APPENDIX L Generalist - Service Standards 2015

Transcription

1 APPENDIX L Generalist - Service Standards 2015 Nominal Insurer And Schedule 5 - Appendix L (Service Standards) Page: 1 of 26

2 Overview Service Standard 1 Premium Calculation Purpose Measurable Elements Methodology Measurable Element Measurable Element Reporting Period and Frequency of Assessment Service Standard Score Expected Level of Performance Service Standard 2 Customer Service - Underwriting Purpose Measurable Elements Underwriting: Premium Collection Methodology Reporting Period and Frequency of Assessment Service Standard Score Expected Level of Performance Service Standard 3 Work Status Index Purpose Measurable Elements Methodology Total Claims in the Pool Number of Claims in Pool with a Positive Return to Work Status Audit Sample Size Reporting Period and Frequency of Assessment Service Standard Score Additional Target Audit Adjustment Expected Level of Performance Service Standard 4 Customer Service - Claims Purpose Measurable Elements Schedule 5 - Appendix L (Service Standards) Page: 2 of 26

3 4.3 Methodology Measurable Element Measurable Element Measurable Element Reporting Period and Frequency of Assessment Service Standard Score Expected Level of Performance Reference Material Service Standard 5 Data Submissions Purpose Measurable Elements Claim Submission: Policy Submission: Methodology Reporting Period and Frequency of Assessment Service Standard Score Expected Level of Performance Reference Material Service Standard 6 Internal Controls Purpose Measurable Elements Methodology Description Reporting Period Service Standard Score Expected Level of Performance Reference Material Service Standard 7 Data Quality Purpose Measurable Elements Methodology Sample Size Reporting Period Service Standard Score Expected Performance Level Schedule 5 - Appendix L (Service Standards) Page: 3 of 26

4 7.7 Reference Material Schedule 5 - Appendix L (Service Standards) Page: 4 of 26

5 Overview Appendix L (Service Standards) outlines the Service Standards required to be met under Year 1 of the Deed. This includes all reporting requirements, measurement standards, audit requirements and scoring method for each standard. Glossary Unless defined in this Appendix L (Service Standards), all capitalised words are as defined in the Glossary and Attachment 1.04 (Handling customer complaints A guide for scheme agents and insurers). Weighting The Service Standards will contribute to an assessment of the Scheme Agent s Generalist Base Fee Service Standard Score (GBFSSS) and Generalist Service Standard Score (GSSS). This will be determined based on the following table. Generalist Base Fee Service Standard Score The Generalist Base Fee Service Standard Score (GBFSSS) will be a score between 90% and 100%. For each scheme agent their GBFSSS will begin at 90%. For each Service Standard, the Scheme Agent s Service Standard Score will be multiplied by the Performance Impact shown in the table below and the results added to the Scheme Agent s GBFSSS. For example, a Scheme Agent that achieved a Service Standard Score of 100% for Data Submissions and 50% for Data Quality would achieve a GBFSSS of 97.5% (90% + 5% + 2.5%). Table 1 Service Standard Performance Impact (GBFSSS) Data Submissions 5% Data Quality 5% Generalist Service Standard Score Schedule 5 - Appendix L (Service Standards) Page: 5 of 26

6 The Generalist Service Standard Score (GSSS) will be a score between 90% and 102%. For each Scheme Agent their GSSS will begin at 90%. For each Service Standard, the Scheme Agent s Service Standard Score will be multiplied by the Performance Impact shown in the table below and the results added to the Scheme Agent s GSSS. For example, a Scheme Agent that achieved a Service Standard Score of 50% for Premium Calculation and 100% for the other Service Standards would achieve a GSSS of 99% (90% + 1% + 2% + 2% + 2% + 2%). Table 2 Service Standard Performance Impact (GSSS) Premium Calculation 2% Customer service Underwriting 2% Work Status Index 2% Customer service Claims 2% Internal Controls 2% Where the Scheme Agent achieves a Service Standard Score of 100% for all Service Standards relating to the GSSS, and achieves the Additional Target outlined in Service Standard 3 Work Status Index, the Scheme Agent will be awarded a further 2% towards the GSSS for a total GSSS of 102%. Schedule 5 - Appendix L (Service Standards) Page: 6 of 26

