SCHEDULE 3 Generalist Claims 2015

Transcription

1 SCHEDULE 3 Generalist Claims 2015 Nominal Insurer And Schedule 3 (Claims) Page: 1 of 23

2 Contents Overview Scope of Services Claims Services Claims Process Assessment Throughout the Life of the Claim Planning Throughout the Life of the Claim Implementation and Review Throughout the Life of the Claim Employer Capabilities to Prevent Injury and Improve Return to Work Outcomes Core Competencies Services to Employers and Workers Claims Performance Management Quality Assurance Fraud Management Competency of Scheme Agent Personnel Claims Specific Competencies Governance Requirements General Requirements General Claims Management Strategic Claims Management Appendices Schedule 3 (Claims) Page: 2 of 23

3 Overview This Schedule 3 (Claims) sets out the requirements for Claims Services that must be delivered by the Scheme Agent acting as agent for the Nominal Insurer. Format of this Schedule The components of this Schedule 3 (Claims) are as follows: 1. Scope of Services - this section describes the obligations of the Scheme Agent with regard to the delivery of Claims Services. 2. Core Competencies - this section identifies the core competencies which the Scheme Agent must demonstrate when performing the Claims Services. 3. Governance - this section identifies the audits and reviews that must be performed by the Scheme Agent to ensure the Claims Services are provided in accordance with the requirements of the Deed. Key Parties Reference to key parties in this Schedule 3 (Claims) includes Workers, Employers, Nominated Treating Doctors and Third Party Service Provider as relevant. Glossary Capitalised terms used in this Schedule 3 (Claims) have the meaning set out in the Glossary. Schedule 3 (Claims) Page: 3 of 23

4 1. Scope of Services 1.1 Claims Services The Scheme Agent must ensure that all notifications and Claims are managed to an appropriate outcome through a focus on recovery at work, timely intervention and competent Case Management. The Scheme Agent must, in the performance of the Claims Services, comply with the Law, Manuals, guidelines and gazetted material in force during the Period of Services, including: Workers Compensation Act 1987; Workplace Injury Management and Workers Compensation Act 1998; Workers Compensation Regulation 2010; (iv) (v) (vi) (vii) (viii) Other sub delegated legislation of the 1987 and 1998 Acts and the 2010 Regulation in force from time to time; Appendix F (Claims Operations Manual); Appendix G (Claims Estimation Manual); Appendix H (Claims Technical Manual); and Appendix J (Taxation Manual). The Scheme Agent must utilise an effective process to ensure that the Claims process of assessment, planning, implementation and review is tailored to: The circumstances of the Worker and Employer; The stage of the Claim, which may include the Worker; (A) (B) (C) Recovering at work; Planning to Return to Work; and Seeking or planning to seek Suitable Employment. The core elements of Injury Management, which include; (A) (B) (C) Return to Work management; Medical and related intervention management; and Claims Management, to ensure the sustainability of health and work outcomes. Schedule 3 (Claims) Page: 4 of 23

5 1.2 Claims Process Initial Notification Schedule 3 Generalist Claims The Scheme Agent must, conduct initial notification of Injury in accordance with the relevant Law Conduct Triage Triage notifications; Assign notifications to a suitably qualified Case Manager depending on the severity of the Injury and the Scheme Agents cohort management approach i.e. size of Employer, Injury or Claims type; and Assign Severe Injury Claims as per the Nominal Insurer s instructions Early Contact Provide key parties with information about the Claims process, the roles and responsibilities of key parties the health benefits of work (physical, social and financial); Establish positive working relationships with key parties; Set expectations of participation and accountability with key parties and the potential impact of not actively participating in driving the Worker s recovery at work; and Gather relevant information to assist in the commencement of the assessment process. 1.3 Assessment Throughout the Life of the Claim Determine Entitlement to Benefits The Scheme Agent must determine a Worker's entitlement to Benefits, including: Liability Liability must be determined in accordance with the relevant Law and the Manuals; and All liability decisions must rely on evidence and be documented appropriately Weekly Payments Pre-injury Average Weekly Earnings (PIAWE) must be accurately calculated in accordance with the relevant Law and the Manuals. Schedule 3 (Claims) Page: 5 of 23

