Wash. Admin. Code § 296-15-350 - Handling of claims
What elements must a self-insurer or third-party administrator (TPA) have in place to ensure appropriate handling of claims? Every self-insurer or TPA must:
(1) Establish procedures for securing the
confidentiality of claim information.
(2) Have sufficient numbers of certified
claims administrators to ensure uninterrupted administration of claims. In this
regard:
(a) Effective July 1, 2021, every
person making claim decisions must be a certified claims administrator or in
the process of getting their certification. For the purposes of this section,
every person making claim decisions includes:
(i) Those persons who manage claims directly;
and
(ii) Who request to allow or
deny claims under WAC
296-15-420;
(iii) Take action on claims under WAC
296-15-425; or
(iv) Close claims under WAC
296-15-450.
(b) Excluded from the requirement of (a) of
this subsection are those persons who manage operations indirectly in support
of claims administrators, such as, human resources, accounting, or executive
management.
(c) When a new person
is hired by the employer or TPA to make claims decisions, if the new person is
not already a certified claims administrator, then the new person, within six
months of hire, must begin working toward achievement of certification through
a comprehensive goal-oriented curriculum approved by the department to achieve
certification within two years. While in process of meeting educational needs,
the employer must ensure mentoring is provided by a Washington certified claims
administrator. Providers of the comprehensive goal-oriented curriculum will
conduct regular training courses to allow for a new person in the process of
completing the training to successfully manage Washington claims and achieve
Washington certification within two years. This will include considering online
alternatives, when feasible.
(d)
When a certified claims administrator leaves the hire of an employer or TPA,
and this results in an employer or TPA temporarily not meeting the
qualifications for a certified claims administrator, the employer may apply for
a temporary waiver for up to six months pending hiring of a
replacement.
(3)
Designate one certified claims administrator as the department's primary
contact person for claim issues.
(4) Designate one address for the mailing of
all claims-related correspondence. The self-insurer is responsible for
forwarding documents to the appropriate location if an employer's claims are
managed by more than one organization.
(5) Establish procedures to answer questions
and address concerns raised by workers, providers, or the department.
(6) Ensure claims management personnel are
informed of new developments in workers' compensation due to changes in
statute, case law, rule, or department policy.
(7) Include the department's claim number in
all claim-related communications with workers, providers, and the
department.
(8) Legibly date stamp
or produce an imprint on incoming correspondence, identifying both the date
received and the location or entity that received it.
(9) Ensure a means of communicating with all
injured workers.
Notes
Statutory Authority: RCW 51.04.020, 51.14.020, 51.32.190, 51.14.090, and 51.14.095. 06-06-066, § 296-15-350, filed 2/28/06, effective 4/1/06.
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