7 1. Service Standard 1 Premium Calculation 1.1 Purpose This Service Standard assesses the Scheme Agent s performance in calculating correct Premiums. 1.2 Measurable Elements There are 2 Measurable Elements for each Policy that will be reviewed: (i) (ii) WIC Class/es allocated; and Total Premium calculated. Each Measurable Element will contribute equally toward the Scheme Agent s Service Standard Score for this Service Standard. 1.3 Methodology The Nominal Insurer will undertake 2 reviews per Calendar Year using a sample of Policies from data submitted by the Scheme Agent to the Corporate Data Repository. (c) The first review will be conducted as a trial for feedback purposes. Each review will be conducted as per the following timetable: Table 3 Review Review to commence Policy Transaction dates Sample Size Ratio of Policies 1 June 2015 Any transaction processed from 1 October 2014 to 31 March policies (same sample to be used for SS2) 15% Small Employer policies 85% Medium and Large Employer policies 2 March 2016 Any transaction processed from 1 April 2015 to 31 December policies 15% Small Employer policies 85% Experience Rated Employer policies (d) (e) Each Policy will be used to assess both Measurable Elements. The Nominal Insurer will conduct on-site reviews and will provide the sample to the Scheme Agent at a minimum of 2 weeks prior to the scheduled on-site review date to prepare the files. Schedule 5 - Appendix L (Service Standards) Page: 7 of 26

8 (f) Appendix L Generalist Service Standards The sample will exclude Retro-Paid Loss Policies Measurable Element 1 The Scheme Agent Score (Measurable Element 1) will be calculated as: Number of files marked correct/number of files in the sample Assessment The Nominal Insurer will assess whether the correct WIC class or classes have been allocated to each Policy by reviewing the business activity description details on file. The result will be expressed as a percentage of Policies marked correct from the total sample. The results will be expressed as the M1 Scheme Agent Score Measurable Element 2 The Scheme Agent Score for Measurable Element 2 will be calculated as: (Correct Premium Pool Absolute Error) / Correct Premium Pool (c) Correct Premium Pool (i) The correct Premium pool is defined as the total of the correct Premium that should have been charged to all Policyholders in the review sample. The Nominal Insurer will assess whether the correct Premium has been calculated and charged to the Policyholder in accordance with Appendix C (Underwriting Guide for the Scheme Agent) and Insurance Premiums Order by reviewing the following components on the Policy file: (ii) (iii) Employees and Wages (including sub-contractors, asbestos, Apprentices Wages); Claims performance (including claim experience and claim performance rate); and Grouping rules applied (to all group members). If the correct Premium has not been charged, the Nominal Insurer will recalculate the Premium correctly to establish the correct Premium pool Absolute Error The absolute error is defined as the difference between the correct Premium that should have been charged compared to the actual Premium charged (negative or positive). For example: Schedule 5 - Appendix L (Service Standards) Page: 8 of 26

9 Total Premium Payable Correct Premium Difference Policy 1 $8, $8, $0.00 Policy 2 $148, $146, ($2,334.81) Policy 3 $2, $2, $ Total Difference $2, Assessment The Nominal Insurer will assess whether the correct Premium has been calculated and charged to the Policyholder. If the correct Premium has not been charged, the Nominal Insurer will recalculate the Premium correctly to establish the correct Premium pool and absolute error. 1.4 Reporting Period and Frequency of Assessment The Nominal Insurer will conduct a Service Standard review 2 times per Calendar Year. This will be followed by the Nominal Insurer providing the Scheme Agent with their final results as an outcome of the information collected during the on-site review only. The Nominal Insurer will provide the Scheme Agent with supported improvement opportunities. (c) The sample will review Policy transaction dates as specified in table 3. (d) The transaction/premium Calculation being reviewed for each Policy will be the latest transaction as at the date the sample was drawn. 1.5 Service Standard Score A Service Standard Score will be calculated for each Measurable Element and the results combined to determine the overall Service Standard Score for the Measurable Element. The Service Standard Score (Measurable Element 1) will be calculated as: A Scheme Agent Score (Measurable Element 1) below 94% will result in a Service Standard Score (Measurable Element 1) of 0% and a Scheme Agent Score (Measurable Element 1) of 98% or above will result in a Service Standard Score (Measurable Element 1) of 100%. There will be a linear progression of Service Standard Score (Measurable Element 1) between 94% and 98%. (c) The Service Standard Score (Measurable Element 2) will be calculated as: Schedule 5 - Appendix L (Service Standards) Page: 9 of 26

