Workers Compensation Claims and Policy Services. Schedule 11 Claims and Policy Transfer

Transcription

1 Workers Compensation Claims and Policy Services DATE 2010 Schedule 11 Claims and Policy Transfer Nominal Insurer And

2 1. Introduction 1.1 (About this Schedule) This Schedule describes the Scheme Agent s obligations regarding the transfer of Policies and/or Claims under Clause 7 of this Deed. 1.2 (Remuneration) During the Period of Services, the Scheme Agent will be remunerated in accordance with Schedule 3 Section 10 (Remuneration) for successful completion of the transfer of Policies and/or Claims in accordance with the File Transfer Manual. 1.3 (Glossary) For the meaning of defined terms used in this Schedule, refer to Subclause 48.1 (Glossary) of this Deed. 1.4 (Obligations) The obligations in this Schedule are in addition to other parts of this Deed. 2. Claims and Policy File Transfer Process 2.1 (File Preparation / Receipt) During the Period of Services, the Scheme Agent may be required to transfer Policies and/or Claims to the Nominal Insurer or any other person who is a scheme agent under Subclause 7.10 of the Deed in accordance with any given Directions. 2.2 (Transfer batches) Claims files may be transferred in batches of up to 1,000 files and Policy files may be transferred in batches of up to 3,000 files. Multiple batches may be transferred simultaneously. 2.3 (Reporting and tracking) The Scheme Agent will be required to conduct a selfassessment of its performance in accordance with the File Transfer assessment criteria described in this Schedule and in the File Transfer Assessment Manual for each batch of files that is transferred. 2.4 (Performance audit) The Nominal Insurer will audit the Scheme Agent's performance in relation to the preparation and receipt of transferred files as part of any transfer program. The Nominal Insurer will select audit batches at its discretion and conduct random sampling of 10% of the Claim batch and 1% of the Policy batch for review. 2.5 (Claims and Policy Transfer Planning) The Scheme Agent must ensure that Claims and Policies are transferred in accordance with the Nominal Insurer's timeframe and to the specified standards as described in the File Transfer Manual. Page 1

3 2.6 (Transfer Plan) The Scheme Agent must develop a Transfer Plan to support the transfer activities in line with any given Directions. The plan must comply with all transfer requirements in this Deed and in this Schedule. 2.7 (Claims and Policy Transfer Management) The Scheme Agent and the Nominal Insurer will form a Claims and Policy Transfer Planning Group to oversee the transfer of Policies and/or Claims as Directed. 3. Claims And Policy Transfer Planning Group TERMS OF REFERENCE Purpose The Scheme Agent is responsible for conducting the Claims and Policy transfer function. The Claims and Policy Transfer Planning Group will review the progress and act as an escalation point for transfer activities. The responsibility of the Claims and Policy Transfer Planning Group extends to: Monitoring delivery and reviewing performance against the Transfer Plan; Escalation of issues / risks to the account management team; and Determination of transfer fees. Attendees/Members Nominal Insurer Nominal Insurer Account Manager Nominal Insurer Transfer Manager Claims and Policy Transfer Team Member/s Scheme Agent Scheme Agent Account Manager Scheme Agent Transfer Manager Other Nominal Insurer and Scheme Agent Personnel as required. The Nominal Insurer may require Other Scheme Agents to participate. Chair Minute Taker Nominal Insurer Representative Scheme Agent Representative Page 2

4 Agenda Review actions from previous meetings; Monitor delivery & performance of transfer in accordance with the Transfer Plan; Review performance against transfer performance assessment as appropriate; Highlight and address issues & risks in relation to transfer; Submit issues concerning the relationship between the parties and identify and refer matters outside the authority of the Claims and Policy Transfer Planning Group to the Nominal Insurer; Submit reports as required; File Transfer timetable as appropriate; Review and present recommendations and suggestions made by the Nominal Insurer and Scheme Agent representatives relating to transfer and initiate appropriate actions; and Discuss any relevant issues or changes, general business and new business arising. Reports Transfer status reports outlining status of the transfer; and Transfer Plan updates outlining accepted changes to the Transfer Plan and proposing any amendments to the Transfer Plan for consideration. 4. Key Transfer Personnel The following describes the Key Transfer Personnel involved in the transfer of Policies and/or Claims under this Schedule. The Key Transfer Personnel have overall responsibility to ensure the transfer objectives are achieved. The Nominal Insurer Account Manager and the Scheme Agent Account Manager will oversee the relationship of the parties during Transfer Period. Nominal Insurer Transfer Personnel The Nominal Insurer transfer manager has overall responsibility for: (Managing) Managing the Nominal Insurer s obligations under the Transfer Plan; (Monitoring) Monitoring and assessing Scheme Agent performance against Transfer Plan Milestones; (Auditing) Auditing the Scheme Agent's assessment of its own performance; and Page 3

