Claims Test Flashcards
Palliative care
This is medical service rendered to reduce or moderate temporarily 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. ORS 656.005(20)
Occupational disease (OD)
This includes any disease or infection arising out of and in the course of employment caused by substances or activities to which an employee is not ordinarily subjected or exposed other than during a period of regular actual employment therein, and which requires medical services or results in disability or death. ORS 656.802
New condition
A condition that develops after the notice of acceptance is issued. ORS 656.627
Medically stationary (Med Stat)
No further material improvement is expected with either treatment or the passage of time. ORS 656.005(17)
Disabling injury
A disabling injury entitles the worker to compensation for disability or death. An injury is not disabling if no temporary benefits are due and payable, unless there is a reasonable expectation that permanent disability will result from the injury. ORS 656.005(7)(c)
Compensable injury
A compensable injury is an accidental injury, or accidental injury to prosthetic appliances, arising out of and in the course of employment requiring medical services or resulting in disability or death. An injury is accidental if the result is an accident, whether or not due to accidental means, if it is established by medical evidence supported by objective findings. ORS 656.005(7)
What are the seven uses for the Form 827
FRRNPCP: Free Rabbits Really Need Pet Caring People
• First report of an injury or disease (must be sent to the insurer within 72 hours of the initial office visit)
• Request to accept a new or omitted medical condition
• Report of aggravation
• Notice of change of attending physician or nurse practitioner (must be sent to the insurer within 5 days of the office visit)
• Progress report
• Closing report
• Palliative care request
What are the 10 key Divisions within OAR 436?
Division 9 – Oregon Medical Fee and Payment Rules
Division 10 – Medical Services Rules
Division 15 – Managed Care Organization Rules
Division 30 – Claim Closure and Reconsideration Rules
Division 35 – Disability Rating Standards
Division 55 – Certification of Claims Examiners Rules
Division 60 – Claims Administration Rules
Division 105 – Employer-at-Injury Program Rules
Division 110 – Preferred Worker Program Rules
Division 120 – Vocational Assistance to Injured Workers
What are the divisions within DCBS that deal specifically with workers’ compensation
Workers’ Compensation Division (WCD)
Workers’ Compensation Board (WCB)
Initial Claim
The first open period on the claim immediately following the original filing of the occupational injury or disease claim until the worker is first declared medically stationary by an attending physician or authorized nurse practitioner. OAR 436-010-0005(19)
Claim
This means 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. ORS 656.005(6)
ALJ
Administrative Law Judge
AP
Attending Provider/Physician
ATP
Authorized Treating Physician
CDA
Claim Disposition Agreement
DCBS
Department of Consumer and Business Services
DCS
Disputed Claims Settlement
DEP
Direct Employment Plan
MNOA
Modified Notice of Acceptance
MOI
Mechanism of injury
NOA
Notice of Acceptance
NOC
Notice of Closure
PCE
Physical Capacity Evaluation
PPD
Permanent Partial Disability
PTD
Permanent Total Disability
PWP
Preferred Worker Program
JA
Job Analysis
JD
Job Description
TPD
Temporary Partial Disability (Disability based upon wage loss)
WCB
Workers Compensation Board
WCD
Workers’ Compensation Division
Which section in the Oregon Revised Statute (ORS) covers the statutes related to workers’ compensation?
Oregon Revised Statute 656 – Laws related to Workers’ Compensation.
Which chapter of the Oregon Administrative Rules (OARs) covers the rules related to workers’ compensation?
OAR 436
What is the purpose of Form 801
Purpose: The employer uses this form to report an on-the-job injury.
Timeframe: It must be submitted to the insurer by the employer within five days of the employer’s date of knowledge of a claim being made.
What are the reasons for the Form 1502
Reasons: The insurer uses this form to report information to WCD including first report of a claim decision (disabling acceptances, all denials including partial denials), new or omitted condition reopening, aggravation decision, reopening for voc training, litigation ordered acceptance, change in acceptance or disability status, correction of previously submitted info, and MCO enrollment after a previous report.
