Provided to Agrip 12-27-02 by Lester Nixon, Mncia Ex. Dir. Since This Is Intended As A

PROVIDED TO AGRIP 12-27-02 BY LESTER NIXON, MNCIA EX. DIR. SINCE THIS IS INTENDED AS A SAMPLE DOCUMENT TO BE USED IN DEVELOPING A CLAIMS MANUAL, THE FORMAT HAS BEEN MODIFIED FOR EASE OF ELECTRONIC TRANSMISSION. H. PUMFORD

NEW MEXICO COUNTY

INSURANCE AUTHORITY

MULTI-LINE CLAIMS UNIT

ADMINISTRATIVE PROCEDURES

Table of Contents

Quality Standards and Claim Procedures Manual Page

NMCIA Multi-Line Claims Unit Administrative Procedures 1-3

NMCIA Multi-Line Claims Manual (Including Law Enforcement)

Multi-Line Claim File Set Up and Maintenance 4

Data Entry for New/Revised NMAC Locations 5

Assignment of New Multi-Line Claims by Supervisors 6

Multi-Line Claim Processing 7-11

Claim Denial Procedure 12

Reserving Procedure 13-14

Excess Claim Reporting 15-16

Request for Reserve Authority In Excess of Established

Limits For Claims Examiners, Claims Manager 17

Request for Settlement Authority for the NMAC 18

Multi-Line Deductible Billing Process 19-20

Supervisor Oversight of Multi-Line Claims 21

Check Writing Security Procedures 22

Check Writing Procedure 23

Requests for Checks in Excess of Authority Levels 24

Voiding of Incorrect/Duplicate Checks 25

Requesting Stop Payments on Checks 26

Crediting of Recoveries to Claim Files 27

Closure of Multi-Line Claim Files 28

Multi-Line Claim Filing 29

Sending/Retrieving file to/from Off Site Storage 30

File Destruction 31

Claim File Review Process 32

NMAC Property/Liability Quality Standards 33-41

NMAC Property and Liability Litigation Policy and Procedure

Initial Receipt of Lawsuit 42-43

Coverage Issues 43

Selection of Defense Counsel 44

Assignment to Defense Counsel 44

Contents of the Legal File 45

Discovery 45-46

Settlement and Alternative Dispute Resolution (ADR) 46-47

Trials 47

Post Trial and Closing Procedures 48

Defense Counsel Billing Requirements 48 Litigation Glossary 49-54

Claims Examiner Litigation Checklist 55

(Template) Assignment to Defense Counsel 56

List of Approved Defense Counsel 57-58

NMAC Claim Office Administrative Procedures

Claims unit consists of:

Risk Manager

Claims Manager for Worker’s Compensation and Claims Manager for Multi-Line

Claims Examiner(s)

Claims Service Representative

Administrative Assistant

Purpose:

These procedures are structured to facilitate the effective movement of verbal and written communications within the claim unit and with the NMAC Risk Management Department and the members.

Mail

The Receptionist must date stamp all incoming mail, including certified and express mail deliveries, on an inconspicuous area of the document.

• Every page needs to be date stamped.
• The envelope should be examined to assist in directing the mail to the proper recipient and attached to item.
• Any mail that cannot be identified to a recipient will be delivered to a supervisor/manager for identification.

All lawsuits for property/liability claims and all unidentified mail will be delivered to the appropriate supervisor for review.

The Administrative Assistant must process all outgoing mail on a timely basis to include all mail designated as needing to be sent via certified mail.

Faxes

The Administrative Assistant must check all fax machines hourly in order for incoming faxes to be delivered to the recipient.

• A search in RISKMASTER must be conducted to attempt to determine the intended recipient of faxes not directed to a specific person.

Confidential Multi-Line fax cover sheets must be attached to outgoing faxes and returned to the sender on an hourly basis.

Copy Work

Files needing copy work will be given to the Administrative Assistant for processing.

