Claim Management - Deferred Claims Flashcards
If injury only needs First-Aid does a claim need to be filed
No
How many days does the IW have to report an injury to the employer
90 days, up to a year with good cause
**90 days from private health insurance denial due to being work related
How long does IW have to report an occupational disease OD to the employer
1 year from discovery of the OD
1 year from date worker became disabled b/c of OD
1 year from informed by DR of OD
1 year from death caused by OD or discovered OD was cause of death
Legal Standards for determining compensability of a claim or condition
Initial Injury Claim - Material contributing cause of the need for treatment
OD Claim - Major contributing cause of the condition
Consequential condition - compensable injury is the major contributing cause of the consequential condition
Combined condition - Major contributing cause of the combined condition’s need for treatment
Who has burden of proof in the claim
The IW has the burden of proof to show a claim is compensable
What 3 situations make a claim NOT compensable
Assaults
Social or recreational activities NOT required by employer
Consumption of drugs or alcohol is major factor of injury
What does “Course and Scope” mean
“Arising out of” means causal relationship to work
“In the course of” refers to Time Place and Circumstances surrounding the accident
Are all workers in Oregon covered by workers’ comp insurance
No
In addition to compensability what other issue needs to be considered
Responsibility ORS 656.307
When must an insurer request suspension of benefits from WCD
IW fails to attend an IME
IW commits insanitary or injurious acts
IW fails to refuses to accept medical treatment
IW fails or refuses to cooperate with investigation
How many days does IW have to appeal a denial
60 days from mailing date
What information is included on the acceptance of a claim
Compensable Conditions
Disabling or Non Disabling status
Information on Expedited Claim Service, hearing and aggravation rights related to non disabling claims
employment reinstatement rights
assistance available from the Reemployment assistance program
reimbursement to the worker for out of pocket expenses for meals, lodging, transportation and prescriptions
what to do if the workers believes a condition has been omitted
what to do if the worker wants the insurer to accept a new condition
What is included on the denial
The factual and legal reasons for the denial
Workers right to request a Worker Requested Medical Exam (WRME)
Whether the denial was based in whole or in part on an independent medical exam (IME)
Whether the AP agreed with the IME
Information about the expedited claim service
Appeal rights
Who receives copies of the denial
Worker
Employer
Worker’s attorney
each medical services provider
private health provider
Workers’ Comp Division (WCD)
Who receives copies of the acceptance
Worker
Employer
Worker’s attorney
Worker’s AP
The MCO if enrolled (Managed Care Org.)
WCD (Workers’ Comp Division) Disabling Claims only
A discrete event versus something over time?
The difference between an Injury and an OD
The number of employers responsible for a compensable injury or OD claim
One
801?
The form used by the worker and the employer to report an injury to the insurer
A permanent loss of use or function of a body part or system related to the compensable condition
Impairment
A Dr or physician who is primary responsible for the treatment of a worker’s compensable injury or illness
An Attending Physician (AP)
A written request for compensation from a subject worker or someone on the worker’s behalf, or any compensable injury of which a subject employer has notice or knowledge
A Claim
A permanent loss of use of a body part or system related to the compensable condition
Impairment
No further material improvement is expected with either rest or the passage of time
Medically Stationary (Med Stat)
How often is TL paid?
Every 14 days
How many days do insurers have to pay medical bills in an accepted claim?
45 days
How many days does a worker have to appeal a denial?
60 days
How much time does a physician have to send the 827 form to the insurer if it is being sent as a first report of injury
72 hours
EDOK
Employer Date of Knowledge
Temporary Total Disability
TTD
Employer At Injury
EAI
Mechanism of Injury
MOI
Number of attending physicians that a worker can have throughout the life of a claim?
3
A Type B medical provider who can rate impairment?
Chiropractor
Number of days a worker needs to be notified before the scheduled IME?
10 days
Number of days a provider has to send medical records to the insurer?
14 days from request
