SOG - Process Flow Template Word Version February 2010

8/3/2019 SOG - Process Flow Template Word Version February 2010

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STANDARD OPERATING GUIDELINES

Roles and Responsibilities

ManagerThe Manager is responsible for providing technical guidance to and coordinating the workflow of your

Abilities Case Managers. They are your contact if you have issues with Claims Management, Speed

of Service etc.

Abilities Case Managers (ACM)The Abilities Case Manager is responsible for the initial absence assessment and for ongoing case

management of all STD/ LTD claims. The ACM is your contact for day to day claims inquiries and

case management planning.

Health Management Consultants (HMC)Our Abilities Case Managers (ACMs) assess every absence for rehab potential. Where rehab is

indicated, they engage one of our professional HMCs to identify and address non-medical

(psychosocial or workplace) issues that may be affecting recovery

The primary goal of our rehabilitation plans is to bring the plan member back to his or her own jobwhere feasible. This may require further treatment, re-conditioning or job accommodations such as

temporarily modified hours. If return to own work is not feasible, the Health Management Consultant

would consider alternate occupation planning.

Disability Payment and Eligibility Analyst (DPEA):

Responsible for LTD coverage eligibility review and management of routine claim related functions.Routine claim related functions include but are not limited to rehabilitation calculations, CPP

calculations and requesting updates on permanent or annual review claims.


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Absence record is set -up within 24 hourson Sun Lifes systems and forward to

ACM

ACM completes case managementabsence assessment in 5 business days

Plan Member , PlanSponsor advised of

absence assessmentconclusion

Plan Member ,Plan Sponsor

advised of

absence

assessmentconclusion

CaseManagement Plan

Developed

HealthManagement ?

Transition to LTD

Appeal,

if applicable

Health ManagementConsultants

Plan Sponsor sends Absence notificationpackage to Sun Life

Plan Member return to work and

absence file closed .

Yes

Sup

ported

No

Plan Sponsoraddresses

employmentstatus

Plan Sponsor /ACM sendTransition forms to Plan

Member and Plan Sponsor

completes their transitionform.

NotSupported

Plan Member /PlanSponsor advised of

additional informationrequired

InsufficientInformation

Yes

No

LTD Transition:

8 - 10 weeks before theend of the STD benefitperiod.

Where applicable , joint

action plan between ACMsto determine next steps for

transition.

Case Management Strategies include :

Frequent contact with Plan Member

to update recovery and potential for

return to work

Ongoing assessment for healthmanagement intervention

Other interventions such as IME ,FAE, Health Partners

EarlyRETURNS

Full Case Management

Process Map

Full Case Management isassessment through to resolution ,

resolution being :

Return to workor

Transition to a LTD claim

Absence assessmentconclusion

Ongoing Case

Management Strategies

Appeal Process

Employee notifies Plan Sponsorof illness


3/10

Absence record is set-up within 24 hours

on Sun Lifes systems and forward to

ACM

ACM completes service provider express

absence assessment in 5 business days

Plan Sponsor sends

Service Provider Expressabsence notification package

to Sun Life

ACM engages correct network provider

ACM notifies Plan Sponsor and PlanMember of engaged network provider

ACM provides Plan Sponsor withrecommendations and appropriate next

steps through to conclusion

EarlyRETURNS

Service Provider Express

Process Map

Potential for ACM to remain involved and

assist with recommendations and next

steps


4/10



ACM

ACM completes assessment for return towork potential in 5 business days

Plan Sponsor sends

Return to Work Advisory Services

absence notification packageto Sun Life

EarlyRETURNS

Return to Work Advisory Services

Process Map

ACM provides one time assessment of

medical and all information provided.

ACM to remain involved and assist with

recommendations and next steps

ACM provides Plan Sponsor withrecommendations which will include

appropriate steps to take in case

management

Employee notifies Plan Sponsor

of illness


5/10



ACM

ACM completes assessment for chronic

casual absence in 5 business days

Plan Sponsor sends Chronic Casual

Absence Services notification packageto Sun Life

EarlyRETURNS

Chronic Casual Absence Services

Process Map

ACM provides Plan Sponsor with

recommendations and appropr iate nextsteps through to conclusion

Potential for ACM to remain involved and

assist with recommendations and next

steps


6/10

STD Adjudication

Claim is set-up on Sun Lifes systemsand forwarded to ACM

ACM Adjudicates claim within 5 businessdays

ClaimDecision

Plan Member, PlanSponsor advised of

claim decision.

Plan Member,Plan Sponsor

advised of claimdecision.

CaseManagement Plan

Developed

HealthManagement

Services Requires?

Appeal?

Health

ManagementServices

Appeal Process

Completed Claim Package Received atSun Life

Yes

Ap

pro

ved

No

Plan Sponsoraddresses

employmentrelationship

Declined

Plan Member/Plan

Sponsor advised ofadditional information

required

IncompleteInformation

MemberRTW?

STD file closedYes

Yes

No

No

Case Management Strategiesmayinclude: Frequent contact with Plan Member

to update recovery and potential forreturn to work

Ongoing assessment for healthmanagement intervention

Other interventions such as IME,FAE, Health Partners

Ongoing Case

ManagementStrategies

Transition to

LTD?

STD ClaimResolved File

Closed

Return to WorkDeathNo Longer DisabledMaximum Age

STD to LTDTransition

No Yes


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LTD Adjudication

DPEA Assesses Contractual Eligibilityand forwards claim to ACM

ACM adjudicates claim within 10business days (LTD)

ClaimDecision


claim decision.


claim decision .