Timeframe: The insurer must submit with 14 days of the action that requires reporting (for example, 14 days from the date of denial or acceptance on a disabling claim).
When should a Form 1502 be sent in a nondisabling claim?
A 1502 is sent only if the nondisabling claim is denied.
What is the purpose of the Form 1503 — Insurer Notice of Closure Summary and when should it be sent to WCD?
Purpose: The insurer uses this form to provide notice of the insurer’s claim closure and includes time loss payments, medical payments, and the worker’s return to work status.
Timeframe: It must be submitted within 14 days of obtaining information needed to close a claim.
What is the purpose of the Form 1644 — Notice of Closure and when should it be sent to WCD?
Purpose: The insurer uses this form to provide notice to the worker of claim closure and includes extent of benefits, time loss payments, permanent disability, if any, and appeal rights.
Timeframe: It must be submitted within 14 days of obtaining information needed to close a claim.
What is the purpose of the Form 2807 — Insurer Notice of Closure Worksheet and when should it be sent to WCD?
Purpose: The form is used by insurers to calculate disability benefits before entering the information on to the Form 1644 – Notice of Closure.
Timeframe: It must be submitted within 14 days of obtaining information needed to close a claim.
LIER
Last Injurious Exposure Rule - Used in occupational disease claims, the employer upon whom the rule “triggers” is presumptively responsible for the claim.
LIR
Last Injury Rule - The last injury that made an independent contribution to the underlying pathology of the condition, even though it is slight, is responsible. A contribution to the symptoms, but not the pathology, is not sufficient.
What is the purpose of a designated paying agent order (also known as a .307 Order)?
The claim is compensable, but there is a dispute as to which insurer or employer is responsible. A designated paying agent order (.307 Order) allows the worker to receive benefits until the responsibility issue is resolved.
What three situations typically make a claim NOT compensable?
- Injury occurs to any active participant in assaults or combats that are not connect to the job assignment and are a deviation for customary duties.
- Injury occurs 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.
How is an injury claim most often described?
An injury claim usually occurs within a discreet period of time. An injury has a sudden and acute onset.
What does the phrase “course and scope” mean?
• “Arising out of” means there is a causal relationship to work.
• “In the course of” refers to the time, place, and circumstances surrounding the accident.
ORS 656.005(7)(a)
What four questions should you ask yourself to help determine if you are dealing with a compensable combined condition?
- Is there a compensable injury?
- Is there a qualified preexisting condition?
(See the General Definitions section.) - Did the injury combine with the qualified preexisting condition?
- Is the combined condition compensable?
MTR
Medical Treatment Review. Formal review of medical treatment. The Insurer can send a form to the Attending Physician and ask them to review the treatment program for a claimant
Can you pay TTD and TPD in the same claim?
Yes
What information is required before an adjuster pays time loss?
AUTHORIZATION - The attending physician or authorized nurse practitioner (or Type B provider if appropriate) must be able to verify the worker’s inability to return to work and then authorize time loss.
Generally, when is the first time-loss payment due by statute?
14 days from the employer’s date of knowledge and/or the worker’s disability.
When is the first time-loss payment due by SAIF’s best practice?
13 days from the employer’s date of knowledge.
After the first time-loss payment is issued, how often is the time-loss benefit paid?
Every 14 days.
When are time-loss benefits NOT payable?
- A person has withdrawn from the workforce. For example, an injured worker is not working and has made no reasonable effort to obtain employment or the injured worker is a full-time student.
- The attending physician or authorized nurse practitioner (or Type B provider) is unable to verify the worker’s inability to work.
- The worker is incarcerated for the commission of a crime.
What are seven situations when an adjuster may stop paying time-loss benefits?
- Expired - The Type B Provider time frames have expired.
- Denied - The claim is denied.
