ATTACHMENT 6.02 Generalist Compliance Matrix 2015

Transcription

1 ATTACHMENT 6.02 Generalist Compliance Matrix 2015 Nominal Insurer And Schedule 6 - Attachment 6.02 (Compliance Matrix) Page: 1 of 5

2 s/ Strategic Audits Financial Returns Monthly Attachment L.01 (Internal Controls ) (a) 4.1 Premiums/Policies 6 monthly Once every 3 (b) 4.2 Claims 6 monthly Once every 3 (c) 4.3 General Computer Controls 6 monthly Once every 3 (d) (e) 4.4 Disaster Recover and Business Continuity Plans 4.5 Accounting and Financial Close Once every 3 6 monthly Once every 3 (f) 4.6 Governance Once every 3 (g) 4.7 Risk Once every 3 (h) 4.8 Assurance Function Once every 3 (i) 4.9 ing to WorkCover Once every 3 (j) 4.10 Variation Notices and Direction Notices Once every 3 Operational Audits Schedule 1 (Code of Conduct and Stakeholder Engagement) Schedule 2 (Underwriting) - S3 Governance Requirements Schedule 2, s3.1 Delivery of Underwriting s (a) Verification of the employers business description activity; (b) Premium Calculation components are accurate; (c) Accurate information is supplied during customer service; (d) Comparing the Schedule 6 - Attachment 6.02 (Compliance Matrix) Page: 2 of 5

3 (e) (f) occupation of Workers with the Employers declared business activity to identify inconsistencies Comparing total Wages declared on a Claim by the injured Worker against total Wages declared on a Policy; Reviewing methods used to identify and target possible underdeclaration of Wages; s/ (g) Reviewing processes used to identify potential failures in Premium Compliance with relevant Law; (h) Reviewing processes used to identify incorrect WIC coding on Claims; Schedule 3 (Claims), s3 Governance Requirements Schedule 3, s3.1 General Claims Early Contact Liability Determination Work Capacity Decisions Claims Estimates Payments Wage Reimbursement Information and Records Determination of permanent impairment Entitlement to compensation for permanent Schedule 6 - Attachment 6.02 (Compliance Matrix) Page: 3 of 5

4 s/ impairment (Lump Sum) Work Injury Damages Effective Planning and review Focus on recovery and Return to Work Effective communication and engagement Evidence based decisions Schedule 3 (Claims), s3.2 Strategic Claims Third party Provider Employer Obligations Claims Operations Manual Media Claims manager capability framework Schedule 2 (Underwriting), s2.1 Schedule 3 (Claims) s2.1, to Employers and Workers Schedule 2 (Underwriting) s2.2 Quarterly Schedule 3 (Claims), s2.2, Performance Schedule 4 (Banking and Financial ), s2.1 Customer Schedule 2 (Underwriting) s2.3, Schedule 3 (Claims), s2.6.4, Schedule 6 (Governance), s4.6 Evidence Based Decision Making Schedule 2 (Underwriting) s2.6 Schedule 3 (Claims) s2.5, Schedule 4 (Banking and Financial ), s2.4, Schedule 6 (Governance), s4.5 Competency of Personnel Schedule 6 - Attachment 6.02 (Compliance Matrix) Page: 4 of 5

5 Schedule 3 (Claims), s2.6 Claims specific competencies Schedule 6 (Governance) Section 4 Fraud Schedule 6, s4.3 Provide a Fraud identification and management model Schedule 6 (Governance) Section 6 Data Schedule 6, s6.1 Data s/ 6 monthly 6 monthly Note: There are several key auditable elements under each internal control, although the internal control will be audited by Insurer annually the key auditable elements will be audited once every three years, unless a qualified audit is received, in which case the measurable will be reaudited until the issue is rectified. In addition if the information reveals a breakdown in controls a key auditable element will be audited. The is required to report the results of its audit findings for audits undertaken under the s and its own Audit Plan on the reporting template provided as part of Schedule 6 (Governance), Section 6.3 and 8. The is required to undertake adequate Health Check reviews of its to ensure that it s the requirements of each Standard. The Health Check reviews are to be built into the s and reported to Insurer quarterly as part of the. Schedule 6 - Attachment 6.02 (Compliance Matrix) Page: 5 of 5