The Quarterly Claims Processing Performance (QCPP) audit is a system-generated summary of reports submitted to the Workers' Compensation Division (WCD) by insurers and self-insured employers and entered in the division’s claims information system.
WCD provides insurers and self-insured employers with the statistical summaries for their own use including allowing companies an opportunity to correct any claims processing problems. Also, WCD continues to use this self-reported data provided by insurers and self-insured employers for performance measures of overall industry compliance levels.
The QCPP audit reviews the insurer and self-insured employer reports for timely performance of four key claims-processing requirements, which include:
- Claim reporting: Insurers and self-insured employers must report initial and aggravation claims to WCD within 14 days of the acceptance or denial date.
- First payment: Insurers and self-insured employers must make first payment of temporary disability (TD) within 14 days of either:
- The employer's date of knowledge of a claim, if an attending physician or an authorized nurse practitioner authorizes TD within the first 14 days.
- The date an attending physician or an authorized nurse practitioner authorizes TD, if more than 14 days from the employer's date of knowledge.
- The date an insurer or self-insured employer receives authorization from an attending physician or an authorized nurse practitioner, when the authorization was requested, but not received within the first 14 days. OAR 436-060-0020.
- Claim Acceptance or Denial: Insurers and self-insured employers must accept or deny a claim within 60 days of the employer's date of knowledge of the claim.
- Notice of Closure: Insurers and self-insured employers must close a claim within 14 days of the date the claim qualified for closure.
Insurers and self-insured employers are not liable for penalties based solely on the QCPP audit statistics. WCD issues penalties for performance deficiencies and inaccurate reporting in these claim processing categories during the Annual Audits.
The industry performance standards have not changed. Performance categories that relate to providing benefits to workers remain at a 90 percent timeliness standard, and claims reporting to the division remains at an 80 percent timeliness standard.
Industry averages for initial claims processing is the total number of claims reports submitted each quarter for the above three claims-processing areas, and the totals by year.