6 Medical and Related Intervention Provision of medical and related intervention must be in accordance with the relevant Law and the Manuals Work Capacity Decision Work Capacity Assessments must be conducted and Work Capacity Decisions are made at required points and in accordance with the relevant Law and the Manuals Lump Sum Payments Claims for lump sum compensation must be managed in accordance with the relevant Law and the Manuals Common Law Claims Common law Claims must be managed in accordance with the relevant Law and the Manuals Commutations Commutations must be managed in accordance with the relevant Law and the Manuals Observing the Requirements of the Law In relation to: Shared Claims, and Cross jurisdictional legal matters Determining Permanent Impairment The Scheme Agent must determine a Worker's permanent impairment, including: Claims are identified as potentially reaching thresholds for either lump sum, ongoing entitlements and/or Seriously Injured Worker categorisation; The optimal timing and coordination of the assessment of permanent impairment when there is evidence that the Worker has reached maximum medical improvement; and Where a permanent impairment assessment has been received, the assessment has been reviewed by a competent person to ensure the correct application of the WorkCover Guidelines for the Evaluation of Permanent Impairment. Schedule 3 (Claims) Page: 6 of 23

7 1.3.3 Identify and Analyse Risk Factors Identify and analyse risk factors and opportunities in consultation with key parties with regard to: Return to Work activities; Medical and related intervention; and Claims strategies for example, third party recovery opportunities utilising a bio psychosocial approach. Encourage an innovative approach to determine the intervention most likely to achieve a timely, cost effective and sustainable Return to Work outcome. 1.4 Planning Throughout the Life of the Claim Planning The Scheme Agent must, utilise effective planning which ensures: Collaboration with key parties; and The development of a plan that: Specifies a goal and strategies focused on recovery at work and finalisation of the Claim; Is tailored and prioritised to the Worker s and Employer s assessed needs with regards to: (A) (B) (C) Return to Work management; Medical and related intervention management; and Claims Management. (iv) (v) (vi) Ensures key parties are committed to and take responsibility for the activities for which they are accountable; Is regularly reviewed based on the circumstances of the Claim; Proactively identifies mitigation strategies to address factors that may pose a risk to the Return to Work strategy and outcome, for example withdrawal of Suitable Employment; and Includes an open and transparent communication strategy with key parties Estimate Claim The Scheme Agent must ensure: Claims are estimated in accordance with the Appendix G (Claims Estimation Manual); Schedule 3 (Claims) Page: 7 of 23

8 Common law estimates are raised in a timely manner in accordance with the Manuals; and All Claim estimates, including initial and material increases, are effectively communicated to the Employer in a timely manner to encourage Employers to actively participate in the Return to Work process Recovery Management (iv) Utilise a systematic recovery methodology to proactively identify potential recovery opportunities against a wholly or partly liable third party; Ensure that Claims Management is not delayed while investigation and pursuit of the recovery is proceeding; Actively manage recovery proceedings and ensure that the proceedings are clearly documented on the Claim record; and Ensure that Claims with potential recovery are not finalised until all recovery options are exhausted or the Nominal Insurer has Approved non-recovery. The Nominal Insurer, or the Nominal Insurer s independent qualified auditor, may at any time audit and verify the recovery actions reported in Schedule 6 (Governance) section 6.2. Subject to the result of audits, the Nominal Insurer may direct the Scheme Agent to undertake specific actions. 1.5 Implementation and Review Throughout the Life of the Claim Implementation (e) (f) Establish and maintain relationships with key parties to negotiate and influence the health and work outcomes for the Worker; Co-ordinate intervention early, actively promote the health benefits of work and facilitate recovery at work; Ensure actions identified in the plan developed in section above are mobilised according to specified timeframes and integrated to avoid duplication of Services; Educate, influence and motivate the Worker to actively contribute and participate in their recovery at work; Take reasonable actions to educate and influence the Employer about the Employer s obligations to support the Worker to recover at work including the provision of Suitable Employment; Ensure key parties remain committed and take responsibility for the activities for which they are accountable within the plan; Schedule 3 (Claims) Page: 8 of 23