10 A Scheme Agent Score (Measurable Element 2) below 98% will result in a Service Standard Score (Measurable Element 2) of 0% and a Scheme Agent Score (Measurable Element 2) of 98% or above will result in a Service Standard Score (Measurable Element 2) of 100%. (d) The overall Service Standard Score will be calculated as: Service Standard Score (Measurable Element 1) x 50% + Service Standard Score (Measurable Element 2) x 50% 1.6 Expected Level of Performance The Scheme Agent is expected to achieve a Service Standard Score of 100% and performance below this will constitute under performance. Schedule 5 - Appendix L (Service Standards) Page: 10 of 26

11 2. Service Standard 2 Customer Service - Underwriting 2.1 Purpose The Service Standard will assess the Scheme Agent s Policy management and Premium Collection. 2.2 Measurable Elements There are 2 Measurable Elements for each Policy that will have sub-elements that are as follows: Underwriting: (c) (d) Employer has been contacted (phone/ /letter) in the last policy period being reviewed to confirm/verify the business activity; Premium documentation has been issued to the Employer detailling the Premium Calculation within the Scheme Agents system and within 1 day of the premium transaction; Premium Calculation has been processed within 1 Calendar Month of receiving documentation (wage declaration, proposal, certificate of currency requests etc); Pre-Set renewal has been accepted/processed within 7 Calendar Days from the Policy expiry including updated Wages or WIC details where received prior to expiry date; (e) Automatic Premium Calculation has been processed within 90 Calendar Days from the Policy expiry where documentation has not been received Premium Collection Tax invoices/premium Demands have been issued offering the appropriate payment options for the Employer s Premium (full annual Premium, paid in full discounts, and quarterly/monthly instalment plans); A payment reminder phone call and notice was issued between 5-10 days prior to the due date of the Premium. (c) (d) (e) The Employer has been contacted by phone when the Premium was between 8-14 days overdue; The Employer is contacted to consider if a repayment plan is suited to the overdue debt before the debt is referred to a Third Party Provider.; A Premium Overdue notice has been issued to the Employer when the Premium is between days overdue. (f) The employer has been contacted when the premium is overdue by 30 or more days and explained the next steps in the process i.e. referral to a Third Party, Litigation, Wind up etc. Schedule 5 - Appendix L (Service Standards) Page: 11 of 26

12 (g) (h) (i) The Scheme Agent has considered and applied suitable collection methods for the particluar facts of the employer economic environment. Tiered Complaints Management Framework and escalation aheared to. Where any Measurable Element is marked as a fail, the Policy will be marked as a fail. The results will be expressed as a percentage of Policies marked correct from the total sample. 2.3 Methodology The Nominal Insurer will undertake 2 reviews per Calendar Year using a sample of Policies from data submitted by the Scheme Agent to the Corporate Data Repository. (c) The first review will be conducted as a trial for feedback purposes. Each review will be conducted as per the following timetable: Review Review to Commence Policy Transaction dates Sample Size Ratio of policies 1 June 2015 Any transaction processed from 1 October 2014 to 31 March policies (same sample to be used for SS1) 15% Small Employer Policies 85% Medium and Large Employer Policies 2 March 2016 Any transaction processed from 1 April 2015 to 31 December policies 4% Small Employer Policies 96% Experience Rated Employer Policies (d) (e) The review will include an analysis of the accuracy of the Scheme Agent s policies and procedures. The audit sample will be provided to the Scheme Agent at a minimum of 2 weeks prior to the scheduled on site review date to prepare the files. (f) The sample will exclude Policies issued as part of the Retro-Paid Loss Scheme. Schedule 5 - Appendix L (Service Standards) Page: 12 of 26

