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Claim adjuster test > Quiz Questions > Flashcards

Quiz Questions Flashcards

1
Q

Which TWO divisions under the DCBS regulate the workers’ comp process

A

Workers’ Comp Board (WCB)

Workers’ Comp Division (WCD)

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2
Q

Which Form is used by the worker and the employer to report an injury to the insurer

A

801 Form

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3
Q

Which of the following are uses of the Form 827 (mark all which apply)

A

Report of Aggravation (Agg)
First report of injury or disease
Request for new or omitted condition
Notice of change of AP or NP

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4
Q

Which of the following are uses for the Form 1502 (mark all that apply)

A

First report of injury
Acceptance or denial of claim
Aggravation

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5
Q

How much time does a physician have to send the 827 to the insurer if it is being sent as the first report of injury

A

72 Hours from initial visit

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6
Q

How much time does the employer have to the the 801 to the insurer

A

5 days from EDOK

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7
Q

When must the notice of changing AP or NP be sent to the insurer using the 827 Form

A

5 days of the office visit

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8
Q

Attending Physician : A doctor or physician who is _________________ or illness

A

Primarily responsible for the treatment of a worker’s compensable injury

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9
Q

Claim : ______________ from a subject worker or someone on the subject worker’s behalf, _______________

A

A written request for compensation/ or any compensable injury of which a subject employer has notice or knowledge

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10
Q

Compensable Injury : ___________ requiring ___________ an injury is accidental if the result is an accident, whether or due to accidental means, if it is ________________

A

An accidental injury, or accidental injury to prosthetic appliances, arising out of an in the course of employment/ medical services or resulting in disability or death/ established by medical evidence

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11
Q

Match the legal standard for determining compensability in an injury claim and in an occupational disease claim

A

Determining compensability in an injury claim - Material contributing cause of the need for treatment or disability

Determining compensability in an occupational disease claim - Major contributing cause of the condition

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12
Q

Choose when a claim would NOT be compensable. Mark all that apply

A

Injury occurs to any active participant in assaults or combats

Injury occurs while engaging in or performing any social or recreational activity for workers pleasure

Major contribution cause of the injury is by the workers consumption of drugs or alcohol. demonstrated by a preponderance of the medical evidence

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13
Q

What does “Course and Scope” mean

A

“Arising out of” - causal relationship to work

“In the course of” - Time, Place, Circumstances

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14
Q

Which is NOT one of the 5 Claim Tenets

A

Claims adjusters will assist employers with labor issues and partner with outside labor attorneys when appropriate to ensure claims management

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15
Q

Claim adjusters will decide the compensability of claims by using available resources and administer timely and appropriate benefits.

A

Claim Tenet 1

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16
Q

Claims adjusters will strive to manage claims to the most appropriate conclusion for workers and employers by facilitation early return to work and claim closure

A

Claim Tenet 2

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17
Q

Claims employees with promptly communicate significant claim developments by partnering with injured workers, employers, and providers to work toward the best possible outcome

A

Claim Tenet 3

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18
Q

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

A

Claim Tenet 4

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19
Q

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

A

Claim Tenet 5

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20
Q

Omitted Condition: A condition that was present ___________ but was omitted from the ________

A

At the time of acceptance / Notice

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21
Q

When is the 3DW period payable?

A

The worker is totally disabled for a period of 14 consecutive days

The worker is admitted as an inpatient to a hospital within 14 days of the onset of total disability

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22
Q

What information is required before an adjuster can assess time loss TL benefits?

A

Attending physician or authorized nurse practitioner needs to verify the workers inability to work and authorize time loss

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23
Q

When is the first time loss payment due to the worker per SAIF’s best practice?

A

13 days from the employer’s date of knowledge and the of the worker’s disability

24
Q

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

A

Nurse practitioner (NP) or (ANP)

25
Q

How many days or office visits can a Type B medical provider provide medical services?

A

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

26
Q

How many days can a ANP authorize time loss benefits?

A

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

27
Q

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

A

45 days from receipt of bill

28
Q

How many days prior to the IME appointment must the adjuster notify the IW of the scheduled exam?