9 (g) (h) Educate the Employer that it is an offence to terminate the employment of an injured Worker within 6 months of them becoming unfit for employment as a result of the Injury; and Effectively manage the participation of injured Workers in job seeking, job placement and vocational program activities Review The Scheme Agent must, ensure each Claim is regularly reviewed in collaboration with key parties and includes: An evaluation of the effectiveness of interventions in moving the Claim to recovery at work and finalisation; Adjustment of goals, strategies and accountabilities to ensure Services contribute to recovery, Return to Work and finalisation; and Re-establish commitment from key parties about the key parties responsibilities Manage Payments The Scheme Agent must ensure: Weekly payment calculations and reviews are determined in accordance with the relevant Law; That all continuing weekly compensation payments to Workers and Employers are made subject to Work Capacity Assessment and decision making in accordance with the relevant Law; and That Benefits are increased, reduced, or ceased in accordance with requirements of the relevant Law Management of Medical and Related Intervention, Legal and Investigative Services Issue timely and appropriate referrals, advice and instructions to Third Party Service Providers; Approve initial or ongoing intervention for a Claim based on sufficient information to enable the application of: The principles of reasonably necessary intervention; and The intervention contributing to recovery at work and/or other Claims outcomes. Appoint Third Party Service Providers in accordance with the Deed; Ensure that legal Third Party Service Providers act as a model litigant on behalf of the Nominal Insurer while retaining the authority to manage and settle Claims; Schedule 3 (Claims) Page: 9 of 23

10 (e) (f) (g) (h) Develop effective working partnerships with Third Party Service Providers to sustain performance based relationships and influence timely cessation of services; Ensure Third Party Service Providers are committed to and take responsibility for the outcomes of their intervention; Document all decisions regarding intervention for a Claim, identifying the objective, expected duration and cost of Third Party Service Provider Services, or the reason for non-approval; and Communicate to key parties the decision, the reasons supporting the decision and the expected outcomes within prescribed or where not prescribed, timeframes identified within the Scheme Agent's processes. Notify the Nominal Insurer of any significant legal matters within 5 Business Days of the Scheme Agent first becoming aware Manage Claim Handovers Ensure continuity of care and effective Claim Handover when there is a temporary or permanent change in Case Manager which includes: (iv) A review of the whole Claim and the current plan occurs at the time of the Claim Handover; Prompt follow through on any urgent actions identified by the Exiting Scheme Agent; The Case Manager receiving the Claim makes contact with the Employer, Worker and key parties to notify and establish working relationships within the timeframe specified in the Scheme Agent processes; and The Claims will be prioritised based on the Worker and Employer needs in the case of the transfer of a portfolio of Claims. Expedite the retrieval and provision of the Claim file to the requesting Scheme Agent in accordance with the Appendix O (File Transfer Manual) Finalisation Finalise Claims in accordance with the WorkCover Guidelines for Claiming Compensation Benefits; and Suitably prepare the Worker, prior to the finalisation of their Claim by defining the extent and the type of entitlements according to the legislative limits. 1.6 Employer Capabilities to Prevent Injury and Improve Return to Work Outcomes Schedule 3 (Claims) Page: 10 of 23

