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
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 practitioner
How many days do insurers have to pay medical bills in an accepted claim
45 from the receipt of the bill
How many days prior to the IME appointment must the adjuster notify the injured worker of the scheduled exam?
10 days
What must be included in a notice of acceptance
- Compensable conditions
- Disabling non disabling status
- Employment reinstatement rights
Which parties must receive a copy of the denial?
6
- IW
- employer
- WCD
- each medical service provider
- private health insurer
- worker’s attorney
In what situation can an insurer request suspension of benefits from WCD
(4)
- Worker commits insanitary or injurious acts
- worker fails to attend or cooperate with an IME
- Worker fails or refuses to cooperate with investigation
- Worker fails or refuses to accept recommended medical treatment
How many days does the insurer have to reclassify a claim from nondisabling to disabling?
14 days from the receipt of information that the claim is disabling or a request from the worker to reclassify
When a worker is represented by an attorney, when does the insurer need to provide discoverable document
14 days from the receipt of the attorney’s discovery request
Provide updates every 30 for 180 days
What four areas are claims adjusters responsible for setting reserves?
- medical
- Temporary Disability
- Permanent Partial Disability
- Legal cost
When a claim denial is appealed, what are the levels of litigation (appeal) that can occur?
- WCB Hearings Division-ALJ
- Worker’s compensation Board
- Oregon Court of Appeals
- Oregon Supreme Court
How many days does an insurer have to pay a CDA once it has been approved?
14 days from the receipt of the approved order from WCB
What is the only benefit a worker cannot settle when agreeing to a Claim Disposition Agreement (CDA)?
Medical benefits
What are the legal standards for determining compensability in an occupational disease ?
Major contributing cause of the condition
Identify the term:
____ : a permanent loss of use or function of a body part or system related to the compensable condition
IMPAIRMENT
Identify the term:
medical service rendered to REDUCE or MODERATE TEMPORARILY , but does not include those medical services rendered to dx, heal or permanently alleviate or eliminate a medical condition.
PALLIATIVE CARE
these are examples of what?
- Surgery
- Diagnostics
- Prosthetic appliance
Examples of medical services
Identify the term:
___ ___ : Means the separate factoring of impairment as modified by AGE, EDUCATION, AND ADAPTABILITY, to per the job at which the worker was injured
WORK DISABILITY
what are the elements of a bona fide (formal) job offer of modified work?
(2)
- AP is notified of physical task to be performed
- AP agrees with MOD work and Commute is within capabilities
What are the seven elements of the written bona fide job offer from the employer
- Start date and time
- Duration of Mod work
- Statement that AP has approved it
- Description of physical requirements
- place or location of the modified work,
- Hrs and days to be worked
- Wages
What are the elements needed to stop or prorate time-loss benefits when a worker has been terminated from the employer at injury?
(2)
- Employer has a written RTW policy
- Approved mod job Description from AP
In order to stop or prorate time-loss benefits when a worker has been terminated from the employer at injury, what elements must be included in the MEMO to the file?
(4)
- Start date & time
- Wages
- HRS and days work available
- Statement that modified work is available but for termination
Which type B med provider is also able to rate impairment?
Chiropractor
How many days can an authorized nurse practitioner provide medical services?
180 days from the date of visit on the initial claim
How many days do insurers have to pay medical bills that were received prior to a claim decision once the claim has been accepted?
14 days from the date of Acceptance
How many days do insurers have to pay worker reimbursements?
30 days from the receipt of the request for reimbursement
The worker has up to one yr to report an occupational disease to the employer. What are the event triggers that may start the time frame?
(4)
- 1 yr from date the worker first discovered OD
- 1 yr from date worker became disabled
- 1 yr from the date worker is informed by Doctor of the OD
- 1 yrs from date of death or when discovered the OD was the cause of death
the Legal standard for determining compensability of a combined condition claim is MAJOR contributing cause of the combined conditions need for treatment
MAJOR contributing cause of the combined conditions need for treatment
Which items of information must be included on the DENIAL
3
- Appeal rights
- factual and legal reasons for the denial
-Whether the denial was based in whole or in part on an IME
What information is needed before closing a claim?
4
- Actual work status
- Medically Stationary status
- Status and date of work release
- Information concerning permanent impairment, if any
How many days do injured workers have to appeal the NOC?
60 days from the mailing date of NOC
How much time does an insurer have to respond to the attending physician’s request for palliative care?
30 days from Receipt of request from AP
How many days does an adjuster have to issue a decision on an aggravation claim?
60 days from the receipt of the request to reopen the claim
What are the elements of a compensable aggravation claim?
5
- An Actual WORSENING,
- after the last ARRANGEMNT OF COMPENSATION
- of ACCEPTED CONDITION
- established by MEDICAL EVIDENCE
- supported by OBJECTIVE FINDINGS
What is the timeframe within which the IW must cooperate with the investigation of the claim to avoid suspension of benefits?
14 days to cooperate w/investigation after written notice was sent.
In what situations can a worker refuse modified work w/o facing a reduction or termination of time-loss benefits?
(5)
436-060-0030
- The COMMUTE is BEYOND PHYSICAL CAPACITIES
- WORKSITE is MORE than 50 MILES from Worksite-at-injury or worker’s residence
- MOD WORK is NOT w/ EAI (employer at injury)
- MOD work is NOT at WORKSITE belonging to the EAI employer at injury.
- different SHIFT than IW works
How many days does a medical provider have to send medical records to the insurer?
Within 14 days from RECEVING THE REQUEST from insurer
How may days does an insurer have to respond, in writing, to a written request for DX preauthorization?
Within 14 days from receiving the request from provider
How many years does an injured worker have to file an aggravation on a DISABLING claim?
5 yrs from the date of the FIRST NOTICE OF CLOSURE
How many years does an injured worker have to file an aggravation on a NONDISABLING claim?
5 yrs from DOI
What are two settlement types in a denied claim?
- Disputed Claims Settlement (DCS) settles all benefits
- Stipulation and Order (STIP) an agreement to rescind the denial and accept the claim
How many days do insurers have to close a claim?
14 days upon receipt of info that QUALIFIES the CLAIM for CLOSURE.
