Claims Management Flashcards
What two questions should adjusters ask themselves every time they review an open claim?
What do I need to do to bring this claim to resolution?
Are my reserves adequate?
How many DAYS does the insurer have to reclassify a claim from NONDISABLING to DISABLING
14 days from
- receipt of information that the claim is disabling
- request from IW to reclassify the claim
- if its MORE than ONE year from the date of acceptance, the IW must file an AGGRAVATION claim
When a worker is represented by an attorney, when do you need to provide discoverable documents?
14 days from the request from the attorney
For an attorneys request, How often and for how long do you need to provide updates ?
every 30 days for 180 days
Why is it important to set reserves on a claim?
5
- Enables SAIF to ESTIMATE FUTURE LIABILITIES
- Reserves are used in RATEMAKING and CALCULATION of the employer’s MODIFICATION RATE
- used to CALCULATE PREMIUM for RETROSPECTIVE POLICIES
- FACILITATE UNDERWRITING DECISIONS
- meets STATUTORY REQUIREMENTS
In what four areas is a claims adjuster responsible for setting reserves?
- Medical
- TD : Temporary Disability
- PPD : Permanent Partial Disability
- Legal Cost (fees)
When is an adjuster required to set reserves on a claim?
3
- Within 30 days of receipt of the request for hearing on a denied claim condition
- Within 30 days of ACCEPTANCE of a DISABLING CLAIM
- On accepted, nondisabling claims, when cost exceed $5,000
These examples should prompt you to do what action?
- change in the TL authorization
- change in Work release or Work Status
- receipt of medical information such as surgery
- claim closure information
- request to reopen a claim
- request to accept new, omitted, consequential, or combined conditions
- Passage of time W/O further TX or activity in the claim
Review the reserves on a claim
How many days does the worker have to report an injury to the employer?
90 days from DOI or accident up to 1 yr with good cause.
worker has 90 days from Date of health benefit rejects a claim as being work related.
In most instances, who has the burden of proof in the claim?
IW has burden of proof to show a claim is compensable
What are the instances when a claim would most likely NOT be compensable?
Injury occurs:
- to an active participant in ASSAULTS OR COMBATS not connected to the job assignment and are a deviation for customary duties
- while engaging in or performing any social or recreational activity primarily for the WORKER’S PLEASURE
- Major contributing cause of the injury is caused by the worker’s consumption of DRUGS OR ALCOHOL. Major cause must be demonstrated by a preponderance of the medical evidence
What are the legal standards for determining compensability in an injury claim ?
material contributing cause of the need for treatment or disability
How much time does the employer have to send Form 801 to the insurer?
5 days from the date of the employers knowledge that a claim is being made
compensable injury is the major contributing cause of the …
consequential condition
What are the legal standards for determining compensability in an occupational disease claim?
MAJOR CONTRIBUTING CAUSE of the CONDITION
_____ _____: is the major contributing cause of the combined condition’s need for treatment
combined condition
What does the phrase “COURSE AND SCOPE” mean?
“arising out of”—causal relationship to work
“ in the course of”— time, place, and circumstances
Is everyone hurt in Oregon covered by Oregon Worker’s Compensation Insurance?
No, not all employees hurt in Oregon work for and Oregon Subject employer; and not all workers are Oregon Subject workers. ORS 656.027
In addition to overall compensability, What other issue must an adjuster consider before making a decision on the claim?
RESPONSIBILITY: only one employer can be responsible for the compensable injury or OD.
Compensability is determined first, then responsibility: if the claim is compensable, is the employer responsible?
under what circumstances must an insurer request suspension of benefits from WCD?
(3)
Worker
- fails to attend an IME OAR436-060-0095(1)
- Worker Commits insanitary or injurious act OAR 436-060-105
- Worker fails or refuses to cooperate with investigation OAR 436-060-0135 (2)
Where can you find information on what is included for notice of acceptance
ORS 656.262 (6)(b),
OAR 436-060-0010,
OAR 436-060-0140(5)
What information must be included on the denial?
6
- Factual and legal reasons for denial
- worker’s 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 attending physician agreed with the IME
- Information about Expedited Claim Service
- Appeal rights
How many days does a worker have to appeal a denial?
60 days from mailing date of denial
When should an adjuster make a referral for a RTW consultant?
- When the IW begins to miss time from work
- When there is an expectation that the worker will soon BEGIN to miss time from work
What are the elements of a formal job offer (BONA Fide Job offer)
(3)
- AP is notified of physical task to be performed
- AP agrees with proposed work MOD and commute is within IW physical capabilities
- Employer provides a written offer to IW
What information must be written in a Bona Fide Job offer?
7
- START DATE and TIME
- DURATION of the MOD work
- APPROVAL STATEMENT from AP
- Description of PHYSICAL REQUIREMENTS
- PLACE and LOCATION of MOD work
- HRS and DAYS to be worked
- WAGES for Mod work
What elements are needed to stop or prorate time-loss benefits when a worker has been terminated?
(3)
(what are the requirements)
- the employer has a RETURN-TO-WORK POLICY
- the AP has APPROVED mod job descriptions
- MEMO
What must be included in the Memo needed to stop or prorate time-loss benefits when a worker has been terminated?
- HRS and DAYS modified work would be available
- WAGES for Mod work
- START DATE and TIME
- STATEMENT that modified work WOULD HAVE BEEN available if the worker had not been terminated
In what situation can a worker refuse modified work without facing a reduction or termination of time-loss benefits?
