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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
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
Complete a preliminary liability
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
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?
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
Complete a preliminary liability
assessment
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?
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
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
Send a letter informing the claimant/representative
and region that the claim is being transferred to
another region
1.3.2. Supplier Claims Registration (Part 1 of 2)
Administrative assistant
Registration senior officer
Registration senior officer
Registration senior officer
Registration officer
Registration officer
Registration officer
Registration officer
Registration officer
Registration officer
Registration officer
Registration officer
Registration 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
Send a letter informing the claimant/representative
and region that the claim is being transferred to
another region
Is the claim for another region?
No
Yes
B
B
1.3.2. Supplier Claims Registration (Part 2 of 2)
Registration officer
Registration senior officer
Registration senior officer
Registration senior officer
Administrative assistant
Registration officer
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
V&V officerV&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 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)
Administrative assistant
Validation and verification
senior officer
Validation and verification
senior officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Receive new claims from registrations
Acknowledge receipt of claims
Have all the claims as listed in register been
received?
Notify registration senior and request outstanding claims
No
Distribute claims amongst officers for
validation & verification
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
Record on template and initiate
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
Record on template and initiate
objection process
No
B
1.3.4. Supplier validation and verification (Part 2 of 2)
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification
officer
Validation and verification officer
Locus standi verified?
Record on template and continue with
process
No
Perform duplicate checks
YesDuplicates
found?
Record on template and initiate
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
validation & verification
Verify all files on register and sign copy of register
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.