11 Provide education and information to Employers including: The Employer s obligations with regard to: (A) (B) (C) (D) Notification; Return to Work (offer of Suitable Employment); Injury Management; and Work health and safety. (iv) The definition of Wages and Workers as it relates to Premium Calculation and weekly payments; The physical, social and financial Benefits of work and recovery at work; and A copy of the Scheme Agent s Injury Management program. Promote and challenge Employers to: Remain engaged with the Employer s Worker when a Claim is made; and Offer Suitable Employment to injured Workers; Identify Employers with a consistently poor Claims record; In collaboration with the Employer, develop strategies tailored to the size of Employer s business (Small Employer, Medium Employer and Large Employer) that can assist and promote accountability in preventing Injury, reducing Claim costs and improving Return to Work outcomes through; Effective work health and safety management systems; and The promotion of recovery at or Return to Work. Schedule 3 (Claims) Page: 11 of 23

12 2. Core Competencies Core competencies are essential elements of the Scheme Agent Deed and are required to support the delivery of the Services. The core competencies for the provision of Claims Services are the requirements and standards described in following sections. 2.2 Services to Employers and Workers The Scheme Agent must deliver Services to Employers and Workers in accordance with the Customer Service Model and Complaints Management Model as detailed in Schedule 1 (Code of Conduct and Customer Engagement). 2.3 Claims Performance Management The Scheme Agent must undertake regular planning, effective measurement and analysis to enable its performance of the Claims Services to be evaluated. The Scheme Agent must undertake regular planning that forecasts and evaluates the level of Scheme Agent achievement against contract obligations, Service Standards and Outcome Measures. (iv) (v) (vi) Utilise a framework for performance measurement that evaluates the Scheme Agent s achievement against plans; Select, collect, align and integrate data and information for tracking operational performance and overall Scheme Agent performance; Analyse data and information to determine the Scheme Agent s performance; Use the analysis of the information to support operational and strategic decision-making; Establish and utilise necessary reports to communicate results from the performance measurement framework to the Nominal Insurer; and Ensure that regular reviews of performance management are undertaken, in accordance with the Scheme Agent s Quality Management Framework. 2.4 Quality Assurance The Scheme Agent must operate a Quality Management Framework that incorporates documented procedures to ensure the consistent delivery of the Services. The Quality Management Framework must meet the requirements of Schedule 6 (Governance). Schedule 3 (Claims) Page: 12 of 23

13 2.5 Fraud Management Schedule 3 Generalist Claims The Scheme Agent must operate a Fraud Identification and Management Model that incorporates documented procedures to ensure the early identification and report of Suspect Activity or Fraud. The Fraud Identification and Management Model must meet the requirements of Schedule 6 (Governance). 2.6 Competency of Scheme Agent Personnel (e) (f) (g) Develop, maintain and comply with a competency matrix that identifies required competencies for Personnel providing Claims Services that includes every business function related to the delivery of the Workers Compensation; For each position, recruit Personnel with the appropriate competencies, as defined in the Scheme Agent s competency matrix; Ensure that the appropriate Personnel are trained and competent in the Scheme Agent s relevant framework, models and methodologies required to deliver the Scheme Outcomes and Claims Services; Demonstrate commitment to building capacity of (subject) Personnel through training needs analyses for each role, and training matrix to demonstrate implementation; Ensure that (subject) skills of Personnel are kept up to date by ensuring that ongoing training is provided to retain skills and enhance them to meet evolving business needs; Managing performance - apply a process of open and honest communication between employees and their managers about performance against defined capabilities and performance indicators promoting consistency, equity and transparency; and Workforce planning - plan and review the workforce to meet current and future organisational needs. 2.7 Claims Specific Competencies Case Manager Specific Competencies The Scheme Agent must, develop and integrate the following Case Manager capabilities and practices into Claims processes: Focus on Work All activities are designed to facilitate and promote recovery at, or Return to Work or capacity for work. Schedule 3 (Claims) Page: 13 of 23

