Washington Administrative Code
Title 200 - Enterprise Services, Department of
RISK MANAGEMENT
Chapter 200-150 - Self-insurance requirements as to nonprofit corporations
Section 200-150-050 - Standards for claims management-Claims administration
Current through Register Vol. 24-06, March 15, 2024
(1) All joint self-insurance programs shall adopt a written claims administration program which includes, as a minimum, the following procedures:
(2) All joint 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 have a written member coverage appeal procedure that contains, as a minimum, procedures for a member filing an appeal with the joint self-insurance program, including the time limit for filing, a time limit for response, and a provision for an additional level of review.
(4) All joint self-insurance programs shall maintain a financial system that identifies claim and claim adjustment expenses.
(5) All joint self-insurance programs shall provide for the purchase of goods and services to replace or repair property in a manner which will, in the judgment of the governing body of the joint self-insurance program, avoid further damage, injury, or loss of use to a member or third-party claimant.
(6) All joint self-insurance programs shall maintain claim expense reports for all claims made against the joint self-insurance program and its members.
(7) All joint self-insurance programs shall obtain an independent audit of claim reserving, adjusting and payment procedures every three years at a minimum. The audit shall be conducted by an independent qualified claims auditor not affiliated with the program, its insurers, 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.
(8) 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 joint self-insurance program.