QA Nicole Baldwin 2014 YTD

Claim Rep Id Casualty Adequacy Report - Claims Associate
Discipline
Line Coverage Prepared on : 1/27/15
Quarter
Year BALDWIN3
Number of Files Casualty
BI;BIUI;BIUM
1;2;3;4
2014
20

Source of Data Manager PLBI Closed File Review;Manager PLBI Open File Review
Saved Status Final Saved
Overall Adequacy - NIC 97.69%

SPECIAL NOTE: The Overall Adequacy score for the claims associate does not include Q#22 of the Manager or Q#24 of t
phases. SCORECARD RESULTS FOR CLAIMS ASSOCIATE: Is the Overall Adequacy utilizing the NIC ind

Contact & Customer Value
Q

O

r

d Yes No
Drivers of Inadequacy Count Counts Counts
eQ # Question
00
Were appropriate efforts made to obtain contact
information on involved parties as needed?

1 Were the first contacts timely and of quality? 20 0
20 0
Were the Claims Associate subsequent contacts 18 2
2 appropriate?

Was written communication clear, concise and
3 grammatically correct?

1 letter/email 2 0 0

Did the claim associate capture accurate e-mail addresses 0 0
and other contact information? 58 2

Question Totals:

Coverage Question Yes No
Q Drivers of Inadequacy Count Counts Counts
O
r
d
eQ #

4 Was the coverage analysis appropriate? 19 1

Quality 1 0 0

5 Were the coverage issues appropriately communicated? 2 0
21 1
Question Totals:

Investigation Question Yes No
Q Drivers of Inadequacy Count Counts Counts
O
r 80
d
eQ #

Were recorded interviews and/or statements taken and
6 documented?

7 Was indexing handled appropriately? 19 1

Match Not Addressed 10 0

8 Was the MD Partnership appropriate? 30
30
Were loss of earnings claims investigated and
9 documented?

10 Applicable claims documents secured? 00
81
Were medical bills audited? (answer for both first party 17 0
11 medical and third party claims)

Were all other aspects of the liability, damages/injury
12 investigation appropriate?

13 Were appropriate resources utilized? 10

14 Was potential fraud exposure recognized and addressed? 00
59 2
Question Totals:

Evaluation Question Yes No
Q Drivers of Inadequacy Count Counts Counts
O
r
d
eQ #

Did the Claims Associate make a timely and appropriate 20 0
15 liability decision and was it documented?
00
Did the Claims Associate recognize and pursue
16 contribution/subrogation? 70

Did the Claims Associate make a timely and accurate 60
17 evaluation of the injury/damages? 33 0

Was the information from the medical bill review
18 considered in the evaluation?

Question Totals:

Reserving Question Yes No
Q Drivers of Inadequacy Count Counts Counts
O
r
d
eQ #

Were reserves set in a timely manner and at the 20 0
19 appropriate level? 20 0

Question Totals:

Negotiation Question Yes No
Q Drivers of Inadequacy Count Counts Counts
O
r
d
eQ #

20 Was the overall negotiation process adequate? 70

Did the Claims Associate recognize the need to make a 00
21 monetary offer early in the claims process? 70

Question Totals:

Manager Question Yes No
Q Drivers of Inadequacy Count Counts Counts
O
r
d
eQ #

22 Was the manager in the file? 19 1

23 Was manager advisory direction followed? 7 1
0 0
Direction partially followed or 1
addressed

Question Totals: 71

Disposition Question Yes No
Q Drivers of Inadequacy Count Counts Counts
O
r
d
eQ #

24 Was the loss payment appropriate? 90

25 Appropriate Release/Receipt Used? 70
16 0
Question Totals:

Compliance Questions

Q

O

r

d Yes No
Drivers of Inadequacy Count Counts Counts
eQ # Question

28 Was a query to CMS completed on all injured claimants? 19 0
2 18
Does the claimant meet the Medicare Secondary Payer 00
29 reporting requirements? 50
10
If there is an existing lien, was the Medicare lien 00
30 compromised or satisfied? 00

Did the Claims Associate utilize appropriate resources to
31 secure the SSN?