- Regular Work - The worker is released to regular work.
- Modified Work - The worker returns to modified work and making their full AWW.
- Bona Fide - A bona fide job offer is made for modified work and the worker refuses the job (if the BJO was made for the full AWW).
- Terminated - The terminated worker process has been completed.
- Closed - The claim is closed.
Can Sup TD be paid on a nondisabling claim?
Yes. Sup TD may be due on a nondisabling claim even if time loss is not due on the primary job.
How many times in a claim can you pay a 3DW?
Only 1
AWW
Average weekly wage
What is the three-day waiting period?
Three consecutive calendar days beginning with the first day the worker loses time or wages from work as a result of the compensable injury.
When is the three-day waiting period payable?
- The worker is authorized and is totally disabled for a period of 14 consecutive days, or
- The worker is admitted as an inpatient to a hospital within 14 days of the onset of total disability.
- If the three-day waiting period is payable, pay one-half for the initial workday lost if worker leaves during first half of the shift and does not return. No compensation is due on the first day if the worker leaves during the second half of the shift.
CMS
Centers for Medicare and Medicaid Services
WCE
Work Capacity Evaluation
Under what circumstances must an insurer request suspension of benefits from WCD?
- Worker fails to attend an IME. OAR 436-060-0095(1)
- Worker commits insanitary or injurious acts. OAR 436-060-0105
- Worker fails or refuses to accept medical treatment. OAR 436-060-105
- Worker fails or refuses to cooperate with investigation. OAR 436-060-0135(2)
What is the timeframe within which the injured worker must cooperate with the investigation of the claim to avoid suspension of benefits?
The worker has 14 days to cooperate with the investigation of the claim after the written notice is sent.
How many days does the worker have to report an injury to the employer?
The worker generally has 90 days from the date of the injury or accident, but the injured worker has up to one year to report the claim if he can show good cause for not reporting it sooner. The worker has 90 days from the date a health benefit rejects a claim as being work related.
What are the legal standards for determining the 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.
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.
What are two common settlement types in a denied claim?
- Disputed claim settlement (DCS): settles all benefits in the claim,
- Stipulation and Order (Stip): an agreement to rescind the denial and accept the claim.
What are the settlement options in an accepted claim?
- Claims Disposition Agreement (CDA),
- Disputed Claim Settlement (DCS) (if there is a partial denial in the claim),
- Stipulation and Order (Stip).
What is the only benefit a worker cannot settle when agreeing to a CDA?
Medical benefits.
How many days do insurers have to pay a CDA once it has been approved?
14 days from receipt of the approved order from WCB.
When a claim denial is appealed, what are the four levels of litigation (appeal) that can occur?
- An in-person administrative hearing before an Administrative Law Judge (ALJ) at the WCB Hearings Division.
- Board review of the ALJ’s opinion by the Workers’ Compensation Board.
- Review by the Oregon Court of Appeals.
- Review by the Oregon Supreme Court.
Why is it important to set reserves on a claim?
- It enables SAIF to estimate future liabilities.
- Reserves are used in ratemaking and calculation of the employer’s modification rate.
- It is used to calculate premium for retrospective policies.
- Reserves facilitate underwriting decisions.
- It meets statutory requirements.
In what four areas is a claims adjuster responsible for setting reserves?
- Medical,
- Temporary Disability (Time loss),
- Permanent Partial Disability,
- Legal Costs (Fees).
When is an adjuster required set reserves on a claim?
- Within 30 days of the receipt of the request for hearing on a denied claim or condition.
- Within 30 days of acceptance of a disabling claim.
- On accepted, nondisabling claims, when medical paid costs exceed $5,000
What are seven examples of significant events that would prompt you to review the reserves on a claim?
- Authorization - A change in the time loss authorization (starting or stopping)
- Work Status - A change in the work release or work status
- Medical Info - Receipt of medical information such as a surgery
- Closure - Claim closure information
- Re-open - A request to reopen a claim
- New - A request to accept new, omitted, consequential, or combined conditions
- Time - The passage of time without further treatment or activity in the claim
What elements are needed to stop or prorate time-loss benefits when a worker has been terminated?
• The employer has a written return-to-work policy.
• The attending physician has approved the modified job description.
• A memo to the file provides the following information:
- The hours and days the modified work would be available
- The wages for the modified work
- The start date and time
- A statement that modified work would have been available if the worker had not been terminated
In what situations can a worker refuse modified work without facing a reduction or termination of time-loss benefits?
- The commute to the modified work is beyond the physical capacities of the worker.
- The worksite is more than 50 miles from worksite-at-injury or the worker’s residence at time of injury.
- The modified work is not with the employer at injury.
- The modified work is not at worksite belonging to the employer at injury.
- The modified work involves a shift different from what the injured worker usually works.
What information is needed before closing a claim?
- Medically stationary status
- Work release and work status information, including dates
- Information concerning permanent impairment, if any
What is the injured worker’s specific vocational preparation (SVP) based upon?
The jobs the injured worker has successfully performed in the five years prior to the date of issuance of the notice of closure.
What is chronic condition impairment? What is the percent value for chronic condition impairment?
This is when the worker is significantly limited in repetitive use of one or more of the following body parts: cervical spine, thoracic spine, lumbar spine, chest, shoulder, arm, forearm, hip, or leg.
The percent value is 5 percent.
What is the first level of appeal if a worker is unhappy with the NOC? Which agency performs that appeal?
The first level is reconsideration and it’s performed by the WCD.
If an injured worker has permanent impairment and is not released by his attending physician to return to his regular job, what additional factoring is included in his permanent partial disability award?
The injured worker will receive both a rating for the physical impairment as well as work disability.
When can a claim be closed administratively?
- When the worker has not sought medical treatment for more than 30 days,
- When a warning letter (known as the “bug letter”) has been sent to the worker explaining that the worker needs to seek medical treatment within 14 days of the mailing date of the letter. If there is no response after 14 days, or the worker responds and indicates no further plans for medical treatment, the claim can be closed.
What date qualifies a claim for closure (the qualification date)?
The qualification date is the date SAIF receives the final piece of medical information needed to close the claim. For administrative closures, use 30 days from the date of the last medical treatment received by the injured worker.
What is the first level of appeal if a worker is unhappy with the NOC? Which agency performs that appeal?
The first level is reconsideration and it’s performed by the WCD.
How many days do insurers have to submit documents when reconsideration has been requested?
14 days from receipt of the director’s notice of the start of the reconsideration process.
What forms are required for claim closure?
- Insurer’s Notice of Closure Summary – Form 1503
- Insurer’s Notice of Closure Worksheet – Form 2807
- Insurer’s Notice of Closure – Form 1644
- Updated Notice of Acceptance
- Medically stationary letter
How many days do insurers have to submit documents when reconsideration has been requested?
14 days from receipt of the director’s notice of the start of the reconsideration process.
Who determines impairment at the reconsideration level?
Medical arbiter physician or the attending physician if there is no medical arbiter exam.
Qualification date
The date we receive the final piece of closing information, except on administrative closures.
Closure due 14 days from the qualification date
Administrative “bug” closure
Claim qualifies for closure 14 days from when bug letter was sent
An injured worker has ? days from the mailing date of the notice of closure (NOC) to appeal the closure.
60
The insurer has ? days from the mailing date of the NOC to appeal the closure.
7
The insurer has ? days from the mailing date of the NOC to pay additional time loss ordered by the NOC.
14
The insurer has ? days from the mailing date of the NOC to pay any PPD award granted by the NOC.
30
Work Disability Due
Awarded when worker has permanent impairment AND permanent work restrictions.
Work Disability NOT Due
Not due when a worker is released to regular work for their job-at-injury even if:
The worker fails to return to available regular work; or,
Employment is terminated for unrelated reasons.
