Wash. Admin. Code § 200-160-200 - Standards for claims management-Claims administration

(1) All joint self-insurance programs shall adopt a written or electronic claims administration manual that includes, as a minimum, the following procedures:

(a) Claims filing procedures and forms;

(b) Standards requiring case reserves for each claim be established in the amount of the jury verdict value;

(c) Standards requiring case reserves be reviewed every ninety days or when reasonably practicable and such review is documented in the claims diary;

(d) Standards requiring appropriate adjuster workloads;

(e) Standards requiring claims payment procedures include sufficient internal controls to ensure adequate review and approval by claims management staff;

(f) Standards requiring file documentation be complete and up-to-date;

(g) Standards requiring timely and appropriate claim resolution practices;

(h) Standards requiring opportunities for recoveries be reviewed and documented for each claim;

(i) Standards requiring compliance with Internal Revenue Service (IRS) rules for 1099-MISC regulations; and

(j) Standards requiring claims files be audited on the following categories: Staffing, caseloads, supervision, diary, coverage, reserves, promptness of contacts, field investigations, file documentation, settlements, litigation management and subrogation.

(2) All joint self-insurance programs may perform claims administration services on their own behalf or may contract for claims administration services with a qualified third-party administrator, provided all of the specific requirements under subsection (1) of this section are included in the contract.

(3) All joint self-insurance programs shall have a written member coverage appeal procedure that contains, as a minimum, procedures for a member filing an appeal with the joint self-insurance program, including the time limit for filing, a time limit for response, and a provision for an additional level of review.

(4) All joint self-insurance programs shall maintain a financial system that identifies claim and claim adjustment expenses.

(5) All joint self-insurance programs shall provide for the purchase of goods and services to replace or repair property in a manner which will, in the judgment of the governing body of the joint self-insurance program, avoid further damage, injury, or loss of use to a member or third-party claimant.

(6) All joint self-insurance programs shall maintain claim expense reports for all claims made against the joint self-insurance program and its members.

(7) All joint self-insurance programs shall obtain an independent audit of claim reserving, adjusting and payment procedures every three years at a minimum. The audit shall be conducted by an independent qualified claims auditor not affiliated with the program, its insurers, its broker of record, or its third-party administrator. Such review shall be in writing and identify strengths, areas of improvement, findings, conclusions and recommendations. Such review shall be provided to the governing body and retained for a period not less than six years. The scope of the claims audit shall include claims administration procedures listed in subsection (1) of this section.

(8) The state risk manager may require more frequent claims audits for programs that, in the state risk manager's opinion, are not operationally or financially sound. Failure to obtain the requested independent claims audit when required may result in the procurement of such audit by the state risk manager on behalf of the program. Costs of these services shall be the responsibility of the joint self-insurance program.

Notes

Wash. Admin. Code § 200-160-200

Adopted by WSR 18-09-086, Filed 4/17/2018, effective 5/18/2018