The person requesting copies must attach an instruction sheet to the work to be copied.

• The instruction sheet must indicate who is requesting the copies, what needs to be copied, number of copies needed, desired date of completion, and any special instructions.
• Completed copies will be returned to the requesting person on time.
• Late delivery of requests must be communicated to the requesting individual, including the time frame when the work will be completed.

Vendor Additions/Changes

The Claims Representative must add all vendor changes into RISKMASTER within 24 hours of receipt of the changes/additions/deletions. The vendor addition request must include:

• Vendor name
• Address
• Phone number
• Federal Tax Identification Number
• Person making the request
• Date of vendor change/additions/deletion request

No vendors will be added to the system if the above information is not provided.

The Administrative Assistant will serve as the back-up vendor addition person.

File Storage (Open & Closed)

Please refer to the Workers’ Compensation Claims Procedures Manual and Property and Liability Claims Procedures Manual for additional procedures.

The Multi-Line Claims Service Representative will process the files for transfer to the off-site vender.

Monthly Loss Run Production

NMAC-WORKERS' COMPENSATION and NMAC-MULTI LINE members receive a monthly loss run of their open claims.

The Claims Representative will be responsible for ensuring the reports are generated and mailed out in a timely manner.

• The reports are to be mailed out by the 3rd business day of the month.

Check Processing

The Claims Representative is responsible for producing and tracking all checks authorized by examiner.

Check logs must be maintained on each fund (NMAC-MULTI LINE, NMAC LAW ENFORCEMENT AND LIABILITY, NMAC-WORKERS' COMPENSATION) that account for each check number in sequence.

Envelopes must be attached to all NMAC issued checks that are returned to the claims office for insufficient address/incorrect postage, etc. These checks will be given to the appropriate Claims Service Representative so an investigation can be made to determine the reason the check was returned.

All checks that are processed but not mailed out must be secured in a locked cabinet for mailing out the next day.

Any printer problems that cause checks to be voided must be brought to the attention of the Claims Manager.

All check stock must be secured in a locked area when not in use.

All incoming checks will be stamped with the appropriate “For Deposit Only” stamp upon arrival by finance. A copy of the stamped check will be given to the appropriate Claims Examiner.

All checks that are to be voided must be documented in RISKMASTER by Claims Representative and given to Risk Management Specialist to capture the check number, amount, payee and the reason for the void.

Deductible Billing Process

The Claims Representative must produce the weekly deductible billing invoices based on the deductible billing request forms completed by the Claims Examiner.

• The invoices must be produced in the NMAC's designated accounting system.

Finance must deposit the paid deductible billing invoice payments and must provide documentation of the payments to the Claims Representative for posting into the RISKMASTER accounting system.

The Claims Manager must review the unpaid deductibles report to confirm its accuracy to NMAC.

Index System

The Claims Representative accesses the Index Bureau and submits all bodily injury claims and lost time workers’ compensation claims electronically.

The Claims Examiners are responsible for gathering the information needed to complete the Index process.

• The date the index submission is completed will be documented in the base information screen within RISKMASTER.
• The Claims Examiner must re-index the claim at six-month intervals if the claim remains open.

Posting of Recoveries to RISKMASTER

The Claims Representative must post all recoveries in RISKMASTER under the proper recovery type upon receipt.

• The recovery types are Subrogation/Refunds/Excess Expense Carrier recoveries/ Salvage/ Deductibles.
• A copy of the check needs to be maintained in the claim file as well as the deposit transaction documentation.
• All checks waiting to be deposited will be secured in a locked cabinet in finance.
• Claims Examiner needs to be notified of receipt and posting of recovery checks.

System Back-ups

The Risk Management Specialist must complete a backup of the network as follows:

• Daily – to be stored onsite.
• Weekly – stored offsite.
• Monthly – The NMAC Information Officer will secure the tape containing the month’s data so it can be stored off-site.