Health

ManagementServices Requires ?

Appeal?

Health ManagementServices

Appeal Process

Declined

Completed Claim Package Received atSun Life

Yes

No

App

rov

ed

No

Plan Sponsor addresses

employment relationship

Plan Member/Plan

Sponsor advised ofadditional information

required

IncompleteInformation

Claim Resolution

Ongoing case management

Decision letter will includenext steps in casemanagement

Assessment may include :Telephone interview with PlanMemberReview by Health PartnerDiscussion with Plan Sponsor

Resolution: Return to Work Settlement Age 65

Retirement

No longer totallydisabled

Death of Member Change of Definition

Ongoing Case Management strategiesmayinclude: Frequent contact with Plan Member to update

recovery and potential for return to workplanning.

Ongoing assessment for health managementservices

Pursue offsets where appropriate (CPP/QPP)

Non-litigated Settlements Strategic partnerships Change of Definition

Yes


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Health Management

ACM refers claim for HealthManagement Services

Referral to HealthManagementConsultant

Pre-clearance callto Plan Sponsor

Schedule Visit with

Plan Member/PlanSponsor/Physician

Health ManagementServices Appropriate ?

Visit outcome communicatedto Plan Member, Plan

Sponsor,Physician and ACM

HealthManagement

Plan Developed

Implement HealthManagement

Plan

Gradual Return to Work/Return to Work Plan

Developed in conjunctionwith Plan Sponsor, PlanMember and Physician

Return to work planmonitored by Sun Life and

Plan Sponsor, andadjusted as required

Return to Work

Ready?

Return to work full-time

Yes

Full-timeReturn toWork?

Return to work full-time

No

Yes

Ongoing casemanagementIntervention

Yes

No

Workplace issues identified Return to work barriers identified Potential for accommodation Preliminary joint planning

No

Return to WorkVocational AssistanceNon-Litigated Settlement


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Start

ACM decline or termination,

with right to object within

contractual appeal period

(contractual period)

Plan member objects*, with or

without new information

ACM considers, with any

argument/information

ACM declines appeal (maintains decision ),

advises in writing with reasoning , & right to

object within original contractual period . If appealis after contractual period , advise that time is up

& decision remains unless extension beyond

original contractual period is appropriate

No Plan Member Objection

Plan member objects, no new

information

Plan member objects, with

new information

ACM considersinformation

ACM decides wouldmaintain decision

ACM writes letter/EM advising that

objection being considered at 2nd

level or

appeal and sends referral to Manager

ACM approves claim

(changes decision ), advises

in writing, benefits paid

END

ACM approves claim,

advises in writing,

benefits paid

**Note: Any appeals that are received >1 year from the original date of decline /

termination letter must be referred to an

SDCC to consider the impact of

applicable limitation period

* All objects in

document should be readas objects in writing

Appeal Level #1 - ACM

Appeal Level #2 Manager

Manager ** declines appeal,

advises in writing with reasoning

& right to object (contractual

period no longer applies)

No Objection

Manager ** approves claim

and sends to ACM for

approval letter and ongoing

claims management


information


new information

Manager decides would

maintain decision

Manager considers

information

Manager writes letter/EM advising thatobjection being sent to Senior Disability

Claims Consultant (SDCC), 3rd and final level

of appeal and sends referral to SDCC queue

END

Manager approves claim and

sends to ACM for approval

letter and ongoing claims

management

Appeal Level #3 SDCC

SDCC considers appeal

SDCC declines appeal,advises in writing with

reasoning

SDCC changes decision afterdiscussion with ACM/Manager, and

sends to ACM for approval letter andongoing claims management

Litigation Ombudsman No Objection END

* All Manager in

document should be readas Manager or

designate

Appeal Flowchart: Clients with contractual appeal wording


10/10

Start

ACM decline or

termination, with

right to object

Plan member objects*, with or

without new information

ACM considers, with any

argument/information

ACM declines appeal(maintains decision ), advises

in writing with reasoning, &

right to object

No Plan Member Objection


information


new information

ACM considers

information

ACM decides wouldmaintain decision

ACM writes letter/EM advising that

objection being considered at 2nd

level orappeal and sends referral to Manager

ACM approves claim

(changes decision ), advises

in writing, benefits paid

END

ACM approves claim,

advises in writing ,

benefits paid

**Note: Any appeals that are received >1 year from the original date of decline/

termination letter must be referred to anSDCC to consider the impact of

applicable limitation period

* All objects in

document should be read

as objects in writing

Appeal Level #1 - ACM

Appeal Level #2 Manager

Manager ** declinesappeal, advises in

writing with reasoning &

right to object

No Objection

Manager ** approves claimand sends to ACM for

approval letter and ongoing

claims management


information


new information

Manager decides would

maintain decision

Manager considers

information

Manager writes letter/EM advising that objection

being sent to Senior Disability Claims Consultant

(SDCC), 3rd

and final level of appeal and sendsreferral to SDCC queue

END

Manager approves claim and

sends to ACM for approval

letter and ongoing claims

management

Appeal Level #3 SDCC

SDCC considers appeal

SDCC declines appeal,

advises in writing with

reasoning

SDCC changes decision after

discussion with ACM/Manager, and

sends to ACM for approval letter and

ongoing claims management

Litigation Ombudsman No Objection END

* All Manager in

document should be readas Manager or

designate

Appeal Flowchart: Clients without contractual appeal wording

SOG - Process Flow Template Word Version February 2010

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Transcript of SOG - Process Flow Template Word Version February 2010