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Follow the links below to find material targeted to the unit's elements, performance criteria, required skills and knowledge

Elements and Performance Criteria

1. Receive and clarify claim information
   • Enter claim information into relevant organisational systems
   • Process claim in accordance with required timeframes and according to relevant Acts, regulations and organisational procedures
   • Complete correspondence in accordance with organisational policy and procedures, and allocate to relevant claims personnel
   • Advise clients of organisational claims procedures and respond to queries in an appropriate manner
   • Check claim information for accuracy and validity in accordance with organisational policy and procedures
2. Determine status of claim
   • Analyse all information against regulatory requirements and organisational guidelines to determine liability
   • Refer claims to internal or external specialists where required and in accordance with organisational guidelines
3. Accept or reject claim
   • Determine liability decision in accordance with organisational guidelines, regulatory requirements, industry codes of practice and defined timeframes
   • Adhere to referral procedures where claim amounts are outside settlement and/or claims management authority
   • Determine decision on liability, considering review and feedback from external stakeholders
4. Document liability decision
   • Communicate liability decisions to relevant stakeholders in accordance with regulatory requirements, operating procedures and relevant codes of practice
   • Communicate reasons for decisions promptly to clients and other relevant stakeholders
   • Document decisions and file to demonstrate basis on which claim decision was determined, including all evidence and information that was considered, where appropriate

Performance Evidence

Evidence of the ability to:

receive and clarify information and determine the status of a claim using organisational guidelines and regulatory requirements

document liability decision using organisational guidelines, and demonstrating knowledge of relevant Acts and regulations and organisational policies and procedures

analyse information to draw meaningful conclusions and determine correct action.

Note: If a specific volume or frequency is not stated, then evidence must be provided at least once.

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Knowledge Evidence

To complete the unit requirements safely and effectively, the individual must:

interpret and describe the key features of insurance policies, reports and related documents

describe the key analysis and research methods used to determine claim liability

categorise data into meaningful terms

outline the major steps in claim liability decision-making processes

describe the key features relevant to determining claim liability of:

insurance policies, reports and related documents

organisational claims processing software

organisational operating procedures

relevant workers compensation, personal injury Acts and regulatory requirements.

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