13 (g) (h) Appendix L Generalist Service Standards The results of the second review will be used to determine the Scheme Agent Score. The Nominal Insurer will provide the Scheme Agent with their final results as an outcome of the information collected during the on-site review only. The Nominal Insurer will use these results to support improvement opportunities with the Scheme Agent. 2.4 Reporting Period and Frequency of Assessment The Nominal Insurer will review the Service Standard twice per Year and will provide the Scheme Agent with their results, along with any supported improvement opportunities. 2.5 Service Standard Score A Scheme Agent Score below 90% will result in a Service Standard Score of 0% and a Scheme Agent Score of 98% or above will result in a Service Standard Score of 100%. There will be a linear progression of Service Standard Score between Scheme Agent Scores between 90% and 98%. 2.6 Expected Level of Performance The Scheme Agent is expected to achieve a Service Standard Score of 100% and performance below this will constitute under performance. Schedule 5 - Appendix L (Service Standards) Page: 13 of 26

14 3. Service Standard 3 Work Status Index 3.1 Purpose This Service Standard assesses the Scheme Agent s performance in successful Return to Work of injured Workers 6 Months after lodging a Claim. 3.2 Measurable Elements The Service Standard will include 1 Measurable Element which is the index calculated as a percentage of the number of Claims with a positive Return to Work status divided by the total number of Claims in the pool. 3.3 Methodology The Nominal Insurer will create an index of the number of Claims with a positive Return to Work status 6 Months after the Claim is lodged divided by the total number of Claims in the pool using Claims from the WorkCover Corporate Data Repository (CDR). This will be supplemented by an audit of Claim files which demonstrate that a return to employment has been achieved Total Claims in the Pool The index will include all Claims in the CDR with the date entered on the Scheme Agent/insurer s system (DEIS) (C: 2.1.8) between 1 January 2015 and 30 June All Claims lodged will be included in the calculation of the index with the exception of null Claims or as otherwise determined by the Nominal Insurer Number of Claims in Pool with a Positive Return to Work Status (i) To determine a positive Return to Work status, the work status code must be 1 of the following values: (ii) (iii) (iv) 01 working same Employer full work capacity; 02 working same Employer current work capacity; 03 working different Employer full work capacity; and 04 working different Employer current work capacity. Each Claim will be assessed based on the Worker status 6 Months after the receipt of the Claim. This will be determined using the work status code (C: ) at the end of the first Month at least 6 Months after the DEIS. That is, where the DEIS is 14 July 2015, the Worker status will be determined using the work status code at the end of January Schedule 5 - Appendix L (Service Standards) Page: 14 of 26

15 3.3.3 Audit The audit will review Claim files where a positive Return to Work status has been coded. The audit will review the evidence on file to verify that the work status code used is appropriate. Where evidence on file contradicts the work status code used or no sufficient evidence is available, the file will be marked as incorrectly coded. In order to be included in the audit, the Claim must have greater than 2 weeks equivalent of weekly Benefits paid Sample Size The sample for the audit will contain no fewer than 100 Claims and will not exceed 200 Claims. 3.4 Reporting Period and Frequency of Assessment The index will be based on Claims with a DEIS between 1 January 2015 to 30 June 2015 and performance will be based on data on those Claims up to 30 January The audit will take place following availability of data from 30 January Service Standard Score An index below or equal to 70% will result in a Service Standard Score of 0% and an index of 80% or above will result in a Service Standard Score of 100%. There will be a linear progression in Service Standard Scores between indexes of 70% to 80% Additional Target A Scheme Agent who has an index of 85% or above may qualify for an increase to the Generalist Service Standard Score (GSSS) as outlined in the introduction of this Appendix L (Service Standards) Audit Adjustment The audit contains an error margin of 5% of Claims (rounded up to the nearest Claim) which have incorrectly been coded as demonstrating a positive Return to Work status. Each Claim deemed to have been incorrectly coded above the error margin will reduce the Service Standard Score by 10%. 3.6 Expected Level of Performance The Scheme Agent is expected to achieve a Service Standard Score of 100% and performance below this will constitute under performance. Schedule 5 - Appendix L (Service Standards) Page: 15 of 26