(4)
- COMMUTE is BEYOND the physical Capacities for IW
- WORKSITE is MORE THAN 50 Miles from worksite-at-injury or IW’s RESIDENCE
- Mod work is NOT WITH EMPLOYER AT INJURY
- Mod work is at a DIFFERENT SHIFT that the IW usually works
identify the term
______: the SEPARATE FACTORING OF IMPAIRMENT as modified by AGE, EDUCATION, AND ADAPTABILITY to perform the job at which the worker was injured
div 35 def.
WORK DISABILITY
How many days do insurers have to close a claim?
14 days - upon receipt of the information THAT QUALIFIES THE CLAIM FOR CLOSURE.
How many days do IW have to appeal the Notice of closure (NOC)?
60 days from the MAILING DATE OF NOC
How many days do insurers have to appeal the Notice of closure (NOC)
7 days from the mailing date of NOC
How many days do insurers have to pay a PPD award granted by Notice of closure (NOC)
30 days from the MAILING date of NOC
What date qualifies a claim for closure (qualification date)?
date when SAI(F receives the final piece of med info.
- admin closures 30 day from the date of the last med tx received by IW
If an injured worker has permanent impairment and is not released by his AP to return to his regular job. What additional factoring is included in his permanent partial disability award?
(rating 2)
The IW will receive BOTH RATING
- PHYSICAL IMPAIRMENT
- WORK DISABILITY
What is the IW’s specific vocational preparation (SVP) based upon?
jobs that IW has SUCCESSFULLY PERFORMED in the last 5 YRS prior to the date of ISSUANCE of the notice of closure NOC.
What is the first level of appeal if a worker is unhappy with the NOC? Which agency performs the appeal?
The first level is reconsideration and its performed by WCD.
What are the subsequent levels of appeal if the parties are unhappy with the Order of reconsideration?
(4)
- Admin hearing before an ALJ at WCB hearing Division :usually done in writing.
- Board review f the ALJ’s opinion by the WCB
- Review by the Oregon Court of Appeals
- Review by the Oregon Supreme Court
Identify the term:
______ : When an otherwise COMPENSABLE INJURY COMBINES with a QUALIFIED PREEXISTING CONDITION TO CAUSE OR PROLONG DISABILITY OR A NEED FOR TX.
COMBINED CONDITION
Identify the term:
_____: care provided to a worker to STABILIZE A TEMPORARY AND ACUTE WAXING AND WANING OF SYMPTOMS.
CURATIVE CARE
Identify the term:
____ ____: condition that develops AFTER THE NOTICE OF ACCEPTANCE is issued.
NEW CONDITION
Identify the term:
_______ _____: condition that was PRESENT AT THE TIME THE NOTICE OF ACCEPTANCE WAS ISSUED but was OMIITTED FROM THE NOTICE
OMITTED CONDITION
Identify the term:
_______ ______: MEDICAL SERVICE RENDERED TO REDUCE or MODERATE TEMORARILY THE INTENSITY OF AN OTHERWISE STABLE MEDICAL CONDITION, but does not include those medical services rendered to diagnose, heal or permanently alleviate or eliminate a medical condition.
PALLIATIVE CARE
Identify the term:
____ ___ ____: where the worker has received PRIOR MEDICAL TX FOR THE CONTION, was DX W/ CONDITION PRIOR TO THE INJURY, or IS DX AS ARTHRITIS OR AN ARTHRITIC CONDITION
QUALIFYING PREEXISTING CONDITION
Identify the term:
____ ____: SEPARATE FACTORING OF IMPAIRMENT as modified by AGE, EDUCATION, AND ADAPTABILITY to perform the job at which the worker was injures
WORK DISABILITY
How many days do insurers have to close a claim?
14 days upon RECEIPT of information that QUALIFIES the CLAIM FOR CLOSURE
how many days do IW have to appeal the Notice of Closure (NOC)?
60 days from MAILING DATE OF NOC
How many days do insurers have to appeal the NOC?
7 days from mailing date of NOC
How many days do insurers have to pay additional time loss ordered by a NOC?
WITHIN 14 days of MAILING DATE NOC
How many days do insurers have to pay a PPD award granted by a notice of closure (NOC)?
30 days from MAILING DATE OF NOC
When can a claim be closed administratively?
2
- When IW has not sought TX for more than 30 days
- Warning letter (“BUG letter”) has been sent to worker explaining that need to seek TX within 14 days of mailing date.
IF no response after 14 days = claim closed
IF the worker RESPONDED + INDICATED no further TX = claim closed
What information is needed before closing a claim?
4
- Medically STATIONARY status
- Work RELEASE by AP
- Work Status INFOR, INCLUDING DATES
- Information concerning PERMANENT IMPAIRMENT
Which types of post-closure medical services are covered under ORS 656.245?
(6)
- Prescription medication
- Repair or replacement of prosthetic devices
- Office visits
- DX test
- Life preserving modalities
- Palliative care
How much time does an insurer have to respond to the AP request for palliative care?
30 Days from RECEIPT of request from AP
What are the elements of compensable aggravation claim?
(5)
(What are the requirements)
- Actual worsening
- after last arrangement of compensation
- Of an accepted condition
- Established by medical evidence
- supported by objective findings
How many years does an IW have to file AGG on a DISABLING claim?
5 yrs from date of FIRST NOC
How many years does an IW have to file AGG on a NONDISABLING claim?
5 yrs from DOI
When is the first time loss payment due on AGG claim
14 days from receipt (PERFECTED 827) of the REQUEST TO REOPEN THE CLAIM
What is a “perfected 827”
clear in writing, signatures, DX and WORK RELEASE