How many days’ notice do you have to provide to an injured worker for a scheduled IME appointment?
10 days prior to the IME appointment.
At a minimum, how many days prior to the scheduled IME appointment should your cover letter and medical records be sent to the IME physician?
Seven days prior to the appointment date.
Qualified preexisting conditions
A qualifying preexisting condition is one where the worker has received prior medical treatment for the condition, was diagnosed with the condition prior to the injury, or is diagnosed as arthritis or an arthritic condition.
Arthritis or arthritic condition.
Previously diagnosed.
Previously treated, regardless of the condition’s diagnosis.
Combined condition legal standard
ORS 656.005(7)(a)
Combined condition legal standard is the Major contributing cause of either the disability OR the need for the treatment of the combined condition .
50% or more the cause of treatment or disability.
How many years does an injured worker have to file an aggravation on a disabling claim?
five years from the date of the first notice of closure.
How many years does an injured worker have to file an aggravation claim on a nondisabling claim?
Five years from the date of injury.
When is the first time loss payment due on an aggravation claim?
14 days from receipt of a written report verifying the worker’s inability to work due to a worsening.
How many days does an adjuster have to issue a decision in an aggravation claim?
60 days from receipt of the request to reopen the claim.
Valid requests for new/omitted conditions
Must be from the worker or the worker’s attorney
May be on a form 827 (signed by the worker)
Must be in writing
Must clearly request a condition
What is the timeframe within which the injured worker must cooperate with the investigation of the claim to avoid suspension of benefits?
14 days to cooperate with the investigation of the claim after the written notice is sent
How many days does a worker have to appeal a denial? Include the event that triggers the start of the time frame?
The worker has 60 days from the mailing date of the denial.
Types of post closure medical services under ORS 656.245
Prescription medication
Repair or replacement of prosthetic devices
Office visits
Diagnostic tests
Life preserving modalities
Palliative care
Time-loss Due
First payment is due no later than the 14th day after receipt of a request and a written report that verifies worker’s inability to work.
Established by written medical evidence
Supported by objective findings
Attributable to the compensable injury.
How many days of office visits can a Type B medical provider provide medical services?
60 days
How many days can a Type B medical provider authorize time loss benefits?
30 days
Which of these Type B medical providers is also able to rate impairment?
Chiropractor
How many days can an authorized nurse practitioner provide medical services?
180 days
How many days can an authorized nurse practitioner authorize time loss benefits?
180 days
How many attending physicians can a worker have during the life of a claim?
Three total—the initial followed by two changes.
How many days do insurers have to pay medical bills in an accepted claim?
45 days
How many days do insurers have to pay medical bills that were received prior to a claim decision once the claims has been accepted?
14 days
How many days do insurers have to pay worker reimbursements?
30 days
How many days does an insurer have to respond to a palliative care request?
30 days from the receipt of the request
Best practice should be as soon as possible
Elements of a compensable aggravation claim
An Actual worsening
After the last arrangement of compensation
Of an accepted claim
Established by medical evidence,
Supported by objective findings
Perfecting an aggravation - The insurer has ? from the date the perfected 827 is received to process a decision
60 days
omitted condition
An omitted condition is a condition that was present at the time the notice of acceptance was issued but was omitted from the notice.
new condition
A condition that develops after the notice of acceptance is issued
What are the time frames for a worker to initiate a new or omitted condition claim?
A worker can initiate a new or omitted condition claim at any time. There are no time limits on filing.
The insurer has ? from the date the request was received to process a decision on a new/omitted condition claim
60 days
When a worker is represented by an attorney, when do you need to provide discoverable documents? How often and for how long do you need to provide updates?
You must provide the documents within 14 days from the request from the attorney and provide updates every 30 days for 180 days.
How many days do insurers have to pay a CDA once it has been approved?
14 days from receipt of the approved order from WCB.
