Company then follows up on outstanding requirements every 30 days. When the claim form and other proof of loss forms are received at the Home Office, the claim is assigned to a Disability Benefits Specialist (DBS). There are some claim types, such as mental health claims, which are handled by a special unit because of technical knowledge needed to determine disability. Most claims, however, are assigned based on processor claim load.
The claim adjudication process is tailored to each claim, but there are common elements to handling claims. These are outlined in the AIndividual Disability Benefits Guide@. The Company states that this manual is a guideline only and is not considered to be a procedures manual. Most actions on claim files are approved and initialed by a supervisor or manager. The DBS reviews a claim and creates a claim action plan. The action plan includes those reports to be ordered and reviews to take place. Outside investigative tools such as independent medical examinations (IME) or personal visits by field representatives are recommended by management and ordered by the DBS. Monthly checks are approved by management. It is rare that a DBS takes any type of action on a claim independently. Claim files are handled by many people prior to payments being made. Each new piece of information (e.g. APS, IME report) requires a supervisory, or medical director’s review prior to further action being taken on the claim. This is a very labor intensive operation.
The Company has a claim audit program. This is not a standardized program, but is risk/control based. The internal audit department conducts the audits which take place on both open and closed claim files. They do not use an audit check list, but do use a test plan and test worksheets to ensure tracking and documentation of audit results. Their test population is chosen specifically to test those areas targeted by the internal audit department. The number of files chosen is based more on the target area rather than a sample based on work from each specialist.
Audit results are reported to management and the board of directors through the Internal Audit Committee of the Board.
Standard #1 Upon notification of a claim, acknowledge receipt of the claim to the claimant within ten working days. WAC 284-30-360(1) and (4). (See Appendix II)
Company procedure states that a letter of acknowledgment will be sent to the claimant upon receipt of a completed claim form and attending physician statement.
Total Claim Population
# Claims in Sample
# Claims not acknowledged within 10 days