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Claims Exams > First Half > Flashcards

First Half Flashcards

1
Q

What is OAR Division 35

A

Disability Rating Standards

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2
Q

What is OAR Division 9

A

Oregon Medical Fee and Payment Rules

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3
Q

What is OAR Division 10

A

Medical Services Rules

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4
Q

What is OAR Division 110

A

Preferred worker Program Rules

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5
Q

What is OAR Division 105

A

EAIP

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6
Q

List 5 reason why an insurer would use the form 1502 - Insurer’s Report

A
  1. When accepting a disabling claim
  2. When denying a NonDisabling claim
  3. When accepting a new or omitted condition
  4. When accepting an aggravation
  5. Correction of previous information
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7
Q

How many days does the insurer have to send the 1502?

A

14 days from the date of denial or acceptance

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8
Q

Define Attending Physician

A

The doctor who is primarily responsible for overseeing the treatment of a worker during a workers compensation injury.

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9
Q

Define Claim

A

Is a written request for compensation from a subject worker, or on a subject workers behalf, from which a subject worker had knowledge of an injury/incident which caused a need for treatment.

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10
Q

Define Combined Condition

A

When a compensable injury combines with a qualified preexisting condition to create a need or prolong the need for treatment

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11
Q

Define a Qualifying Preexisting Condition?

A

When an worker has been previously diagnosed or previously sought treatment for the area or the condition or has arthritis or an arthritic condition.

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12
Q

List 4 situations in which you can stop paying timeloss?

A
  1. The claim has been denied
  2. The claim is closed
  3. The worker returns to regular work
  4. The worker returns to modified work at full hours/wages
  5. The terminated worker process has been completed.
  6. BJO has been sent but the worker refuses.
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13
Q

What is the legal standard for determining compensability in an occupation disease claim?

A

Major contributing cause of the condition

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14
Q

In what situations could you issue a backup denial once a claim has been accepted?

A

If there is any fraud, misrepresentation, illegal activity or if the insurers receives information that proves the initial injury was not compensable or if the new information changes who is responsible for the injury.

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15
Q

List 5 items that need to be included on the denial?

A
  1. The reason behind the denial - the factual evidence/objective findings
  2. The workers right to request their own medical exam (WRME)
  3. The workers right to appeal
  4. Info on the expedited claim service
  5. If the AP agreed with the decision
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16
Q

Which settlement settles all benefits in the claim?

A

Disputed Claims Settlement

17
Q

How many days prior to the IME appointment must you notify the IW?

A

10 days

18
Q

Name a situations an IME report could be given deference over a report of the AP?

A

When the IME doctor is a specialist in the particular area compared to the AP.

If the IME doctor has clearer, concise, well reasoned or provides a better explanation

19
Q

According to the claims communication standards, what is considered a contact with the IW?

A

A verbal dialogue between the IW and the adjuster. The adjuster needs to make 2 attempts by phone at varying times of the day. If the above doesn’t work then send a letter requesting an specific interview time.

20
Q

What are 5 types of 3rd Party Claims?

A 
Dog Bites
Assaults
MVA
Negligence
Product Liability
Premises Liability
21
Q

What are the 4 situation which you can as the WCD to suspends workers benefits?

A
  1. Worker Fails to attend and IME.
  2. Worker refuses to respond or cooperate with investigation.
  3. Worker refuses to follow or continue with medical treatment plan
  4. Worker commits insanitary or injurious acts
22
Q

What does HIP stand for? Explain the info on a HIP?

A

History, Issues, Plan

23
Q

What other issues must an adjuster consider before making a decision on a claim?

A

Responsibility

24
Q

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

A

60 days from the date of the mailing of the denial.

25
Q

List type A providers

A

Medical Doctor
Osteopathic Doctor
Podiatric Doctor or Surgeon
Oral or Maxillofacial Surgeon

26
Q

Which section of the ORS covers statues related to workers comp?

A

ORS 656

27
Q

List 7 uses of the Form 827

A
  1. To first report an injury or disease
  2. To requite a new or omitted condition
  3. To report an aggravation.
  4. To change a AP or ANP
  5. For a progress report
  6. For a closing exam
  7. To request palliative care
28
Q

What is the legal standard for determining compensability of an injury claim?

A

It is the material contributing cause for the need for treatment

29
Q

Describe an injury vs OD

A

An injury occurs over a discrete period of time and has a sudden and acute onset, where an OD occurs over a longer period of time as a result of the type of work, conditions or environment the worker is subject too.

30
Q

Define Compensable Injury

A

An accidental injury or accidental injury to a prosthetic appliance, arising out of and during the course of employment requiring medical treatment resulting in disability or death. Must be established by medical evidence supported by objective findings.

31
Q

What triggers the start of the timeframe for insurers to accept or deny a claim?

A

60 days from the EDOK

32
Q

What 3 activities are generally not compensable?

A

Injury is from an active participant in an assault or combat that is not a part of the general job requirements or a deviations from daily duties.

The injury occurred while the worker engaged in or performing a social or recreational activity for the workers pleasure.

If the major cause of the injury was the result of the workers consumption of drugs or alcohol. Must have medical evidence to prove drugs/alcohol was the cause of the injury.

33
Q

What information is required before an adjuster can pay time loss

A

Must be authorized from an AP or ANP, stating that the IW is disabled or unable to return to their regular job duties.

34
Q

Write out the Claim Tenets (5)

A

Compensability, Manage, Communicate, Financial Stability, Climate.

Claims Exams (5 decks)

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