16 4. Service Standard 4 Customer Service - Claims 4.1 Purpose This Service Standard assesses the effectiveness and quality of the Scheme Agent s Customer Service Model and Work Capacity Decision making. 4.2 Measurable Elements There are 3 Measurable Elements: (c) Review of Work Capacity Decision making and Internal Reviews; Review of appropriateness and effectiveness of the Customer Service Model in reducing complaint escalations; and Review of timeliness of the Scheme Agent s responses where complaints enter WorkCover. 4.3 Methodology Measurable Element 1 This Measurable Element measures the type of Merit Review outcome that is determined at the end of the Merit Review process. The Scheme Agent Score (Measurable Element 1) will be the proportion of Merit Review decisions that are different to the original Work Capacity Decision with no new information provided compared to the total number of Merit Review decisions issued. Where the proportion of Merit Review decisions that are different to the original Work Capacity Decision with no new information provided is; (i) (ii) up to 20% of the total Merit Review decisions issued, then the Scheme Agent Score (Measurable Element 1) is the full allowance of 100%; and 40% or greater of the total Merit Review decisions issued, then the Scheme Agent Score (Measurable Element 1) is reduced completely to 0%. (c) There will be a linear progression in Scheme Agent Score (Measurable Element 1) between the ratios of 20% and 40% of decisions. Schedule 5 - Appendix L (Service Standards) Page: 16 of 26

17 (d) Appendix L Generalist Service Standards In the event that the Scheme Agent has less than 20 Merit Review decisions in the measurable period, the above methodology will not apply and instead the Scheme Agent must submit details of each Merit Review decisions to the Nominal Insurer. These decisions will be reviewed by the Nominal Insurer and any improvement actions identified under this review will be included in the Performance Management Register. For each item on the Performance Management Register that is not finalised by the agreed rectification timeframe, there will be a deduction of 5% from the Scheme Agent Score (Measurable Element 1) to a minimum score of 0% Measurable Element 2 (c) (d) (e) (f) (g) This Measurable Element measures the complaints that have been received by WorkCover s Customer Service Centre and move from Level 1 Complaint to Level 2 Complaint. The Nominal Insurer will be supplied with a report from WorkCover s Customer Service Centre detailing the number of complaints that have been registered as Level 1 Complaints, as well as those registered as Level 2 Complaints. The WorkCover Customer Service Centre will categorise all new Level 2 Complaints by origin, 1 of those will be complaints which have escalated from a Level 1 Complaint. Level 1 Complaints and Level 2 Complaints will be monitored for the Calendar Year 2015 throughout the Year. Where the proportion of Level 2 Complaints that have escalated from Level 1 Complaints is greater than Scheme average, the Scheme Agent may on request be required to submit to the Nominal Insurer an assessment of the effectiveness of its Customer Service Model. This submission should note any areas that have been identified as requiring improvement and any identified reasons for the greater than Scheme average proportion of such escalations. The submission will form the basis for a performance discussion between the Nominal Insurer and the Scheme Agent, from which agreed actions items will be added to the Performance Management Register along with a risk rating for the items and an agreed time for resolution. Any items that are added to the Performance Management Register must be addressed by the agreed resolution date with outstanding items resulting in an adjustment to the Scheme Agent Score (Measurable Element 2). Schedule 5 - Appendix L (Service Standards) Page: 17 of 26

