Misc Test Need To Know Flashcards
3 day waiting period def
three consecutive calendar days beginning with the first day the worker loses time or wages from work as a result of the compensable injury.
When is the 3 day waiting period payable? Which 2 circumstances?
- Hospitalized – confirmed and typically paid on 1st check
- Authorized TTD is authorized for a period of consecutive 14 days. (paid on the 2nd check)
What is needed before an adjust approves time loss?
Authorization: from MD, NP or Type B provider must verify the workers inability to return to work and then authorize time loss
When is time loss due to the worker?
by statute 14 days from EDOK
by SAIFs best practice its 13 days from EDOK
After first payment how often do, we pay time loss?
every 14 days
Which one is not a type A medical provider who can serve as an attending physician in a claim?
- MD
- Dr of osteopathic Medicine
- Oral and Maxillofacial surgery
- Nurse Practitioner (CORRECT)
- Podiatrist
Which of the following is not a type B
- Chiro
- Nat Path
- PA
- Cardiologist (CORRECT)
How many days of office visits can a Type B medical Provider provide medical services?
60 days or 18 office visits from the date of the first on the initial claim
How many days can a Type B Medical provider authorize time loss benefits?
30 days from the date of the first office visit on the initial claim
How many days can an authorized NP provide medical services
180 days from the date of the first visit on the initial claim.
How many days can an authorized NP authorize time loss benefits?
180 days
How many attending physicians can a worker have during the life of a claim?
three
How many AP can be in a claim at one time?
One
How many days do insurers have to pay medical bills in an accepted claim?
45 days from the receipt of the bill
How many days do insurers have to pay medical bills that were received prior to a claim decision once the claims have been accepted?
14 days of the accept
How many days do insurers have to pay workers reimbursement?
30 days
How many days prior to the IME do the adjuster need to let the IW know of the scheduled appt?
10 days
An Exam with multiple IME examiners completed within 72 hours will be considered one IME Exam
true
Injury
Material or Major need for treatment/ disability
OD
Major cause of condition
Major
we need a medical opinion
Material
We don’t need a medical opinion
How Many days can an ER Dr authorize time loss beneifts?
14 days
How many days do insurers have to pay medical bills in accepted claim?
45 days from receipt of bill
Which type of type B med provider is able to rate impairment?
Chiropractor
What types of things can a worker request reimbursement for?
meals, lodging, prescriptions and potentially lost wages
How many days does an insurer have to respond in writing to a written request for diagnostic preautho?
within 14 days of receiving the request from the provider
SAIF current contracts with which MCOs
- Caremark comp(CMC)
- Kaiser on the job
- Majoris health systems
Who approves MCO to offer service to workers
DCBS
Types of Settlements for denied claims
DCS and STIP
DCS
Disputed Claim settlements : settles all benefits in the claim
Stip
Stipulation and Oregon : recid the denial and accept the claim
Types of settlements for accepted claims
CDA
DCS (if there is a partial denial in the claim)
STIP
CDA
Claims Disposition agreement (CDA)
What is the only benefit a worker cannot settle when agreeing to CDA?
medical benefits
4 Levels of Appeal
- 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
Who receives a copy of the acceptance
- The worker
- The employer
- the workers atty
- the workers AP
- the MCO if enrolled
- WCD
What information must be included on the acceptance?
- 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
Who receives a copy of the denial?
- The worker
- The employer
- The workers atty
- Each Medical Provider
- Private Health Insurer
- WCD
What information must be included in the denial?
- 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
How Many days does a worker have to appeal a denial?
- The worker has 60 days from the mailing date of the denial
How many days does the insurer have to reclassify a claim from nondisabling to disabling?
- 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.
When a worker is represented by an attorney, when do you need to provide discoverable documents?
14 days from the request from the attorney
How often and for how long do you need to provide updates?
provide updates every 30 days for 180 days
Under what circumstances must an insurer request suspension of benefits form WCD?
- 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
What four areas is a claim adjuster responsible for setting reserves?
- Medical
- TD (temporary Disability aka Time Loss)
- Permanent Partial Disability (PPD)
- Legal Costs (Fees)
How many days does the worker have to report an injury to the employer?
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
who has the burden of proof in the claim?
The injured worker has the burden of proof to show a claim is compensable.
What three situations typically make a claim NOT compensable?
- 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.
When it comes to Course and Scope what does arising out of mean?
a causal relationship to work
When it comes to Course and Scope what does in the course of mean?
refers to the time, place, and circumstances surrounding the accident
Is everyone hurt in Oregon covered by Oregon Workers’ Compensation Insurance?
No. Not all employees hurt in Oregon work for an Oregon subject employer; and not all workers are Oregon subject workers
In addition to overall compensability, what other issue must an adjuster consider before making a decision on the claim?
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?
Three types of tenets
- Claims Tenets
- Reserving Tenets
- Settlement Tenets
The 5 Claims Tenets
- 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.
Claim
- Written request for compensation from a subject worker, or any compensable injury.
Two types of claims
Injury Claim (material cause) and OD Claim (major cause)
What are the elements of a formal job offer (also known as a bona fide job offer)?
- 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
What is included a written formal job offer?
- 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
When can a worker refused the modified work without facing a reduction or termination of time- loss benefits?
- 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
If a RTW Consultant is not already involved in the claim, when should the adjuster make a referral?
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.
What elements are needed to stop or prorate time-loss benefits when a worker has been terminated?
- 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
What information needs to be included in the memo to stop or prorate time-loss benefits when a worker has been terminated?
- 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
4 elements of closure
- Med stat status
- work release
- actual work status including dates
- impairment information
How many days does an insurer have to close a claim?
14 days upon receipt of information needed for closure
How many days do IW have to appeal the notice of closure?
Once closed the worker has 60 days from mailing date of NOC
How many days prior to the IME appt do you have to provide to an injured worker for scheduled IME appointment?
10 days prior to the IME appt
An IME with multiple examiners must be completed within what period of time in order to be considered one IME?
72 hours
work disability
This means the separate factoring of impairment as modified by age, education, and adaptability to perform the job at which the worker was injured
Legal standards for determining the compensability of a initial injury claim?
Material contributing cause of the need for treatment
Legal standards for determining the compensability of a OD claim?
Major Contributing cause of the condition
Legal standards for determining the compensability of a combined condition?
Major Contributing Cause of the Combined Conditions need for treatment and/or disability
Qualified PreExisting Conditions
- Arthritis or Arthritic condition
- Previously Diagnosed
- Previously treated, regardless of the conditions diagnosis
Objective Findings :
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.
How many days does an insurer have to respond to AP request for palliative care?
30 days from the receipt of the request from the AP
Elements of a compensable aggravation claim
- an actual worsening
- after the last arrangement of compensation
- of an accepted claim
- established by medical evidence
- supported by objective findings
How many years does an injury worker have to file an aggravation on a disabling claim?
5 years from the dates of the first notice of closure
How many years does an injured worker have to file an aggravation on a nondisabling claim?
5 years from date of injury
How many days from the date of the perfected 827 is received to process a decision?
6 days
What is a new condition?
a condition that develops after the notice of acceptance is issued
What is an omitted condition?
an omitted condition is a condition that was present at the of acceptance was issued but was omitted from the notice
How many days does an adjuster have to issue a decision in an aggravation claim?
60 days from receipt of the request to reopen the claim