The date of the backup must be written on the outside of the backup tape.

Backups stored in the Santa Fe office must be retained for 12 months.

Computer Software and Hardware Maintenance

The Risk Management Specialist must schedule and oversee the completion of all needed office, building, and office equipment maintenance.

The individual identifying an issue must provide specific information for maintenance requests to the Administrative Assistant.

• Necessary corrections must be initiated on the day the request is made, and followed through to completion.

The Administrative Assistant must discuss unresolved issues and all repairs that will generate a cost to NMAC with the Risk Manager for direction and approval.

NMAC Claim Office Policies and Procedures

Purpose:

The policies and procedures are structured to ensure compliance with the mission to provide exceptional customer and claims management services. These policies and procedures address a variety of topics that impact the overall operations and functions of the Claims Unit.

Business Hours

The NMAC observes a 40-hour workweek. Each workday is eight (8) hours with one (1) hour lunch break. All employees will complete an NMAC timesheet to reflect worked hours and time off from work. Timesheets are to be submitted each designated pay period.

Subject to Management approval, flex-hours may be implemented. Management, at its sole discretion, reserves the right to implement the standard NMAC office work hours of 8:00 am to 5:00 pm.

Possible Flex hours are:

7:30 am to 4:30 pm

8:00 am to 5:00 pm

8:30 am to 5:30 pm

Requests for flex-hours should be presented to the employee’s immediate supervisor or manager. Consideration will be given based upon available staffing, workload, and pending Claims Unit activities.

Attendance

Employees are expected to report for work punctually and be prepared for the tasks appropriate to each individual’s position. Excessive tardiness and absenteeism creates a hardship on fellow employees and significantly impairs the ability of the Claims Unit to deliver exceptional customer and claim management services.

Occasionally, employees need time off from work, either due to personal or family illness. Except in cases of extreme emergency, employees are expected to notify their immediate supervisor or manager prior to the beginning of their workday to report personal or family illnesses. Absences due to family illness may be granted at the discretion of the immediate supervisor or manager and will include only immediate family members residing in the employee’s household and in the immediate care of the employee. Employees should phone their supervisor or manager directly to report their absence. A voicemail message does not serve as adequate and proper notice.

Absences in excess of two (2) consecutive workdays or absences exceeding five (5) workdays in a thirty (30) day period will require a release from a physician prior to the employee returning to work.

In the case of extreme emergency, employees are expected to notify their supervisor or manager as soon as is practically possible.

Requests for Time Off

Requests for time off, including vacation, medical or personal leaves of absence, bereavement, jury duty, military assignment or other time away from work should be submitted in writing to the employee’s immediate supervisor or manager. Dates of expected absence, nature of absence, and anticipated date of return to work are to be documented. Each request will be signed by the employee and reviewed by the immediate supervisor or manager. The supervisor or manager will document on the request the ability to accommodate the request for time off. The supervisor or manager will retain a copy of the request with the original request returned to the employee.

Requests for time off will be reviewed after careful consideration for adequate staffing coverage, workload, and pending Claims Unit activities.

Inclement Weather Conditions Necessitating Absence from Work

Common sense should be used in determining if weather conditions are safe for travel to and from work. In all situations, employees are expected to use reasonable efforts to report to work. Should an employee be unable to travel safely to and from work, the policies regarding attendance will apply. Employees may use accrued vacation time for isolated missed workdays when weather has been a factor.

Voice Mail Greeting and Messaging Functions

Voice mail is not a substitute for exceptional customer service and, in all cases, all employees are expected to make every effort to attend to each phone call. If, however, the employee is away from his/her desk or is on another line, callers may be routed to voice mail.

Employees are to record an appropriate greeting to advise callers of availability. Greetings must advise callers of procedures to “zero out” of the voice mail system to speak with an individual. In all cases, voice mail messages should be returned on the same business day in which they are received. In extreme circumstances, it may be necessary to return calls the next business day. In no event will voice mail messages go unanswered for more than one (1) full business day.