18 (h) (i) (j) Appendix L Generalist Service Standards Each high risk action item that remains on the Performance Management Register as unresolved after the agreed time for resolution, will result in an reduction of 20% from the Scheme Agent Score (Measurable Element 2) for the first Month and 10% for each Month thereafter to a minimum of 0%. Each medium, low or unrated risk action item that remains on the Performance Management Register as unresolved after the agreed time for resolution will result in an adjustment of 10% from the Scheme Agent Score (Measurable Element 2) for the first Month and 5% for each Month thereafter to a minimum of 0%. Additionally, where the proportion of Level 2 Complaints that have escalated from Level 1 Complaints is greater than 50%, the Scheme Agent Score (Measurable Element 2) will be 0% Measurable Element 3 (c) (d) (i) This Measurable Element measures the time taken to respond to a WorkCover request for information resulting from a complaint. The Nominal Insurer will be supplied with a report from WorkCover s Customer Service Centre detailing the number of complaints where a response is required and provide detail of the proportion of responses that have been received within 5 Business Days of the request for information. The Scheme Agent Score (Measurable Element 3) will be the proportion of complaints when the time to respond is less than 5 Business Days compared to the total number of complaints responded to. This refers to the initial request and response relating to any complaint. Where the proportion of responses to requests for information have been received within 5 Business Days is: (ii) 90% or greater of the responses received by WorkCover s Customer Service Centre, then the Scheme Agent Score (Measurable Element 3) will be 100%; and 80% or less of the responses received by WorkCover s Customer Service Centre, then the Scheme Agent Score (Measurable Element 3) is 0%. There will be a linear progression in Scheme Agent Score (Measurable Element 3) between the proportions of 90% and 80% of responses. Schedule 5 - Appendix L (Service Standards) Page: 18 of 26

19 4.4 Reporting Period and Frequency of Assessment The Reporting Period for the Service Standard is annual however monitoring for each Measurable Element will be made available quarterly. 4.5 Service Standard Score The overall Service Standard Score will be calculated as: 4.6 Expected Level of Performance Scheme Agent Score (Measurable Element 1) x 40% + Scheme Agent Score (Measurable Element 2) x 40% + Scheme Agent Score (Measurable Element 3) x 20% For example, where the score for Measurable Action 1 is 100%, the score for Measurable Action 2 is 50% and the score for Measurable Action 3 is 50%, the Service Standard Score is 70% (40% + 20% + 10%). The Scheme Agent is expected to achieve a Service Standard Score of 100% and performance below this will constitute under performance. 4.7 Reference Material Schedule 1 (Code of Conduct and Customer Engagement) Attachment 1.01 (SRWS customer service charter) Attachment 1.02 (Fact Sheet How to make a complaint about your claim, insurer, premium or dispute a decision) Attachment 1.03 (Workers Compensation Complaints Standard) Attachment 1.04 (Handling customer complaints A guide for scheme agents and insurers) Attachment 1.05 (Managing complex customer behaviour policy) Schedule 5 - Appendix L (Service Standards) Page: 19 of 26

20 5. Service Standard 5 Data Submissions 5.1 Purpose This Service Standard assesses the Scheme Agent s provision of timely and quality Claims and Policy data to the Nominal Insurer. 5.2 Measurable Elements Each monthly submission has an available maximum score of 4 points, 2 points for Claim submissions and 2 points for Policy submissions. Only whole points are awarded Claim Submission: Element 1 Point value 1. 1A - 100% Claim submission files must be received by the 10th Calendar Day of the Month due, and 1B - with 99% of total Claim payment value fatal error free. Element 2 Point value 1. For each Claim submission, the Scheme Agent is required to correct or suppress data errors, according to the WorkCover Guidelines in force at the time. 2A - 100% of fatal errors within the next Month s submission file; 2B - 80% of suspect errors within the next Month s submission file; and 2C - 100% of suspect errors within 12 weeks of the first occurrence. If sub-element 2A, B and C are not applicable, that is there are no errors to be corrected, then 1 point will be awarded Policy Submission: Element 1 - Point value 1. (c) 1A 100% Policy submission files must be received by the 10th Calendar Day of the Month due; and 1B - with 99% of total Policy Premium value fatal error free. Element 2 Point value 1 point. For each Policy submission, the Scheme Agent is required to correct or suppress data errors, according to the WorkCover Guidelines in force at the time. 2A - 100% of fatal errors within the next Month s submission file; 2B - 80% of suspect errors within the next Month s submission file; and 2C - 100% of suspect errors within 12 weeks of the first occurrence. If sub-element 2A, B and C are not applicable, that is there are no errors to be corrected, then 1 point will be awarded. Each Element, that is Element 1 and 2, is entitled to 1 point. As an example; 1 point will be allocated for a submission received by the Schedule 5 - Appendix L (Service Standards) Page: 20 of 26

