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PDFWAC 296-15-350

Handling of claims.

What elements must a self-insurer have in place to ensure appropriate handling of claims? Every self-insurer 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) There must be at least one certified claims administrator involved in the daily management of the employer's claims.
(b) If claims are administered in more than one location, there must be at least one certified claims administrator in each location where claims are managed. Effective July 1, 2020, to ensure consistent application and delivery of benefits pursuant to Washington laws, every person making claim decisions outside the state of Washington must be a certified claims administrator and maintain core business office hours for Pacific Standard Time. 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.
(c) Excluded from the requirement of (b) of this subsection are those persons who manage operations indirectly in support of claims administrators, such as, human resources, accounting, or executive management.
(d) When a new person is hired by the out-of-state employer to make claims decisions, if the new person is not already a certified claims administrator, then the new person 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 and maintain a minimum of one Washington certified employee at each out-of-state location where claims are managed. 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.
(e) When a certified claims administrator leaves the hire of an employer or third-party administrator, whether in-state or out-of-state, and this results in an employer 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 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. 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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