14 2.7.3 Effective Communication and Engagement (e) Transparent and effective communication from notification of an Injury onwards to build rapport and set clear expectations of key parties roles and responsibilities and Return to Work outcomes; Communication must be respectful, open and considerate of the Worker s and Employer s primary language, cultural background and literacy skills; Tailored and event driven (for example Claims decisions) communication to maintain collaboration with key parties which allows prompt resolution of issues; Builds relationships with key parties to negotiate and influence the best outcomes; and Relationships are developed to motivate and empower key parties to accept their responsibilities in driving the Return to Work process Evidence Based Decisions Utilise an evidence based decision making model that includes methods that: (e) (f) (g) (h) Determines the issue or matter that requires a decision; Gathers relevant information and evidence about the issue in a manner free of preference or prejudice; Proposes and evaluates relevant option/s to address the issue. Considers all the implications of the decision on the relevant Employer, Worker and key parties, including cost benefit, risk assessment and alternatives; Selects the best option based on the most logical, rational, reasonable and commercial outcome; Ensures decisions are made and communicated within defined time frames and reviews processes are articulated; Considers and applies the relevant Laws and WorkCover Guidelines; Identifies escalation points in the management of decisions requiring higher authority levels or for decisions that may be contentious; and Ensures that regular reviews of the effectiveness of the evidence based decision making model are undertaken, in accordance with the Scheme Agent s Quality Management Framework A Tailored, Cost Effective Approach The Scheme Agent must ensure: That the needs of the Claim are identified by means of adequate and appropriate assessment; The Service levels match Claim needs; Schedule 3 (Claims) Page: 14 of 23

15 The Service costs match the range and extent of service provision; and Innovative strategies are utilised and tailored to the Worker s and Employer s circumstances Timely Intervention The Scheme Agent must ensure: The Claim receives prompt attention and intervention appropriate to the needs; That all actions are coordinated and integrated; and That proactive management of Claims including predicting and preparing for events that will have an impact on Claim progress and outcome Accountability Take ownership of the management of the Claim in its entirety; Seek to understand the Worker s and Employer s circumstances and is engaged throughout the life of the Claim; Impartially and objectively manage the Claim; and Identify when to seek information and assistance Knowledge Demonstrate knowledge of the Workers Compensation legislation, guidelines and regulatory requirements; and Demonstrate knowledge of relevant information technology systems Cohort Management Effectively manage their cohort of Claims in line with its resources and capability, for example segmenting Claims into: (iv) (v) Medical only Claims; Early intervention Claims recovery at or early Return to Work; Claims where Workers are seeking Suitable Employment; Employer size and industry type; and Common Law, Commutation and Claims for lump sum compensation. Have sufficient appropriately qualified and experienced Personnel to provide guidance and advice to effectively manage common law, Commutation and Claims for lump sum compensation. Schedule 3 (Claims) Page: 15 of 23

16 3. Governance Requirements 3.1 General Requirements Schedule 3 Generalist Claims The Scheme Agent must comply with the requirements detailed in Schedule 6 (Governance). In addition the following Governance requirements apply to general and strategic Claims Management. 3.2 General Claims Management Early Contact The Scheme Agent must make contact with the injured Worker, Employer and Nominated Treating Doctor (where appropriate) within 3 Business Days of being notified of a significant Injury Liability Determination Conduct provisional weekly payments within relevant timeframes unless a reasonable excuse exists; Make a determination regarding liability within relevant timeframes; and Communicate to the Worker regarding provisional payments, reasonable excuse and liability decision is conducted in accordance with WorkCover Guidelines for claiming compensation Benefits Work Capacity Decisions Conduct the Work Capacity Assessment at required points in accordance with Work Capacity Guidelines: (iv) Throughout the life of the Claim; In response to new information; After 78 weeks of weekly payments; and At least once every 2 years after 130 weeks. Communicate Work Capacity Decisions to cease or reduce weekly payments to the Worker in accordance with the Work Capacity Guidelines fair notice provisions: At least 2 weeks notice of potential decision provided to Worker; Allowance made for delivery of documents timeframe requirement; Information provided to Worker in a manner appropriate to the Worker s circumstances; and Schedule 3 (Claims) Page: 16 of 23