21 10th Calendar Day of the Month with 99% of total Claim payment fatal error free (Element 1A and 1B). Another 1 point will be allocated for the correction/suppression of errors within the required timeframes (Element 2A, 2B and 2C). The same principle applies to Policy file submissions. (d) (e) The Scheme Agent may earn bonus points that will be added to the monthly score. 3 consecutive submissions with a maximum score of 4 will attract a 1 point bonus. Each consecutive submission with a score of 4 will attract an additional bonus point. A maximum of 4 bonus points will be awarded for the Year. Bonus points will not be earned in any Month where an allowance for errors is granted. 5.3 Methodology A monthly data submission (Claims and Policy) can result in a total of 0, 1, 2, 3 or 4 points for a Month s submission. The total number of points earned by the Scheme Agent in the Year will be used to determine the final Service Standard Score. 5.4 Reporting Period and Frequency of Assessment The Reporting Period for the Service Standard is annual. The Nominal Insurer will report to the Scheme Agent monthly on the Scheme Agent s data submission performance from January to December Service Standard Score Table 4 There will be a progression in Service Standard Scores from 40 points to 46 points as displayed in the following table: Points Earned for the Year Service Standard Score 40 and below 0% 41 16% 42 33% 43 50% 44 67% 45 84% 46 and above 100% Schedule 5 - Appendix L (Service Standards) Page: 21 of 26

22 5.6 Expected Level of Performance The Scheme Agent is expected to achieve a Service Standard Score of 100% and performance below this will constitute under performance. 5.7 Reference Material Appendix H (Claims Technical Manual) Appendix E (Policy Technical Manual) Schedule 5 - Appendix L (Service Standards) Page: 22 of 26

23 6. Service Standard 6 Internal Controls 6.1 Purpose The Service Standard will assess the adequacy and timeliness of the Scheme Agent s responses to findings from the Internal Controls Audit. 6.2 Measurable Elements The Service Standard will have 1 Measurable Element, being the timely and adequate resolution of findings resulting from the Internal Controls audit. 6.3 Methodology An Internal Controls audit will be carried out by the Nominal Insurer s independent auditor in accordance with the Deed. The components to be audited are detailed in the Attachment L.01 (Internal Controls Framework). Findings will be recorded in the Performance Management Register. Unless agreed to the contrary by the Nominal Insurer, any items that are added to the Performance Management Register must be adequately addressed by the date advised by the Nominal Insurer. Outstanding items will result in an adjustment to the Service Standard Score. 6.4 Description Audits will take place to ensure that the Scheme Agent has designed appropriate Internal Controls to ensure that the assets of the Nominal Insurer are prudently managed and Services provided meet the requirements set out in the Deed. The Internal Controls audit will ensure that the Internal Controls are also working effectively to meet these requirements. The details of the Internal Controls to be audited are contained in the Attachment L.01 (Internal Controls Framework) and communicated to the Scheme Agent. The Nominal Insurer s nominated independent qualified auditor will conduct the Internal Controls audit and report the results. Any findings arising from the audit will then be added to the Performance Management Register, with a risk rating assigned by the Nominal Insurer, taking into account the risk rating, if any, determined by the independent auditor. Based on the risk rating, the Nominal Insurer will determine the timeframe within which the Scheme Agent must rectify the findings, in accordance with Schedule 5 (Performance Management and Remuneration) section 3. This timeframe will be no longer than the commencement of the following year's Internal Controls audit. Schedule 5 - Appendix L (Service Standards) Page: 23 of 26

