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adjuster certification test > Misc Test Need To Know > Flashcards

Misc Test Need To Know Flashcards

1
Q

3 day waiting period def

A

three consecutive calendar days beginning with the first day the worker loses time or wages from work as a result of the compensable injury.

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2
Q

When is the 3 day waiting period payable? Which 2 circumstances?

A
  • Hospitalized – confirmed and typically paid on 1st check

- Authorized TTD is authorized for a period of consecutive 14 days. (paid on the 2nd check)

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3
Q

What is needed before an adjust approves time loss?

A

Authorization: from MD, NP or Type B provider must verify the workers inability to return to work and then authorize time loss

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4
Q

When is time loss due to the worker?

A

by statute 14 days from EDOK

by SAIFs best practice its 13 days from EDOK

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5
Q

After first payment how often do, we pay time loss?

A

every 14 days

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6
Q

Which one is not a type A medical provider who can serve as an attending physician in a claim?

A
  • MD
  • Dr of osteopathic Medicine
  • Oral and Maxillofacial surgery
  • Nurse Practitioner (CORRECT)
  • Podiatrist
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7
Q

Which of the following is not a type B

A
  • Chiro
  • Nat Path
  • PA
  • Cardiologist (CORRECT)
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8
Q

How many days of office visits can a Type B medical Provider provide medical services?

A

60 days or 18 office visits from the date of the first on the initial claim

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9
Q

How many days can a Type B Medical provider authorize time loss benefits?

A

30 days from the date of the first office visit on the initial claim

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10
Q

How many days can an authorized NP provide medical services

A

180 days from the date of the first visit on the initial claim.

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11
Q

How many days can an authorized NP authorize time loss benefits?

A

180 days

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12
Q

How many attending physicians can a worker have during the life of a claim?

A

three

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13
Q

How many AP can be in a claim at one time?

A

One

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14
Q

How many days do insurers have to pay medical bills in an accepted claim?

A

45 days from the receipt of the bill

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15
Q

How many days do insurers have to pay medical bills that were received prior to a claim decision once the claims have been accepted?

A

14 days of the accept

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16
Q

How many days do insurers have to pay workers reimbursement?

A

30 days

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17
Q

How many days prior to the IME do the adjuster need to let the IW know of the scheduled appt?

A

10 days

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18
Q

An Exam with multiple IME examiners completed within 72 hours will be considered one IME Exam

A

true

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19
Q

Injury

A

Material or Major need for treatment/ disability

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20
Q

OD

A

Major cause of condition

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21
Q

Major

A

we need a medical opinion

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22
Q

Material

A

We don’t need a medical opinion

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23
Q

How Many days can an ER Dr authorize time loss beneifts?

A

14 days

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24
Q

How many days do insurers have to pay medical bills in accepted claim?

A

45 days from receipt of bill

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25
Q

Which type of type B med provider is able to rate impairment?

A

Chiropractor

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26
Q

What types of things can a worker request reimbursement for?

A

meals, lodging, prescriptions and potentially lost wages

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27
Q

How many days does an insurer have to respond in writing to a written request for diagnostic preautho?

A

within 14 days of receiving the request from the provider

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28
Q

SAIF current contracts with which MCOs

A
  • Caremark comp(CMC)
  • Kaiser on the job
  • Majoris health systems
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29
Q

Who approves MCO to offer service to workers

A

DCBS

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30
Q

Types of Settlements for denied claims

A

DCS and STIP

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31
Q

DCS

A

Disputed Claim settlements : settles all benefits in the claim

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32
Q

Stip

A

Stipulation and Oregon : recid the denial and accept the claim

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33
Q

Types of settlements for accepted claims

A

CDA
DCS (if there is a partial denial in the claim)
STIP

34
Q

CDA

A

Claims Disposition agreement (CDA)

35
Q

What is the only benefit a worker cannot settle when agreeing to CDA?