17 (iv) Attempted by telephone conversation or in person and confirmed in writing. Notify the Worker of the Work Capacity Decision, including: Attempting to make contact by telephone or in person with the Worker at the time of the decision; In writing in accordance with the Work Capacity Guidelines; and Notifying the Worker of the correct rate and date of effect for cessation / reduction of weekly payments. Where the Worker has applied for an internal review, conduct the internal review in accordance with the Work Capacity Guidelines including: (iv) (v) Providing written acknowledgement to the Worker of their application for review within 7 Calendar Days; Appointing an appropriate, independent reviewer to consider the application; Ensuring that the reviewer considers all information and makes a fresh decision; Providing written notification of a decision to the Worker within 30 Calendar Days of receipt of their application; and Review decision notice states the reasons for the decision, impact for the Worker and their further review options. (e) Where a Worker has made an application for a Merit Review: Lodge a reply with the Merit Review Service within 7 Calendar Days of the receiving the Worker s application for Merit Review; Provide all relevant information to the Merit Review Service in the reply; Give effect to the recommendations following a Merit Review and WIRO review determination; and (iv) Applies the correct rate and date of effect for cessation / reduction / increase of weekly payments. (f) Where a Worker has made an application for a procedural review by the WIRO: Give effect to the recommendations made by WIRO; and Apply the correct rate and date of effect for cessation / reduction / increase of weekly payments. Schedule 3 (Claims) Page: 17 of 23

18 3.2.4 Claims Estimates The Scheme Agent must ensure that the Claims estimate is accurate in accordance with Appendix G (Claims Estimation Manual) Payments The Scheme Agent must ensure that: Weekly payments of compensation commenced, where appropriate: Within 7 Calendar Days of notification; Within 21 Calendar Days of a Claim being duly made; and Within Worker s usual pay intervals. (e) (f) (g) Injured Worker s weekly payments are correct and accurately adjusted in accordance with legislative requirements and entitlement periods; Weekly payments are paid in accordance with legislative timeframes; Entitlements to medical and related expenses in accordance with legislative timeframes / limits; Payments other than weekly payment (for example medical provider, Worker reimbursements) have been made within 15 Business Days of receipt of all necessary documentation to support the amount paid; Invoices and payments of non-weekly Benefits have been paid in accordance with gazetted fees, applicable approvals or reasonable rates; and Review systems in place to avoid and detect duplicate payments to Workers, Employers and Third Party Service Providers Wage Reimbursement The Scheme Agent must ensure that: Wage reimbursements to Employers are made within: 15 Business Days of receiving all necessary documentation where a Wage reimbursement agreement exists; and 5 Business Days of receiving all necessary documentation where no Wage reimbursement agreement exists. Correct amount of weekly payments is reimbursed to the Employer, with supporting documentation to verify reimbursement amount on the case record Information and Records Management The Scheme Agent must maintain a records management system that complies with legislative requirements for record-keeping. It must have the following capabilities: Schedule 3 (Claims) Page: 18 of 23

19 Case record identification; Archive, storage and retrieval procedures; Relevant authority to release and obtain information prior to disclosure; and Application of confidentiality and Australian Privacy Principles to the collection, maintenance and storage of information Determination of Permanent Impairment The Scheme Agent must ensure that: Claims are identified as potentially reaching thresholds for either lump sum, ongoing entitlements and/or Seriously Injured Worker categorisation; The optimal timing and coordination of the assessment of permanent impairment occurs when there is evidence that the Worker has reached maximum medical improvement; and The assessment of permanent impairment is made in accordance with the WorkCover Guidelines for the Evaluation of Permanent Impairment Entitlement to Compensation for Permanent Impairment (Lump Sum) The Scheme Agent must ensure that: Entitlement for lump sum compensation determined in accordance with thresholds under the legislation; The complying agreement includes the required documents as outlined in the Guidelines for Claiming Compensation Benefits; The Claim for lump sum compensation has been determined within the latter of the following timeframes: 1 month of the permanent impairment being fully ascertainable; or 2 months after all relevant particulars have been supplied. Injured Worker has been paid their correct entitlement in accordance with the Workers Compensation Benefits Guide Work Injury Damages The Scheme Agent must ensure that: The Claim for Work Injury Damages has been reviewed to ensure it meets the criteria to Claim, as follows: The Injury resulted in the death of the Worker or a degree of permanent impairment of the Worker that is at least 15%; or The Injury was caused by the negligence or other tort of the Worker s Employer. Schedule 3 (Claims) Page: 19 of 23