A

10 days

29
Q

Which of the following items of information must be included in the Notice of Acceptance? Mark all that apply

A

Compensable conditions

Disabling or nondisabling status

employment reinstatement rights

30
Q

Which parties must receive a copy of the denial?

A

The worker, employer, WCD, each medical services provider, private health insurer if any and the worker’s attorney if represented

31
Q

In what situations can an insurer request suspension of benefits from WCD? Mark all that apply

A

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

32
Q

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

A

14 days from receipt of information that the claim is disabling or a request from the worker to reclassify

33
Q

When a worker is represented by an attorney, when does the insurer need to provide discoverable documents?

A

14 days from receipt of the attorney’s discovery request

34
Q

In what areas are claims adjusters responsible for setting reserves? mark all that apply

A

Medical

Temporary Disability (Time Loss)

Permanent Partial Disability

Legal Cost (Fees)

35
Q

When a claim denial is appealed, what are the levels of litigation (appeal) that can occur? Mark all that apply

A

WCB hearings division - ALJ

Workers Comp board (review)

Oregon Court of Appeals

Oregon Supreme Court

36
Q

How many days does an insurer have to pay a Claims Disposition Agreement (CDA) once it has been approved?

A

14 days from the receipt of the approved order from WCB

37
Q

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

A

Medical benefits

38
Q

Definition of Impairment

A

A permanent loss of use or function of a body part or system related to the compensable condition

39
Q

Definition of Palliative Care

A

Medical service rendered to reduce or moderate temporarily the intensity of an otherwise stable medical condition

40
Q

Examples of medical services Mark all that apply

A

Surgery

Diagnostics

Prosthetic appliances

41
Q

Definition of Work Disability: separate factoring of the impairment as modified by________________

A

Age, education, and adaptability

42
Q

Which are elements of a bona fide (Formal) job offer of modified work? mark all that apply

A

The AP is notified of physical tasks to be performed

The AP agrees with the modified work and the commute is within capabilities

43
Q

Seven elements of the written bona fide (formal) job offer from the employer? mark all that apply

A

Start date and time, duration of the modified work, statement that the AP has approved the modified work, description of physical requirements, place or location of the modified work, hours and days to be worked, wages

44
Q

Elements needed to stop or prorate time-loss benefits when a worker has been terminated from the employer at injury? Mark all that apply

A

Employer has written RTW policy

Approved modified job description from AP

45
Q

In order to stop prorate TL benefits when a worker has been terminated from the employer at injury what elements must be included in the Memo to the file? Mark all that apply

A

Start date and time
Wages
Hours and days work available
Statement that modified work is available but for termination

46
Q

What info is needed before closing a claim? Mark all that apply

A

Actual work status

Med stat status

status and date of work release

infor. concerning permanent impairment, if any

47
Q

What are the elements of a compensable aggravation claim?

A

An actual worsening, after the last arrangement of compensation, of an accepted condition, established by medical evidence, supported by objective findings

48
Q

Which Type B provider can also rate impairment?

A

Chiropractor

49
Q

How many days can an authorized nurse practitioner provide medical services?

A

180 days

50
Q

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

A

14 day from acceptance

51
Q

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

A

60 days from request

52
Q

How much time does an insurer have to respond to the AP request for palliative care?

A

30 days from request

53
Q

How many days do IW have to appeal the Notice of Closure?

A

60 days from mailing date

54
Q

Which items of information must be included on the denial? mark all that apply

A

Appeal rights

The factual and legal reasons for denial

whether the denial was based in whole or in part on an IME

55
Q

The legal standard for determining compensability of a combined condition claim is material contributing cause of either the disability or the need for treatment of the combined condition.

A

False

“Major contributing cause of the combined condition’s need for treatment”

56
Q

The IW has one year to report an OD to the employer. What are the event triggers that may start this timeframe?

A

1 year from date the worker discovered OD

1 year from the date the worker became disabled

1 year from the date the IW was informed by a Dr. of the OD

1 year from the date of death or when discovered the cause of death was OD

57
Q

of days insurers have to pay worker reimbursements?

A

30 days from receipt

Claim adjuster test (12 decks)

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