A

medical benefits

36
Q

4 Levels of Appeal

A
  • in person administrative hearing before an ALJ at the WCB hearings division
  • Board review of ALJs opinion by WC board
  • Review of the Oregon Court of Appeals
  • Review of the Oregon Supreme Court
37
Q

Who receives a copy of the acceptance

A
  • The worker
  • The employer
  • the workers atty
  • the workers AP
  • the MCO if enrolled
  • WCD
38
Q

What information must be included on the acceptance?

A
  • Compensable conditions
  • Disabling or nondisabling status
  • Information about the expedited claim service, hearing and aggravation rights related to nondisabling injuries
  • Employment reinstatement rights
  • Assistance available from the Reemployment Assistance Program
  • Reimbursement to the worker for out of pocket expenses for meals, lodging, transportation and prescriptions
  • What to do if the worker believes a condition has been omitted
  • What to do if the worker wants the insurer to accept a new condition
39
Q

Who receives a copy of the denial?

A
  • The worker
  • The employer
  • The workers atty
  • Each Medical Provider
  • Private Health Insurer
  • WCD
40
Q

What information must be included in the denial?

A
  • The factual and legal reasons for the denial
  • The workers 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 the IME
  • Information about the Expedited Claim Service
  • Appeal Rights
41
Q

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

A
  • The worker has 60 days from the mailing date of the denial
42
Q

How many days does the insurer have to reclassify a claim from nondisabling to disabling?

A
  • The insurer has 14 days from receipt of information that the claim is disabling, or
  • A request from the injured worker to reclassify the claim.
  • If it is more than one year from date of acceptance, the injured worker must file an aggravation claim.
43
Q

When a worker is represented by an attorney, when do you need to provide discoverable documents?

A

14 days from the request from the attorney

44
Q

How often and for how long do you need to provide updates?

A

provide updates every 30 days for 180 days

45
Q

Under what circumstances must an insurer request suspension of benefits form WCD?

A
  • Worker fails to attend an IME
  • Worker commits insanitary or injurious acts
  • Worker fails or refuses to accept medical tx
  • Worker fails or refuses to cooperate with investigation
46
Q

What four areas is a claim adjuster responsible for setting reserves?

A
  • Medical
  • TD (temporary Disability aka Time Loss)
  • Permanent Partial Disability (PPD)
  • Legal Costs (Fees)
47
Q

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

A

generally has 90 days from the date of the injury or accident,
sometimes up to one year to report the claim if he can show good cause

48
Q

who has the burden of proof in the claim?

A

The injured worker has the burden of proof to show a claim is compensable.

49
Q

What three situations typically make a claim NOT compensable?

A
  • 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.
50
Q

When it comes to Course and Scope what does arising out of mean?

A

a causal relationship to work

51
Q

When it comes to Course and Scope what does in the course of mean?

A

refers to the time, place, and circumstances surrounding the accident

52
Q

Is everyone hurt in Oregon covered by Oregon Workers’ Compensation Insurance?

A

No. Not all employees hurt in Oregon work for an Oregon subject employer; and not all workers are Oregon subject workers

53
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?

54
Q

Three types of tenets

A
  • Claims Tenets
  • Reserving Tenets
  • Settlement Tenets
55
Q

The 5 Claims Tenets

A
  • Claims adjusters will decide the compensability of claims by using available resources and administer timely and appropriate benefits.
  • Claims adjusters will strive to manage claims to the most appropriate conclusion for workers and employers by facilitating early return to work and claim closure.
  • Claims employees will promptly communicate significant claim developments by partnering with injured workers, employers, and providers to work toward the best possible outcome.
  • Claims employees will guarantee current and future benefits to workers by managing reserves, administering compensable benefits, and aggressively managing litigation to ensure corporate financial stability.
  • Claims employees will be mindful of the changing business climate and workers’ compensation landscape to positively influence a culture of change that anticipates the future needs of Oregon’s workforce and the state’s economy.
56
Q

Claim

A
  • Written request for compensation from a subject worker, or any compensable injury.
57
Q

Two types of claims

A

Injury Claim (material cause) and OD Claim (major cause)

58
Q

What are the elements of a formal job offer (also known as a bona fide job offer)?