Dress Code

Appropriate business dress is essential to the professional functioning of a service-related activity. The dress code for the Claims Unit is “Business Casual Attire.” Business casual attire includes:

• Dresses (including denim skirts and jumpers with appropriate sport tees)
• Suits
• Skirts – moderate length (no mini skirts)
• Sweaters
• Slacks – Dress, Khaki, Dockers or Stirrup Pants
• Casual day as scheduled (includes denim jeans, but not T-Shirts or shorts)

“Business Casual Attire” DOES NOT INCLUDE:

• Leggings capri or spandex sports clothes
• Strapless or spaghetti strap dresses or blouses
• Tank tops
• Halter tops
• Athletic wear including sweat suits or jogging suits
• T-Shirts (Souvenir or T-Shirts with messages imprinted)

Employees reporting to work in inappropriate attire may be asked to change. Time away from work for the purposes of changing clothes will not be compensated. Decisions regarding attire are at the discretion of management.

Employees will wear Business Attire when visiting a client, vendor, provider, claimant or other external customer.

Use of Personal Automobiles

Occasionally, it is necessary for employees to travel on company business using their personal automobiles. Prior approval from the employee’s supervisor or manager is required. Employees will notify their supervisor or manager prior to any business related travel. Authorization for business related travel will be at the discretion of NMAC management. The Risk Manager or Claims Manager may grant approval. In all cases, the employee’s immediate supervisor or manager must be notified of the intended purpose of travel, estimated expense and length of time away from work.

Employees will be reimbursed the NMAC approved rate per mile for authorized travel when using personal vehicles. All employees are required to complete an expense report. Expense reports must be completed immediately upon completion of the business related travel. Expense reports will be submitted to the Claims Manager for approval.

Office Safety and Security

Awareness and attention to personal safety and security is the responsibility of all employees. Every effort will be made to keep the NMAC Claims Unit location as safe as possible. However, in the unlikely event of suspicious or threatening circumstances, the situation should be brought immediately to the attention of the Claims Manager. The Claims Manager will access the situation and make appropriate assignments regarding notifying authorities or other emergency procedures.

Claimants are NOT to visit the office for purposes of conducting claims related business: picking up checks, signing releases, etc. If claimants request this as an option, they are to be instructed that appropriate information/documentation will be mailed to their designated address. Under no circumstances are employees to grant permission for claimants to visit the Claims Unit office.

Each employee will be assigned a key to the office space. The rear entrance/exit door of the Claim Unit office is to remain locked at all times, although the door may be used for entry/exit.

The first staff member arriving each morning will de-activate the security system. The last person leaving each evening is to engage the security system and ensure its proper setting.

Employees whose work areas are located near windows must close the blinds at the close of business each day.

Employees who bring space heaters, fans or other electrical devices from home must use only Underwriters Laboratory approved devices. Employees must also obtain prior approval of their immediate supervisor or manager before using electrical appliances in the work area. Cords that are frayed, items not UL approved or items that may interfere with the work environment or function may not be used in the work area. All electrical devices are to be unplugged at the close of business each day and safely stored, away from paper or other flammable products.

Office Supplies

All requests for office supplies are to be coordinated through the Receptionist. When employees notice standard supplies are low, notify the Receptionist for re-order. All requests for individual use supplies over $50.00 are to be approved by the Claims Manager and will be coordinated through the Receptionist for order.

Break Room and Common Areas

A clean, orderly work environment is critical to the success of the Claims Unit. It is the responsibility of each employee to assist in keeping the break room and all common areas clean and neat. Employees who use the refrigerator and microwave must clean any spills and discard any unused items immediately. Coffee mugs, dishes and silverware must be washed and dried at frequent intervals and at the close of business each day. All employees need to be mindful of their responsibility to maintain a sanitary and neat working environment.