20 Where Work Injury Damages proceedings were commenced outside 3 years of the date of Injury, the Worker had leave of the court in which the proceedings were to be taken or alternatively, an acceptable explanation for the delay was provided. The Claim was determined no later than 2 months after receipt of all particulars, and action taken by either: The issue of a notice under section 74 of the 1998 Act; or An offer of settlement Effective Planning and Review Develop a plan within required time frame (as outlined in the Injury Management program). Develop, in consultation with Worker, Employer, Nominated Treating Doctor, insurer and other relevant parties, a plan which must include: (iv) (v) Goal; Actions tailored to Worker s workplace / rehabilitation and treatment / Claims Management; Person(s) responsible for actions; Review dates; Stakeholder expectations, rights and obligations communicated (including information on how to change Nominated Treating Doctor); Ensure that plans have been distributed to key parties (must include Worker, Employer and any persons identified as responsible for an action item); and Review the plans in accordance with plan timeframes or new information. Review of plans must include: An evaluation to determine that the Return to Work goal remains appropriate; An evaluation of the effectiveness of interventions in moving the case to finalisation; and Adjustment of strategies and goals Focus on Recovery and Return to Work Ensure that all activities are designed to facilitate and promote recovery at, or Return to Work or capacity for work, including: Schedule 3 (Claims) Page: 20 of 23

21 Encouraging/challenging the Employer to offer Suitable Employment when the Worker has capacity to work; Encouraging/challenging the Nominated Treating Doctor to support the Worker s recovery at work when there is evidence that Worker has capacity to work and the Employer provides the opportunity to work; and Review Certificates of Capacity to ensure a focus recovery at, or Return to Work or capacity for work Effective Communication and Engagement The Scheme Agent must ensure that communication and engagement with relevant parties is: Consistent (messaging and in line with the legislative intent); Respectful; Considerate of the Worker s and Employer s primary language, cultural background and literacy skills; and Documented and provides evidence about the chronology of a Claim. It includes notes and correspondence about conversations, Claims activities, decisions and expected outcomes Evidence Based Decisions Evidence based decisions include: Gathering relevant information; Considering all the implications of the decision on the relevant parties, including cost benefit, risk assessment and alternatives; Selecting the best option based on the most logical, rational, reasonable and commercial outcome; and Ensuring decisions are made and communicated within defined time frames. 3.3 Strategic Claims Management Third Party Service Provider Management Framework The Scheme Agent must monitor, evaluate and manage the performance of Third Party Service Providers in relation to quality, cost effectiveness, behaviours, outcomes, alignment with Scheme objectives and any other requirements to identify and address outliers, including over servicing, increased costs with no Benefit/outcome etc. Schedule 3 (Claims) Page: 21 of 23

22 3.3.2 Employer Obligations The Scheme Agent must ensure Policy holders are meeting their legislative obligations, especially their obligation to provide opportunities for Workers to recover at work through Suitable Employment Claims Operations Manual Media The Scheme Agent must comply with the requirements of Appendix F (Claims Operations Manual). The Scheme Agent must comply with the Media and Public Relations clause 48 (Media and Public Relations) of the Deed in relation to Claim risks Claims Management Capability Framework The Scheme Agent must ensure competency of Claims Management Personnel through recruitment based on competencies, building of capacity through the implementation of continuous training, development and support models. Schedule 3 (Claims) Page: 22 of 23

23 4. Appendices Appendix F (Claims Operations Manual) Appendix G (Claims Estimation Manual) Appendix H (Claims Technical Manual) Schedule 3 (Claims) Page: 23 of 23