Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners

FNSPIM417 Mapping and Delivery Guide
Analyse and manage medical indemnity claims

Version 1.0
Issue Date: May 2024


Qualification -
Unit of Competency FNSPIM417 - Analyse and manage medical indemnity claims
Description
Employability Skills
Learning Outcomes and Application This unit describes the skills and knowledge required to analyse and evaluate claims within a medical indemnity context. It encompasses collecting, analysing and using appropriate evidence and criteria to determine cause and apportion liability.It applies to individuals who use specialised legal and medical knowledge to make judgements within their level of responsibility. They work independently and in teams and take responsibility for assessing claims within a structured organisational framework. No licensing, legislative or certification requirements apply to this unit at the time of publication.
Duration and Setting X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.

Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the personal injury management field of work and include access to :

office equipment, technology, software and consumables

organisational records, policies and procedures.

Assessors of this unit must satisfy the requirements for assessors in applicable vocational education and training legislation, frameworks and/or standards.

Prerequisites/co-requisites
Competency Field
Development and validation strategy and guide for assessors and learners Student Learning Resources Handouts
Activities 		Slides
PPT 		Assessment 1 Assessment 2 Assessment 3 Assessment 4
Elements of Competency Performance Criteria              
Element: Receive and organise information relating to medical indemnity claim
  • Organise and collate information relating to the claim into a coherent file
  • Enter relevant claim details in organisational systems
  • Identify any information deficiencies and seek specific additional information from appropriate sources including medical experts
  • Maintain confidentiality of information according to legislative requirements, industry principles and organisational requirements
       
Element: Research claim and validate medical indemnity claim information
  • Determine type of medical indemnity claim and the key parties involved
  • Assess sufficiency and thoroughness of information supplied including expert medical 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
  • Review claim information to determine legitimacy of claim including validity and coverage of insurance policy
  • Review, segment and prioritise claims for assessment of liability
       
Element: Assess medical indemnity claim to determine cause, liability and quantum
  • Undertake thorough and systematic review and assessment of facts, expert medical evidence and information relevant to circumstances of the claim
  • Consult with technical and/or claims advisers to clarify information and seek advice as required
  • Follow organisational procedures and use analysis tools to assess evidence in determining cause and liability
  • Apportion liability and determine quantum fairly and impartially within limits of delegated authority according to regulatory and organisational guidelines
       
Element: Document decisions and determine quantum of claim settlement
  • Record outcome of analysis documenting all relevant information used to support the decision-making process
  • Use organisational tools and systems to determine quantum including claim settlement amount and note any additional considerations or exceptions
  • Update organisational systems accurately with required information in a timely manner
       


Evidence Required

List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.

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.

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assignment, checklist) and due date here

Assessment task 1: [title]      Due date:

(add new lines for each of the assessment tasks)

Assessment Tasks

Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.

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

Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.

Observation Checklist

Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice Yes No Comments/feedback
Organise and collate information relating to the claim into a coherent file 
Enter relevant claim details in organisational systems 
Identify any information deficiencies and seek specific additional information from appropriate sources including medical experts 
Maintain confidentiality of information according to legislative requirements, industry principles and organisational requirements 
Determine type of medical indemnity claim and the key parties involved 
Assess sufficiency and thoroughness of information supplied including expert medical 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 
Review claim information to determine legitimacy of claim including validity and coverage of insurance policy 
Review, segment and prioritise claims for assessment of liability 
Undertake thorough and systematic review and assessment of facts, expert medical evidence and information relevant to circumstances of the claim 
Consult with technical and/or claims advisers to clarify information and seek advice as required 
Follow organisational procedures and use analysis tools to assess evidence in determining cause and liability 
Apportion liability and determine quantum fairly and impartially within limits of delegated authority according to regulatory and organisational guidelines 
Record outcome of analysis documenting all relevant information used to support the decision-making process 
Use organisational tools and systems to determine quantum including claim settlement amount and note any additional considerations or exceptions 
Update organisational systems accurately with required information in a timely manner 

Forms

Assessment Cover Sheet

FNSPIM417 - Analyse and manage medical indemnity claims
Assessment task 1: [title]

Student name:

Student ID:

I declare that the assessment tasks submitted for this unit are my own work.

Student signature:

Result: Competent Not yet competent

Feedback to student

 

 

 

 

 

 

 

 

Assessor name:

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Date:

Assessment Record Sheet

FNSPIM417 - Analyse and manage medical indemnity claims

Student name:

Student ID:

Assessment task 1: [title] Result: Competent Not yet competent

(add lines for each task)

Feedback to student:

 

 

 

 

 

 

 

 

Overall assessment result: Competent Not yet competent

Assessor name:

Signature:

Date:

Student signature:

Date: