Call Flow
Health Care
Miscellaneous
Performance
Appeals
100

What is step when reviewing a claim for call flow

Segmentation 

100

What is the standard length of an approved MSK POC ?

8 Weeks

100

What is the best way to submit a claim to the WSIB

Online services 

100

What is the wrap time target ?

322 seconds 


100

What two screens can you look at to find the appeals coordinator

Workplan and objections/appeals 

200

How do you generate a PLI CM?

  • Blank activity - z PLI to CM
200

Who approves the first extension on an MSK POC

Clinical Expert 

200

How do you decide if a call requires an escalation. 

Review the escalation criteria 

200

What is the FCR target

65%

200

What is the timeline to submit an ARF?

No Timeline

300

True or false: Covid claims do not follow specialized call flow

False: Covid claims do follow their own specialty call flow

300

Who do you transfer to when you have a specialty program referral ? 

Case Owner

300

On a service delivery claim who authorizes travel for a new medical travel request ?

Case owner

300

What is the call quality target ?

90%

300

What is the role of the AICM?

To implement changes to the claim based on an ARO decision – ex. paying retroactive LOE

400

What is the process for a cheque re-issue on an allowed LT claim?

New claim activity to Case Management SOC Resolution Team Queue 

400

Who pays for the ambulance ride on the day of the injury ?

Employer

400

What must you do when you provide an adverse decision ?

Add a CSR Adverse decision memo to the file.

400

What is the conformance target ?

98%

400

True or false: the PWI/rep can only object to the release of HC info once

False: they can object twice

500

Who would be the NC for OD claim 01234567

Janet Nguyen

500

In order to receive these benefits you must have a NEL of 60% or higher or 100% PD

Personal care allowance (PCA) and 

Independent living allowance (ILA)

500

Name one benefit status letter a CSR is unable to draft for a PWI

  • Serious Injury Program (SIP),
  • Occupational Disease (OD) and
  • Mental Stress Injury Program (MSIP) claims, including:
    • Chronic mental stress (CMS)
    • Traumatic mental stress (TMS) and
    • Post-traumatic stress disorder (PTSD).
  • Claims with an ongoing non-economic loss (NEL) benefit payments.
  • Pre-1990 claims (unless you are trained, warm transfer these calls to "CSR New Pre90 En/Fr" for a trained CSR to help).
  • Loss of retirement income (LRI) and LRI deductions from benefits.
  • Ongoing partial loss-of-earnings (PLOE) (Note: This includes ongoing PLOE in post lock-in (PLI) claims).
  • Return-to-work (RTW) issues.
  • Retroactive appeals payments, 3rd party/insurance assignments and garnished payments.
  • Survivor claims with multiple dependents.
  • Covered by advances (i.e., LOE paid to employer)
500

What is the Adherence target ?

95%

500

True or false: the respondent form must be completed no matter what

False: it only needs to be completed if the non-objecting party is participating

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