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PDFWAC 296-15-350

Handling of claims.

What elements must a self-insurer or third-party administrator (TPA) have in place to ensure appropriate handling of claims? Every self-insurer or TPA must:
(1) Establish procedures for securing the confidentiality of claim information.
(2) Have sufficient numbers of certified claims administrators to ensure uninterrupted administration of claims. In this regard:
(a) Effective July 1, 2021, every person making claim decisions must be a certified claims administrator or in the process of getting their certification. For the purposes of this section, every person making claim decisions includes:
(i) Those persons who manage claims directly; and
(ii) Who request to allow or deny claims under WAC 296-15-420;
(iii) Take action on claims under WAC 296-15-425; or
(iv) Close claims under WAC 296-15-450.
(b) Excluded from the requirement of (a) of this subsection are those persons who manage operations indirectly in support of claims administrators, such as, human resources, accounting, or executive management.
(c) When a new person is hired by the employer or TPA to make claims decisions, if the new person is not already a certified claims administrator, then the new person, within six months of hire, must begin working toward achievement of certification through a comprehensive goal-oriented curriculum approved by the department to achieve certification within two years. While in process of meeting educational needs, the employer must ensure mentoring is provided by a Washington certified claims administrator. Providers of the comprehensive goal-oriented curriculum will conduct regular training courses to allow for a new person in the process of completing the training to successfully manage Washington claims and achieve Washington certification within two years. This will include considering online alternatives, when feasible.
(d) When a certified claims administrator leaves the hire of an employer or TPA, and this results in an employer or TPA temporarily not meeting the qualifications for a certified claims administrator, the employer may apply for a temporary waiver for up to six months pending hiring of a replacement.
(3) Designate one certified claims administrator as the department's primary contact person for claim issues.
(4) Designate one address for the mailing of all claims-related correspondence. The self-insurer is responsible for forwarding documents to the appropriate location if an employer's claims are managed by more than one organization.
(5) Establish procedures to answer questions and address concerns raised by workers, providers, or the department.
(6) Ensure claims management personnel are informed of new developments in workers' compensation due to changes in statute, case law, rule, or department policy.
(7) Include the department's claim number in all claim-related communications with workers, providers, and the department.
(8) Legibly date stamp or produce an imprint on incoming correspondence, identifying both the date received and the location or entity that received it.
(9) Ensure a means of communicating with all injured workers.
[Statutory Authority: RCW 51.04.020, 51.32.190 and 2020 c 277. WSR 21-11-083, § 296-15-350, filed 5/18/21, effective 7/1/21. Statutory Authority: RCW 51.04.020. WSR 19-01-095, § 296-15-350, filed 12/18/18, effective 7/1/19. Statutory Authority: RCW 51.04.020, 51.14.030. WSR 14-02-121, § 296-15-350, filed 1/2/14, effective 2/2/14. Statutory Authority: RCW 51.04.020, 51.14.020, 51.32.190, 51.14.090, and 51.14.095. WSR 06-06-066, § 296-15-350, filed 2/28/06, effective 4/1/06.]
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