A
  • The AP has to be notified of the physical task to be performed.
  • The AP agrees with the proposed modified work and that the commute is within the workers physical capabilities
  • The employer writes a written offer
59
Q

What is included a written formal job offer?

A
  • Start date and Time
  • Duration of the modified work
  • statement that the AP has approved the modified work
  • a description of physical requirements
  • the place or location of the modified work
  • the hours and days to be worked
  • the wages for the modified work
60
Q

When can a worker refused the modified work without facing a reduction or termination of time- loss benefits?

A
  • the commuted to modified work is beyond the physical capacities of the worker
  • the worksite is more than 15 miles from the worksite at injury or residence
  • 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
61
Q

If a RTW Consultant is not already involved in the claim, when should the adjuster make a referral?

A

The adjuster should make a referral when the worker begins missing time form work, or when there is an expectation that the worker will soon begin missing time from work.

62
Q

What elements are needed to stop or prorate time-loss benefits when a worker has been terminated?

A
  • The employer has a written return-to-work policy.
  • The attending physician has approved the modified job description.
  • A memo to the file that provides specific information
63
Q

What information needs to be included in the memo to stop or prorate time-loss benefits when a worker has been terminated?

A
  • 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 termination
64
Q

4 elements of closure

A
  • Med stat status
  • work release
  • actual work status including dates
  • impairment information
65
Q

How many days does an insurer have to close a claim?

A

14 days upon receipt of information needed for closure

66
Q

How many days do IW have to appeal the notice of closure?

A

Once closed the worker has 60 days from mailing date of NOC

67
Q

How many days prior to the IME appt do you have to provide to an injured worker for scheduled IME appointment?

A

10 days prior to the IME appt

68
Q

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

A

72 hours

69
Q

work disability

A

This means the separate factoring of impairment as modified by age, education, and adaptability to perform the job at which the worker was injured

70
Q

Legal standards for determining the compensability of a initial injury claim?

A

Material contributing cause of the need for treatment

71
Q

Legal standards for determining the compensability of a OD claim?

A

Major Contributing cause of the condition

72
Q

Legal standards for determining the compensability of a combined condition?

A

Major Contributing Cause of the Combined Conditions need for treatment and/or disability

73
Q

Qualified PreExisting Conditions

A
  • Arthritis or Arthritic condition
  • Previously Diagnosed
  • Previously treated, regardless of the conditions diagnosis
74
Q

Objective Findings :

A

These are verifiable indications of injury or disease that may include, but are not limited to, range of motion, atrophy, muscle strength, and palpable muscle spasm.

75
Q

How many days does an insurer have to respond to AP request for palliative care?

A

30 days from the receipt of the request from the AP

76
Q

Elements of a compensable aggravation claim

A
  • an actual worsening
  • after the last arrangement of compensation
  • of an accepted claim
  • established by medical evidence
  • supported by objective findings
77
Q

How many years does an injury worker have to file an aggravation on a disabling claim?

A

5 years from the dates of the first notice of closure

78
Q

How many years does an injured worker have to file an aggravation on a nondisabling claim?

A

5 years from date of injury

79
Q

How many days from the date of the perfected 827 is received to process a decision?

A

6 days

80
Q

What is a new condition?

A

a condition that develops after the notice of acceptance is issued

81
Q

What is an omitted condition?

A

an omitted condition is a condition that was present at the of acceptance was issued but was omitted from the notice

82
Q

How many days does an adjuster have to issue a decision in an aggravation claim?

A

60 days from receipt of the request to reopen the claim

adjuster certification test (16 decks)

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