Knowledge quizes Flashcards
What does the acronym EDOK stand for at SAIF Corporation?
Employer date of knowledge
What does the acronym EAI stand for at SAIF Corporation?
Employer at injury
What does the acronym MOI stand for at SAIF Corporation?
Mechanism of injury
Which section number of the Oregon Revised Statues (ORS) covers the laws concerning workers’ compensation?
ORS 656
Which chapter of the Oregon Administrative Rules (OAR) covers the laws concerning the processing of workers’ compensation claims?
OAR 436
Which Oregon Administrative Rule division number covers Claims Administration Rules?
Division 60
Which TWO divisions under the Department of Consumer and Business Services regulate the workers’ compensation process?
WCB- Workers’ Compensation Board
WCD- Workers’ Compensation Division
Which Form is used by the worker and the employer to report an injury to the insurer?
801
What are the uses for Form 827- Workers’ and Health Care Provider’s report of Workers’ Compensation Claim?
(7)
- 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
What are the uses for Form 1502? and who is it sent to?
WCD
- Acceptance or denial of the claim
- Aggravation
- New or omitted condition reopening
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?
72 hrs of the initial office visit
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
When must the notice of change of attending physician or nurse practitioner be sent to the insurer using Form 827?
5 days of the office visit
A doctor or physician who is primarily responsible for the treatment of a workers’ compensable injury or illness
ATTENDING PHYSICIAN
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
CLAIM
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.
COMPENSABLE INJURY
What are the legal standards for determining compensability in an injury claim ?
material contributing cause of the need for treatment or disability
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 does the phrase “COURSE AND SCOPE” mean?
“arising out of”—causal relationship to work
“ in the course of”— time, place, and circumstances
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
The five Claims tenets
When is the three day waiting period payable?
2
- The worker is totally disabled for a period of 14 consecutive days
- IW is admitted as an inpatient to a hospital within 14 days of the onset of total disability
What information is required before an adjuster can assess time loss benefits?
Attending physician or authorized nurse practitioner needs to verify the worker’s inability to work and authorize time loss
When is the first-time loss payment due to the worker per SAIF’s best practice?
13 days from the employer’s date of knowledge and of the worker’s disability
Which one is NOT a type A medical provider who can serve as an attending physician in a claim?
-medical doctor
-Dr of osteopathic medicine
-Oral & maxillofacial surgeon
-nurse Practitioner
Podiatric physician & surgeon
Nurse practicioner
How many days or office visits can a type B medical provider provide medical services?
60 days or 18 office visits from the date of the first visit on the initial claim
How many days can an authorized nurse practitioner authorize time loss benefits?
180 days from the date of the first visit on the initial claim
