Open/Closed Claims Flashcards
Open claims management
When managing an open/accepted claim, adjusters assist the injured worker in recovery and return to work by paying benefits accurately and timely, and ensuring the worker receives reasonable and necessary medical services related to the accepted conditions, to bring the claim to an appropriate resolution (claim closure or settlement).
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? How often and for how long do you need to provide updates?
You must provide the documents within 14 days from the request from the attorney and provide updates every 30 days for 180 days.
Why is it important to set reserves on a claim?
▪It enables SAIF to estimate future liabilities.
▪Reserves are used in rate making and calculation of the employer’s modification rate. ▪It is used to calculate premium for retrospective policies.
▪Reserves facilitate underwriting decisions.
▪It meets statutory requirements.
In what four areas is a claims adjuster responsible for setting reserves?
▪Medical,
▪Temporary Disability (Time loss),
▪Permanent Partial Disability,
▪Legal Costs (Fees)
When is an adjuster required set reserves on a claim?
▪Within 30 days of the receipt of the request for hearing on a denied claim or condition.
▪Within 30 days of acceptance of a disabling claim.
▪On accepted, nondisabling claims, when medical paid costs exceed $5,000
What are examples of significant events that would prompt you to review the reserves on a claim?
▪A change in the time loss authorization (starting or stopping)
▪A change in the work release or work status
▪Receipt of medical information such as a surgery
▪Claim closure information
▪A request to reopen a claim
▪A request to accept new, omitted, consequential, or combined conditions
▪The passage of time without further treatment or activity in the claim
Which types of medical providers can be attending physicians?
Type A providers: medical doctors, osteopathic physician, oral and maxillofacial surgeons, and podiatric physicians and surgeons.
Type B providers: chiropractors, naturopathic physicians,and physician assistants.
For how many days or office visits can a Type B medical provider provide medical services and authorize time loss benefits?
Medical services: 60 days or 18 office visits from the date of the first visit on the initial claim.
Timeloss: 30 days from the date of the first office visit on the initial claim.
Which of the Type B medical providers is also able to rate impairment?
Chiropractors.
Can an emergency room physician authorize time loss benefits? If so, for how many days?
Yes, for up to 14 days from the emergency room visit.
For how many days can an authorized nurse practitioner provide medical services and authorize time loss benefits?
Medical services: 180 days from the date of the first visit on the initial claim.
Time loss: 180days from the date of the first visit on the initial claim.
How many attending physicians can a worker have during the life of a claim?
Three total—the initial attending physician (AP) followed by two changes.
What are NOT considered AP changes by choice of the worker?
▪Emergency services by a physician
▪Exams requested by the insurer
▪Consultations or referrals for specialized treatment or services requested by AP
▪Referrals to radiologists or pathologists for diagnostic studies
▪When a worker is required to change providers because their medical service provider is no longer qualified as an AP or authorized to provide medical services
▪Changes due to conditions beyond the worker’s control
▪A Worker Requested Medical Exam (WRME)
▪When AP works in a group setting or facility and worker is seen by another group member due to team practice, coverage, or on-call routines
▪When the AP is not available and worker sees a covering physician
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 the claim decision once the claim has been accepted?
14 days from the date of the acceptance.
How many days do insurers have to pay worker reimbursements?
30 days from the receipt of the request for reimbursement.
What types of things can a worker request reimbursement for?
▪Meals ▪Lodging ▪Use of public transportation ▪Use of a private vehicle ▪Prescriptions ▪Other out-of-pocket, claims-related expenses
What is the time frame for an injured worker to request reimbursement?
Two years from the date the costs were incurred or from the date the claim or medical condition is finally determined to be compensable.
Within what time period do medical providers need send the Form 827 to the insurer when the worker is initiating a claim for workers’ compensation benefits?
72 hours from the initial office visit.
How many days do medical providers have to submit the Form 827whennotifying the insurer of a change in the attending physician?
Five days from the first treatment with the new attending physician.
How many days does an insurer have to respond, in writing, to a written request for diagnostic pre-authorization?
Within 14 days of receiving the request from the provider.
How many days does a medical provider have to send medical records to the insurer?
Within 14 days of receiving the request from the insurer.
What is the purpose of the MCO?
The purpose is to help manage the medical services in a claim, to ensure the medical treatment is reasonable and necessary, to assist with obtaining return-to-work information, and to facilitate claim closure.
