CSR SPR Criteria - Loss Cost Management

mcvonbraun's version from 2015-06-17 20:32

Section 1

Question Answer
While completing FNOL in CSR, what is appropriate regarding reserves?It is appropriate to open applicable reserve lines.
What happens if the reserve lines are not opened at the time of completing the FNOL?Atlas allows automatic opening of some exposures and reserve lines given the rules appropriate to that exposure. The examiner should allow the exposure and reserve line to auto open, if applicable, and not force a manual open prematurely.
Delayed updating of known information that creates a delay of auto open of an exposure or reserve line could be downgraded if what...?If the exposure or reserve line is not opened within 2 calendar days of the known exposure. Alternatively, a manual open of an exposure or reserve line prematurely could also result in a downgrade.
For reserve lines where handling complete is applicable, how should the reserve lines be closed?Utilizing the handling complete functionality. It's necessary for specific criteria to be updated in Atlas prior to changing handling complete to yes.
How long does the file handler have to update this criteria prior to setting handling complete to yes?The criteria must be updated within 15 days of known information to avoid a delay in converting handling complete to yes.
Through the normal progression of the claim, how long does the file handler have to mark handling complete on all non-injury reserve lines? Within 15 days the non-injury reserve line should be marked handling complete, 15 days from the final payment postingnotice to the file handler or at next activity date if no notice is provided (notice could be an email or receipt of an estimate). (Critical)
Manually closing a reserve line is improper unless it meets the criteria listed where?In Addendum A

Section 2

Question Answer
How long does the file handler have to issue payments?All payments should be paid within 15 days or within state specific requirements if more rigid, once the pertinent supporting documentation has been obtained, or an amount has been agreed upon. Payments must be made in accordance with Regional Authority Levels.
What are some questions that apply when reviewing payments on an SPR?1. Was the deductible waived, if applicable?
2. Was the waiver of deductible done timely?
3. Was the reason for the waiver documented?
4. Were all paycodes appropriate?
5. Were paycodes updated timely and AD notified?
6. Were all payments issued by liability accurate - the correct payee, reserve line (critical), TIN/expense code, and amount?
6. is there supporting documentation for the payment?
What type of payment is not evaluated in CSR review?Payments issued by Auto Damage

Section 3

Question Answer
What questions apply when reviewing PRU/recoveries by the CSR reviewer?1. Is there recovery potential?
2. Did the file handler refer the case to PRU timely?
3. Was the Atlas file referred to PRU within 15 days after auto open of subrogation? (critical)
4. Was information provided that would develop the file for recovery?
5. Was the adverse/responsible party placed on notice?
Failure to timely refer the file to PRU or no PRU referral will result in a downgrade
2. Establishing of unnecessary reserve lines
3. Failure to etablish the needed reserve lines
4. Incorrect reserve lines established
5. Insufficient reserves
6. Premature reserve line closure
7. Premature reserve line opened
8. Delayed payment
9. Improper payment
10. Owed payment
11. No PRU referral
12. Failure to utilize handling complete for COL/COMP/REN/PD/LOU