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Evidence Guide: FNSPIM417 - Analyse and manage medical indemnity claims

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

 

FNSPIM417 - Analyse and manage medical indemnity claims

What evidence can you provide to prove your understanding of each of the following citeria?

Receive and organise information relating to medical indemnity claim

  1. Organise and collate information relating to the claim into a coherent file
  2. Enter relevant claim details in organisational systems
  3. Identify any information deficiencies and seek specific additional information from appropriate sources including medical experts
  4. Maintain confidentiality of information according to legislative requirements, industry principles and organisational requirements
Organise and collate information relating to the claim into a coherent file

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Enter relevant claim details in organisational systems

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify any information deficiencies and seek specific additional information from appropriate sources including medical experts

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain confidentiality of information according to legislative requirements, industry principles and organisational requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Research claim and validate medical indemnity claim information

  1. Determine type of medical indemnity claim and the key parties involved
  2. Assess sufficiency and thoroughness of information supplied including expert medical evidence
  3. Determine if case needs to be referred to other personnel according to organisational delegation rules for cases with unresolved complexity, abnormalities, classification uncertainties or insufficient information
  4. Review claim information to determine legitimacy of claim including validity and coverage of insurance policy
  5. Review, segment and prioritise claims for assessment of liability
Determine type of medical indemnity claim and the key parties involved

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess sufficiency and thoroughness of information supplied including expert medical evidence

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Determine if case needs to be referred to other personnel according to organisational delegation rules for cases with unresolved complexity, abnormalities, classification uncertainties or insufficient information

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Review claim information to determine legitimacy of claim including validity and coverage of insurance policy

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Review, segment and prioritise claims for assessment of liability

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess medical indemnity claim to determine cause, liability and quantum

  1. Undertake thorough and systematic review and assessment of facts, expert medical evidence and information relevant to circumstances of the claim
  2. Consult with technical and/or claims advisers to clarify information and seek advice as required
  3. Follow organisational procedures and use analysis tools to assess evidence in determining cause and liability
  4. Apportion liability and determine quantum fairly and impartially within limits of delegated authority according to regulatory and organisational guidelines
Undertake thorough and systematic review and assessment of facts, expert medical evidence and information relevant to circumstances of the claim

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consult with technical and/or claims advisers to clarify information and seek advice as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Follow organisational procedures and use analysis tools to assess evidence in determining cause and liability

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apportion liability and determine quantum fairly and impartially within limits of delegated authority according to regulatory and organisational guidelines

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Document decisions and determine quantum of claim settlement

  1. Record outcome of analysis documenting all relevant information used to support the decision-making process
  2. Use organisational tools and systems to determine quantum including claim settlement amount and note any additional considerations or exceptions
  3. Update organisational systems accurately with required information in a timely manner
Record outcome of analysis documenting all relevant information used to support the decision-making process

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use organisational tools and systems to determine quantum including claim settlement amount and note any additional considerations or exceptions

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Update organisational systems accurately with required information in a timely manner

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

ELEMENT

PERFORMANCE CRITERIA

Elements describe the essential outcomes.

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Receive and organise information relating to medical indemnity claim

1.1 Organise and collate information relating to the claim into a coherent file

1.2 Enter relevant claim details in organisational systems

1.3 Identify any information deficiencies and seek specific additional information from appropriate sources including medical experts

1.4 Maintain confidentiality of information according to legislative requirements, industry principles and organisational requirements

2. Research claim and validate medical indemnity claim information

2.1 Determine type of medical indemnity claim and the key parties involved

2.2 Assess sufficiency and thoroughness of information supplied including expert medical evidence

2.3 Determine if case needs to be referred to other personnel according to organisational delegation rules for cases with unresolved complexity, abnormalities, classification uncertainties or insufficient information

2.4 Review claim information to determine legitimacy of claim including validity and coverage of insurance policy

2.5 Review, segment and prioritise claims for assessment of liability

3. Assess medical indemnity claim to determine cause, liability and quantum

3.1 Undertake thorough and systematic review and assessment of facts, expert medical evidence and information relevant to circumstances of the claim

3.2 Consult with technical and/or claims advisers to clarify information and seek advice as required

3.3 Follow organisational procedures and use analysis tools to assess evidence in determining cause and liability

3.4 Apportion liability and determine quantum fairly and impartially within limits of delegated authority according to regulatory and organisational guidelines

4. Document decisions and determine quantum of claim settlement

4.1 Record outcome of analysis documenting all relevant information used to support the decision-making process

4.2 Use organisational tools and systems to determine quantum including claim settlement amount and note any additional considerations or exceptions

4.3 Update organisational systems accurately with required information in a timely manner

Required Skills and Knowledge

ELEMENT

PERFORMANCE CRITERIA

Elements describe the essential outcomes.

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Receive and organise information relating to medical indemnity claim

1.1 Organise and collate information relating to the claim into a coherent file

1.2 Enter relevant claim details in organisational systems

1.3 Identify any information deficiencies and seek specific additional information from appropriate sources including medical experts

1.4 Maintain confidentiality of information according to legislative requirements, industry principles and organisational requirements

2. Research claim and validate medical indemnity claim information

2.1 Determine type of medical indemnity claim and the key parties involved

2.2 Assess sufficiency and thoroughness of information supplied including expert medical evidence

2.3 Determine if case needs to be referred to other personnel according to organisational delegation rules for cases with unresolved complexity, abnormalities, classification uncertainties or insufficient information

2.4 Review claim information to determine legitimacy of claim including validity and coverage of insurance policy

2.5 Review, segment and prioritise claims for assessment of liability

3. Assess medical indemnity claim to determine cause, liability and quantum

3.1 Undertake thorough and systematic review and assessment of facts, expert medical evidence and information relevant to circumstances of the claim

3.2 Consult with technical and/or claims advisers to clarify information and seek advice as required

3.3 Follow organisational procedures and use analysis tools to assess evidence in determining cause and liability

3.4 Apportion liability and determine quantum fairly and impartially within limits of delegated authority according to regulatory and organisational guidelines

4. Document decisions and determine quantum of claim settlement

4.1 Record outcome of analysis documenting all relevant information used to support the decision-making process

4.2 Use organisational tools and systems to determine quantum including claim settlement amount and note any additional considerations or exceptions

4.3 Update organisational systems accurately with required information in a timely manner

Evidence of the ability to:

Collate, analyse and research medical indemnity claims information

Assess claim to determine causation, apportion liability and determine quantum for medical indemnity claims.

Document decisions and update records.

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

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

identify and explain key features of relevant regulatory requirements and industry codes of practice relating to medical indemnity claims

describe the types and key features of medical indemnity insurance policy coverage and terms and conditions

outline risk management in the medical indemnity context

outline organisational procedures for medical indemnity claims evaluation including the use of case law

explain organisational systems and administrative requirements for data entry and filing including coding requirements

describe the organisation's methodology for determining causation and apportioning liability

outline requirements of health practitioners in providing expert medical evidence including qualifications and experience

list and describe key legal terminology used in the medical indemnity sector

provide a brief overview of the principles of cost estimating in claims assessments

describe analysis tools used to assess medical indemnity claims and to calculate losses or damages

describe organisational arrangements for delegations of authority.