A general overview of the adjusting function. For most of us, it will be a refresher, but it will be very useful for people new to the business.
Handling Individual Claims Files
- Immediate acknowledgement
- Understand the coverage involved. Keep coverage in mind during the life of the claim.
- 24-hour contact (or attempted contact) with parties involved in the claim
- On-time reporting (7 to 14 days, depending upon client’s desires)
- Outline at the beginning of the report the extent of the assignment
- Appropriate aggressive follow-up until claim is concluded, or a passive approach is required
- Timely follow-up reporting
- Clear and proper evaluation and presentation of claim details to the client
- Proper file documentation throughout (whether using a paper file, or an imaged file)
- Appropriate storage of records in accordance with CPLIC guidelines
- Prompt closing and billing when file is concluded
- Proper dairy
The above items are applicable to TPA programs. However, there are many more items that adjusters handling TPA programs must keep in mind.
- You are generally reporting to someone who is not a claims professional. This places a high duty upon you to adjust, evaluate, and document the file properly.
- Maintain good accounting reports
- Provide detail reporting from risk management information systems on a regular basis.
- Report to excess carriers as soon as a case approaches the carrier’s guidelines for reporting.
- Those guidelines vary by excess carrier. This must be clearly documented in the file.
- Identify and request subrogation as soon as it is obvious.
- For workers’ compensation, understand second injury fund requirements, and comply with them promptly.
- All claims organizations should have accountability through diary systems.