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Claim adjuster test prep > Combined Knowledge > Flashcards

Combined Knowledge Flashcards

1
Q

What does the acronym EDOK stand for at SAIF Corporation?

A

Employer date of knowledge

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2
Q

What does the acronym EAI stand for at SAIF Corporation?

A

Employer at injury

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3
Q

What does the acronym MOI stand for at SAIF Corporation?

A

Mechanism of injury

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4
Q

Which section number of the Oregon Revised Statues (ORS) covers the laws concerning workers’ compensation?

A

ORS 656

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5
Q

Which chapter of the Oregon Administrative Rules (OAR) covers the laws concerning the processing of workers’ compensation claims?

A

OAR 436

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6
Q

Which Oregon Administrative Rule division number covers Claims Administration Rules?

A

Division 60

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7
Q

Which TWO divisions under the Department of Consumer and Business Services regulate the workers’ compensation process?

A

WCB- Workers’ Compensation Board

WCD- Workers’ Compensation Division

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8
Q

Which Form is used by the worker and the employer to report an injury to the insurer?

A

801

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9
Q

What are the uses for Form 827- Workers’ and Health Care Provider’s report of Workers’ Compensation Claim?

A
  • Report of aggravation
  • First report of an injury or disease
  • Request for a new or omitted medical condition
  • Notice of change of attending physician or nurse practitioner
  • progress report
  • closing report
  • palliative care request
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10
Q

What are the uses for Form 1502? and who is it sent to?

A

WCD

  • First report of an injury
  • Acceptance or denial of the claim
  • Aggravation
  • New or omitted condition reopening
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11
Q

How much time does a physician have to send the Form 827 to the insurer if it is being sent as the first report of an injury?

A

72 hrs of the initial office visit

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12
Q

How much time does the employer have to send Form 801 to the insurer?

A

5 days from the date of the employers knowledge that a claim is being made

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13
Q

When must the notice of change of attending physician or nurse practitioner be sent to the insurer using Form 827?

A

5 days of the office visit

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14
Q

A doctor or physician who is primarily responsible for the treatment of a workers’ compensable injury or illness

A

ATTENDING PHYSICIAN

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15
Q

written request for compensation from a subject worker or someone on the worker’s behalf, or compensable injury of which a SUBJECT EMPLOYER has notice or knowledge

A

CLAIM

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16
Q

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 established by medical evidence supported by objective findings.

A

COMPENSABLE INJURY

17
Q

What are the legal standards for determining compensability in an injury claim ?

A

material contributing cause of the need for treatment or disability

18
Q

What are the instances when a claim would most likely NOT be compensable?

A

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
19
Q

What does the phrase “COURSE AND SCOPE” mean?

A

“arising out of”—causal relationship to work

“ in the course of”— time, place, and circumstances

20
Q

What are these called

Claims adjusters will:

  • Decide the compensability of claims by using available resources and administer timely and appropriate benefits
  • Strive to manage claims to the most appropriate conclusion for works and employers facilitating early return to work and claim closure
  • promptly communicate significant claims developments
  • guarantee current and future benefits by managing reserves.
  • Be mindful of the changing business to positively influence a culture of change
A

The five Claims tenets

21
Q

What are the legal standards for determining compensability in an occupational disease claim?

A

Major contributing cause of the condition

22
Q

compensable injury is the major contributing cause of the …

A

consequential condition

23
Q

major contributing cause of the ———need for treatment

A

combined condition

24
Q

under what circumstances must an insurer request suspension of benefits from WCD?

A

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)
25
Q

Is everyone hurt in Oregon covered by Oregon Worker’s Compensation Insurance?

A

No, not all employees hurt in Oregon work for and Oregon Subject employer; and not all workers are Oregon Subject workers. ORS 656.027

26
Q

In addition to overall compensability, What other issue must an adjuster consider before making a decision on the claim?

A

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?

27
Q

How many days does the worker have to report an injury to the employer?

A

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.

28
Q

In most instances, who has the burden of proof in the claim?

A

IW has burden of proof to show a claim is compensable

29
Q

What information must be included on the denial?

A
  • 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 eh IME
  • Information about Expedited Claim Service
  • Appeal rights
30
Q

Who received a copy of the denial?

A
  • The worker
  • Employer (ORS)
  • Worker’s attorney, if represented
  • Each medical Services provider
  • Private Health insurer if any
  • WCD

ORS656.262(9), OAR 436-060-0010 and OAR -060-0140

31
Q

How many days does a worker have to appeal a denial?

A

60 days from mailing date of denial

32
Q

When a claim denial is appealed, What are the four levels of litigation (appeal) that can occur?

A
  1. An in person admin. Hearing before an Admin. Law Judge at the WCB Hearings division
  2. Board review of the ALJ’s opinion by the Workers’ Compensation Board.
  3. Review by the Oregon Court of Appeals
  4. Review by the Oregon Supreme Court
33
Q

How many days’ notice do you have to provide to an injured worker for a scheduled IME appointment?

A

10 days prior to the IME appointment

34
Q

An IME with multiple examiners must be completed within what period of time in order to be considered on IME?

A

72 hrs

35
Q

Where can you find information on what is included for notice of acceptance

A

ORS 656.262 (6)(b), OAR 436-060-0010, OAR 436-060-0140(5)

36
Q

How many days does a worker have to appeal a denial and when does it begin?

A

60 days from mailing date of denial

Claim adjuster test prep (5 decks)

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