Coverage
documentation that should include a coverage decision and analysis
What is a Coverage note ?
noted within one business day of claims assignment and before initial IW contact, if available
What are ISO Findings?
the amount of time after claim assignment the insured contact should occur
What is One Business Day?
this should be used as a guide, supplemental questions for the scenario may be needed
What is a R/S interview guideline?
may require continuous investigation throughout the life of the claim
What are claims?
should be documented within 14 days, when possible, however jurisdiction timelines may dictate the ultimate time-frame
What is a Compensability Decision?
occurs throughout the life of the claim and upon receipt of every new or reassigned claim
What is Coverage Anaylsis?
Should set the expectations and explain next steps to the injured worker and the employer
What is every communication?
the amount of time after claim assignment the Injured worked or legal representative contact should occur
What are Two Business Days?
the amount of time a recorded statement should be transcribed and uploaded to the claim file
What is one business day ?
this may need to be run again and relevant records pursued
What is an ISO report?
the amount of time, after initial unsuccessful contact, that at least two subsequent contacts temps should be made via telephone/email
What is 5 business days ?
Includes attributes such as; Underwriting company, Policy Number & MOD, Claim Jurisdiction as Identified in 3A, etc.
What is Coverage validation?
is thorough, timely and accurate. Helps to ensure that claims are handed in a professional manner and meet regulatory requirement
What is a compensability investigation?
the amount of time after identification that the medical provider contact should occur
What are Two Business Days?
the adjuster shoulder enter this after a R/S with the details of the conversation and any critical information
What is a summary note?
pursuit of these types of records may be relevant to the investigation of the triggering event
What are medical records?
these should be updated appropriately to align with the compensability determination
What are PICs ?
should be elevated to the Unit Manager for review. Requires AVP approval before issuance
What is a Coverage denial ?
should be conducted with empathy, active listening and a problem-solving mindset
What are investigations?
the amount of time after identification that the witness contact should occur
What are Two Business Days?
may be needed from any involved party or witness and may need to taken throughout the life of the claim
What are recorded statements?
these may need to be pursued from the employer, Injured worker/legal representative and/or witnesses
What are updated statements?
Receipt of these should be noted, EX. claim questionnaire, medical treatment history, signed release for records.
What are new loss packet documents?
is crucial to ensure claims are handled in a professional manner and meet regulatory requirements
What is a timely assessment of coverage?
should be attempted first by telephone, unless otherwise noted via Special Claims Handling Instructions?
What are initial adjuster contacts?
required after 5 business days if contact efforts are unsuccessful
What is a contact letter?
Ex. Compensability is in question, Accidents Occur Offsite from ER location, Multiple Body parts alleged
What are indicators to take an R/I?
may include newly alleged body parts, intervening/subsequent injury, and/or new injury details not originally reported
What are events triggering additional investigation?
Captured during the investigation Ex. accident location, work location, accident details, alleged injuries, etc.
What are facts of loss/loss description?