Was the Medicare reporting form utilized and submitted
32 properly?

If establishing an MSA is necessary, were appropriate
33 steps taken?

Were matters entered and/or closed in the legal tracking
system? - (Changed for 2015. In 2013 it was 'Was CCS
49 used?')

35 Was an adverse risk report submitted if necessary? 21

Unlisted driver 10 0

Was the At Fault indicator updated appropriately? 00
27 1
Question Totals:

Supplemental Questions
Q

O

r

d Yes No
Drivers of Inadequacy Count Counts Counts
eQ # Question
50
Did the MD Claims Associate authorized to issue the PD

payment apply comparative / contributory negligence as

instructed in the payment authorization sent by the

36 Casualty Associate?

Were all liens satisfied as appropriate? 00

47 State Specific Question 11 10

48 State Specific Question 12 01

49 State Specific Question 13 00

50 State Specific Question 14 00

51 State Specific Question 15 00

52 State Specific Question 16 00

53 State Specific Question 17 00

54 State Specific Question 18 00

55 State Specific Question 19 00

56 State Specific Question 20 23

Question Totals:

of the Manager or Q#24 of the Payment
dequacy utilizing the NIC indicator.

NA Possible Adequacy
Counts Counts utilizing the

NIC
Adequacy indicator

1 0 N/A NA

0 20 100.00% 100%

0 20 100.00% 100%

0 20 90.00% 90%

0 0 N/A NA

1 0 N/A NA
0 60 96.67% 96.67%

NA Possible Adequacy
Counts Counts utilizing the

NIC
Adequacy indicator

0 20 95.00% 95%

0 0 N/A NA

18 2 100.00% 100%
18 22 95.45% 95.45%

NA Possible Adequacy
Counts Counts utilizing the

NIC
Adequacy indicator

12 8 100.00% 100%

0 20 95.00% 95%

0 0 N/A NA

17 3 100.00% 100%

17 3 100.00% 100%

20 0 N/A NA

11 9 88.89% 100%

3 17 100.00% 100%

19 1 100.00% 100%

20 0 N/A NA
119 61 96.72% 98.33%

NA Possible Adequacy
Counts Counts utilizing the

NIC
Adequacy indicator

0 20 100.00% 100%

20 0 N/A NA

13 7 100.00% 100%

14 6 100.00% 100%
47 33 100.00% 100.00%

NA Possible Adequacy
Counts Counts utilizing the

NIC
Adequacy indicator

0 20 100.00% 100%
0 20 100.00% 100.00%

NA Possible Adequacy
Counts Counts utilizing the

NIC
Adequacy indicator

13 7 100.00% 100%

20 0 N/A NA
33 7 100.00% 100.00%

NA Possible Adequacy
Counts Counts utilizing the

NIC
Adequacy indicator

0 20 95.00% 95%

12 8 87.50% 87.5%

0 0 N/A NA

12 8 87.50% 87.50%

NA Possible Adequacy
Counts Counts utilizing the

NIC
Adequacy indicator

11 9 100.00% 100%

13 7 100.00% 100%
24 16 100.00% 100.00%

NA Possible Adequacy
Counts Counts utilizing the

NIC
Adequacy indicator

1 19 100.00% 100%

0 20 10.00% 10%

20 0 N/A NA

15 5 100.00% 100%

19 1 100.00% 100%

20 0 N/A NA

1 0 N/A NA

17 3 66.67% 66.67%

0 0 N/A NA

1 0 N/A NA
93 28 96.43% 96.43%

NA Possible Adequacy
Counts Counts utilizing the

NIC
Adequacy indicator

15 5 100.00% 100%

1 0 N/A NA

4 1 100.00% 100%

4 1 .00% 0%

5 0 N/A NA

5 0 N/A NA

5 0 N/A NA

5 0 N/A NA

5 0 N/A NA

5 0 N/A NA

5 0 N/A NA

0 5 40.00% 40%

%%