200-110-110  <<  200-110-120 >>   200-110-130

WAC 200-110-120

Standards for claims management—Claims administration.

(1)(a) All self-insurance programs shall have a written claims administration program which includes, as a minimum, claims filing procedures, internal financial control mechanisms, and claim and claim adjustment expense reports.
(b) All individual and joint health and welfare self-insurance programs shall have a written claim appeal procedure that contains, as a minimum, a time limit for filing an appeal, a time limit for response, and a provision for the second level of review.
(2) All self-insurance programs may perform claims administration services on their own behalf or may contract for claims administration services with a qualified third-party administrator, provided all of the specific requirements under subsection (1) of this section are included in the contract.
(3) All joint self-insurance programs shall maintain a financial system that identifies claim and claim adjustment expenses.
(4) All joint self-insurance programs shall maintain claim expense reports for all claims made against the joint self-insurance program and its members.
(5) All self-insurance programs offering medical coverage shall obtain a claims audit of claim reserving, adjusting and payment procedures every three years at a minimum. A claims audit shall be conducted by a qualified claims auditor not affiliated with the program, its broker of record, or its third-party administrator. Such review shall be in writing and identify strengths, areas of improvement, findings, conclusions and recommendations. Such review shall be provided to the governing body and retained for a period not less than six years. The scope of the claims audit shall include claims administration procedures listed in subsection (1) of this section.
(6) The state risk manager may require more frequent claims audits for programs that, in the state risk manager's opinion, are not operationally or financially sound. Failure to obtain the requested independent claims audit when required may result in the procurement of such audit by the state risk manager on behalf of the program. Costs of these services shall be the responsibility of the self-insurance program.
[Statutory Authority: 2011 c 43. WSR 11-23-093, recodified as § 200-110-120, filed 11/17/11, effective 11/17/11. Statutory Authority: RCW 48.62.061. WSR 10-14-034, § 82-65-120, filed 6/28/10, effective 10/1/10.]
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