24 6.5 Reporting Period The Internal Controls audit is based on the previous financial year (that is, for 2015 the audits are conducted on the 2014/2015 financial year). 6.6 Service Standard Score The Scheme Agent will commence with a Service Standard Score of 100%. Each high risk action item that remains on the Performance Management Register as unresolved after the rectification timeframe, will result in an adjustment of 10% from the Service Standard Score. Each medium risk action item that remains on the Performance Management Register as unresolved after the rectification timeframe, will result in an adjustment of 5% from the Service Standard Score. 6.7 Expected Level of Performance The Scheme Agent is expected to achieve a Service Standard Score of 100% and performance below this will constitute under performance. 6.8 Reference Material Attachment L.01 (Internal Controls Framework) Schedule 5 - Appendix L (Service Standards) Page: 24 of 26

25 7. Service Standard 7 Data Quality 7.1 Purpose This Service Standard assesses the successful quality entry and submission of data items for key business practices. 7.2 Measurable Elements The Service Standard will have 1 Measurable Element being the proportion of Claims with accurate coding of all of the nominated data items. 7.3 Methodology For the Service Standard outcome, the Nominal Insurer will undertake an annual audit on a sample of Claims from the WorkCover Corporate Data Repository (CDR). The sample for the audit will be made up of Claims with a benefit payment (incapacity period) between 1 January 2015 and 31 December 2015 using Payment Classification Number (Appendix H (Claims Technical Manual) reference C: ) WPT005-WPT007 and WPP005-WPP008. This will be a random sample of the eligible pool Sample Size The sample for the audit will contain no fewer than 100 Claims and will not exceed 200 Claims. The audit will assess the accuracy of the following data items: (i) (ii) (iii) (iv) (v) Weekly Benefit type payment classification and amount (Appendix H (Claims Technical Manual) references C: , C: and Chapter 12.4) including the calculation of the maximum weekly compensation amount; Workers Pre Injury Average Weekly Earnings (PIAWE) (Appendix H (Claims Technical Manual) reference C: ); Hours paid (Appendix E (Claims Technical Manual) references C: and C: ); Determined Weekly Benefit amount (Appendix H (Claims Technical Manual) reference C: ); and Estimated Whole Person Impairment (Appendix H (Claims Technical Manual) reference C: ). (c) Where the data item is transactional based, the accuracy of all Records for the data item within the period defined above will be assessed. Where any item on the Claim is marked as incorrect the whole Claim will be marked as incorrect. Schedule 5 - Appendix L (Service Standards) Page: 25 of 26

26 7.4 Reporting Period The audit will take place based on data from the WorkCover CDR for the period to 1 January 2015 to 31 December 2015 dependent upon the availability of December data. 7.5 Service Standard Score The audit result will be the number of Claims with all nominated data items marked as correct as a proportion of the number of Claims in the sample (less any Claims marked as not applicable). (c) (d) An audit result below or equal to 70% will result in a Service Standard Score of 0% and an outcome audit result of 80% or above will result in a Service Standard Score of 100%. There will be a linear progression in Service Standard Scores between outcome audit results of 70% to 80%. For example: The sample contains a total of 170 Claims, of which 2 Claims are not applicable, 5 Claims incorrect and 163 Claims correct. The outcome audit result for this example is: (170-2) = 168 Numerator: Expected Performance Level Agent outcome audit result = 163 / 168 = 97.02% The Scheme Agent is expected to achieve a Service Standard Score of 100% and performance below this will constitute under performance. 7.7 Reference Material Appendix H (Claims Technical Manual) Schedule 5 - Appendix L (Service Standards) Page: 26 of 26