5 (d) (Reviewing) Reviewing and assessing the Scheme Agent's entitlement to Remuneration for the successful transfer of Policies and/or Claims under Schedule 3. Nominal Insurer Transfer Team Member/s The Nominal Insurer Transfer Team member is responsible for delivering individual activities that support the transfer of Policies and/or Claims, such as the provision of the extract file of Claims and Policies to be transferred and the transfer file for upload in the system of the Receiving Scheme Agent s, or in the case of a transfer to the Nominal Insurer, the Nominal Insurer. This function works with the Scheme Agent transfer team and the Nominal Insurer to facilitate the completion of Claims and Policy File transfers. The Nominal Insurer transfer team member s primary responsibility is to conduct specific obligations under the Transfer Plan on behalf of the Nominal Insurer. Scheme Agent Transfer Personnel The Scheme Agent transfer manager has the overall responsibility for successful transfer of Claims and Policy. The Scheme Agent transfer manager is to be a dedicated role for the Transfer Period. The Scheme Agent transfer manager s primary responsibilities include: (d) (e) (Developing) Implementing and managing the Transfer Plan; (Manage obligations) Managing the Scheme Agent s transfer obligations under the Transfer Plan; (Report progress) Reporting progress of Milestones against the Transfer Plan; (Submit claim) Submit transfer payment claim following Approval for File Transfer/receipt; and (Identification of risks) Ensuring the prompt identification and analysis and mitigation of risks impacting the transfer. 5. Identification of Key Transfer Personnel The parties will provide the individual s name and role/title for each of the Key Transfer Personnel. Contract Function Name Role in Organisation Nominal Insurer Transfer Manager Scheme Agent Transfer Manager Scheme Agent Transfer Team Page 4

6 Contract Function Name Role in Members (based on Transfer Plan) Organisation 6. Transfer Performance Management 6.1 Performance of a Transfer Period will be managed through the tracking of metrics against: The Transfer Plan and achievement of Milestones; Claims and Policy performance assessment criteria; and Performance data and information through the Transfer Period The performance data and supporting information will be sourced from: (i) (ii) (iii) the Scheme Agent s performance measurement framework described in this Schedule 11; reports on transfer activity; and the Nominal Insurer s analysis of its own data. 6.2 Transfer Plan The Scheme Agent must develop a Transfer Plan that; has all the obligations set out in the File Transfer Manual completed; and includes as a minimum, a project plan and corresponding project schedule describing all activities, and a statement of the Milestones for each batch of Claims and Policy File Transfers as defined by the Nominal Insurer. 6.3 Transfer Plan Milestones (Review) At the Transfer Planning Group meeting, the Scheme Agent must provide a Transfer Plan to reflect the Claims and Policy File Transfer timetable nominated by the Nominal Insurer. The Scheme Agent must provide any proposed updates to the Transfer Plan to the Nominal Insurer for review, comment and Approval; (Approval) The Scheme Agent must ensure that each Milestone reflects the Nominal Insurer Directed transfer timeframe. (Process) The procedures for obtaining Approval of the Milestones are: (i) The Scheme Agent must notify the Nominal Insurer when it considers it has achieved each Milestone described in the Transfer Plan and deliver to the Nominal Insurer supporting Documents to enable the Nominal Insurer to review the Scheme Agent s performance; and Page 5

7 (ii) The Nominal Insurer will, within 10 Business Days of receiving such notification and supporting Documents, review and advise the Scheme Agent in writing that it: (A) (B) (C) (D) intends to conduct a Site visit to validate/verify the Scheme Agent s notification; will provide its Approval without requiring any further action by the Scheme Agent; will provide its Approval subject to further actions by the Scheme Agent, as specified by the Nominal Insurer in the notice; or intends to reject the relevant Milestone, for reasons which it must specify in the notice. (d) (e) (f) (g) (h) The Scheme Agent will complete the actions requested by the Nominal Insurer in any notice under above within the specified timeframe; The Nominal Insurer may require the Scheme Agent to repeat the process described in, and above until the Nominal Insurer provides its Approval of the transfer Milestone; (file audit) the Nominal Insurer will conduct assessments of selected batches using a random sample size of 10 percent for Claims and one percent for Policies; The Scheme Agent will be advised of the batches of files selected for assessment five Business Days in advance of the on-site audit. The Scheme Agent will be required to ensure staff and files are available for and during the audit; and (Sampling) A random sample method will be used to ensure a minimum 95% confidence level. Page 6