WEEK 1
The limit for medical benefits on a Workers Compensation policy is
There is no limit
This must be updated prior to updating reserves
POA
HEP stands for this
Home Exercise Program
True or False: Claim Associates can file full denials on claims
False
As of January 1, 2020, an Employee has this many days to report an Injury
60 days
These are the three types of work related injuries
Traumatic, Cumulative, and Occupational Disease
Name 3 questions to ask during a subrogation investigation for a motor vehicle accident
What were the weather conditions on the day of the accident? Was there any warning before the accident? Who was at fault for the accident? Please provide names and addresses of all persons who witnessed the accident. What damage was sustained to you and/or your vehicle?
This must be received prior to paying a medical bill
Medical Records – can be in IR or in Corvel but we must have the records prior to payment
After filing your paper NOC, you should do this
Contact EE & ER to inform them of the denial if you haven’t already. Set a diary 30 days out to see if the EE appeals the NOC
An Employer has this many days to report an injury to MEMIC, and this is what happens if the Employer misses the deadline
Employers have 7 days to report an injury to MEMIC. If the claim is report or medical only with no lost time, there is no fine. If there is lost time and the claim is reported late, the WCB may fine the Employer $100. The fine is initially paid by MEMIC and MEMIC requests reimbursement from the Employer
The general Claims fax number is
207.791.3334
A way that an adjuster can take action to manage the medical portion of a claim
Proactively pursue medical records, approving or denying medical referral requests, utilizing diaries to trigger claim actions
SOAP stand for this
Subjective, Objective Assessment, and Plan
A mediation prep is due to an adjuster handling a mediation this many days prior to the mediation
5 days
You should use this date as the Date of Injury on a repetitive or gradual injury
Use the older date of: date notice of an injury is reported to an Employer OR date the Employee first received treatment and the condition was determined to be work related
This department is responsible for evaluating applications through an assessment of risk
Underwriting
The 3 types of non-consecutive lost time
Reduced hours, reduced wages, losing full non-consecutive days
These are 3 reasons an IME might be needed
Determine causality, work capacity, treatment plan, baseline, possible apportionment, confirm maximum medical improvement or confirm permanent impairment
The difference between a mediation notice and petitions are
Mediation notice is informing you that the claim is heading to the first step in litigation: mediation. This can be handled by a Claim Associate II or Claim Specialist. Mediation Prep should be completed. Petitions are legal notice requesting a formal hearing, and they usually appear after a mediation has happened. If petitions are received, a litigation referral should be made within 3 business days so an attorney can be assigned and enter their appearance.
If a claim goes to mediation and MEMIC agrees to pay, you have this many days to pay the Employee (medical bills, mileage, etc.)
10 days from the mediation date
The amount of money paid out in claims, plus company expenses, over the amount of money collected in premium gives us this
Profit
The 3 places where you can find information about lost time (other than talking to the employee and employer) are
FROI, statement of the injured worker, medical records, provider contact, prior notepads, legal findings
You should take these actions if you receive a prescription request in Corvel/CareMC
Review the prescription to determine if it was prescribed by the treating provider. If it was prescribed and relates to the work injury, authorize the script. If it was not prescribed by the treating provider, or is not commonly used for the injury, consider: contacting the provider to see if it is truly for our injury, assigning a NCM task, reaching out to your CTM, and requesting a letter of medical necessity from the provider prior to authorization. The letter can be requested through CareMC
You should do this if you receive a letter of representation from an attorney on a claim you closed two months ago
Reopen and reinvestigate the claim. Add reserves and update your POA. Request updated medical notes. Troubleshoot the issue with the attorney prior to the mediation date. Complete mediation prep template
The Statute of Limitations on claims is (Two parts!)
The Employee has six years from the date of the last payment made on the claim OR two years from the date of injury or the date the Employer filed the first report (whichever is later) if no bills have ever been paid