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Claim File and System Documentation Part 1

Sunday, November 24, 2002 | 0

Importance of Documentation

File documentation is critical from both a communication as well as a legal standpoint. This documentation represents the lifeline and history of the claim. There are potentially many people that will be reviewing a claim throughout the course of the claims history. They need to be able to understand what was going on with the claim at all times. In addition, with the hundreds of claims files you are responsible for, you need to be able to quickly, and easily, understand the status of each individual claim. Thorough and professional file documentation is an absolute requirement to ensure effective and consistent handling of any claim. It is critical that the file documentation be concise and easy to understand for the layman.

As you will see in this series, there are different kinds of documentation depending on the ultimate purpose, as well as different documentation strategies.

Kinds of Documentation

Files are documented in two ways, electronically in the claims management system, and on paper in the claim file. The paper file and the on-line system documentation will become a permanent record of your representation as an employee, and your interpretation of the claim file during the period of time that you are the handling Adjuster. In other words, file documentation is your work product and directly reflects your skills, abilities, and most importantly, your professionalism.

Who Will Be Reviewing Your Documentation?

There are many others through out the claims history that will be reviewing your work: other Adjusters who may handle the file, all levels of management, auditors (claim technical, operational and financial), other auditors within your branch office, corporate, etc., external reinsurance auditors and state regulators.

In other words, what you write gets reviewed by many people. The point being, you need to always plan and think about what you are going to document before you document it.

Another very important "rule" that seems to follow hand in hand with documentation: "if it is not documented in the file, it doesn't exist". This means that those reviewing the file cannot rely on representations that something was or wasn't done - not documenting the file is as bad as not performing a required function. Documentation is part of the job, a very necessary part of the job.

What Documentation Can Be Released?

While it is important to document the claim file, it is just as important to document the file properly. Understanding what kind of information can be made public, or released to third parties, will help guide your documentation.

In most states, the employer is allowed to review the claim file. But, depending on the state, the information that they are entitled to varies. In most states, the employer is generally restricted to viewing your action plan, the agent status reports, medical reports (though this is becoming more and more limited in scope - California for instance permits the employer to view only that medical information that either affects the employer's premium, or affects return to work decisions), and reserve documentation (both paid and outstanding).

What Documentation Is Privileged?

Some documentation is privileged from general viewing, and states will vary about what is and isn't privileged, as well as degrees of privileged status.

In general, privileged information will include:
Legal correspondence,
Depositions, and
Investigation reports.
Check your state jurisdiction and account guidelines as this can vary. In most cases, if you restrict the release of information, the requesting party has the option to subpoena the documentation. Your company policies (generally created by the company's counsel) on document release were created to eliminate confusion in this arena.

The next article in this series will review the different kinds of documentation, how and why they are generated, and the significance of each type of documentation so you have an understanding as to what can happen given any particular piece of documentation.

Author, Cyndi Koppany, is Director of Corporate Training for Cambridge Integrated Services Group, Inc. E-mail her at ckoppany@earthlink.net.


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