes

Is it concluded that the file is

finalised?

No

End

YesSenior liaises with

the relevant department

Team leader or senior allocates

newly settled files to team

File is requested from CAFS, ‘Claims Determination’ or ‘Claims Litigation’

Check if file has been settled using

checklist, checking on ‘Claims View’ and

‘Payment system’

Update the file cover, notes on ‘Claims

View’ and change status to “F”

Send the file to CAFS and update notes on

‘Claims View’

Receive payments from other units

· Capital payment· Legal costs· Finance· Writ payment

Frequently asked questions in finalisation

Is capital payment a duplication of effort as this function currently exists in finance?Capital payment will do the checking and finance will do the approval of payments, batch checking and forward the payment to treasury.Capital payment will also be responsible for the manual loading of expert, writ and assessor payments.

Will legal costs validation request payments?Legal costs validation will request payments and these payments will approved by legal costs payments.

Should all payments be amalgamated into one unit (payments)?All payments (legal cost payment, capital payment and writ payment) can be amalgamated into one unit but different officers should handle different portfolios.

Will the finalisation mandate be removed from all other units?The finalisation mandate should be removed from all other units and this should be handled in the claims file closure unit.