Coverage
Prior to investigating the compensability of a claim, you must do this as the first step in handling your claim.
What is verify coverage?
The initial contacts to the injured worker and employer should be initiated in _____ day(s).
What is 1 business day?
The four things needed to determine compensability are: Injury resulting from an Accident; Arising out of Employment; in the Course of Employment; and having a ____________ between the diagnosed condition and mechanism of injury.
What is Causal Relationship?
The claim handler is not responsible for issuing payments for medical services, but this department is.
What is Medbill?
These two things are needed to set up EFT.
What are Bank Account and Bank Routing number?
This is the definition of WC.
What is a statutory law which provides wage replacement and medical coverage when an employee suffers a work related injury or disease?
This changes, adds or removes coverage on a policy.
What is an endorsement?
It is this persons job to identify the potential for subrogation.
Who is the claim handler?
This rule determines if an injured worker would have a compensable injury if in a car accident on the way to work.
What is the coming and going rule?
This program allows injured workers' to get their initial RX from a pharmacy with no expense to them.
What is the First Fill Program?
The acronyms TTD, TPD, PPD and PTD stand for these terms.
What is Temporary Total, Temporary Partial, Permanent Partial and Permanent Total?
If this happens during the life of a claim, the claim handlers would have 20 days to update a reserve.
What is a material change?
The most common endorsement found on WC policies.
What is the Broad Form Endorsement?
"An injured worker is disgruntled or soon to be fired" and "An injured worker that is overly familiar with the Work Comp process" are examples of this.
What are Fraud Red Flags?
A dual purpose trip is when an employee is engaged in an activity that is both business and ______ in nature.
What is personal?
IME Consult, PPD Consult and Vended Case Management are all types of this.
What are clinical referrals?
Claims that are segmented as core claims can be put on recurring indemnity payments for this number of weeks.
What is 6 weeks?
This is the special handling procedures contracted between the insurer and the insured.
What is an ASA?
This section of a policy shows the location, writing company, number of employees and job class codes.
What is the schedule of operations?
This is the term for our right to recover from a negligent 3rd party.
What is Subrogation?
Stopping to get lunch and visiting a sick relative while working a delivery job are examples of these two deviations.
What are minor and major?
This term is used to describe a newly added body part or injuries alleged on the claim after the initial report of injury.
What is a injury creep?
PDA, PCE, NCM and IMEs are all tools used to facilitate this?
What is Early Return to Work (ERTW)
According to the Authenticate Call process in the KMT, either of these two pieces of information would be needed from the insured to verify the caller and protect the injured workers PII.
What is the policy number or the claim number.
Work Comp insurance and other states coverage are found under these two sections of the policy.
What are 3A and 3C?
Along with directing medical care, and developing a relationship, this is a reason timely investigations are important.
What is to get information while it is fresh?
An employee would be considered to be on a _____ mission if they are stopping at the bank for their employer on their way home from work.
What is a special mission?
A broken leg from falling off a ladder and a sprained shoulder from repeated overhead work are examples of these two types of injuries.
What are Acute and Cumulative?
These early return to work tools are sent to and completed by the employer and doctor respectively.
What are the Physical Demands Analysis (PDA) and the Physical Capabilities Evaluation (PCE)?
The acronym CSTP stands for this.
What is customer service touch point?
Ray is injured while working at a company that he is a partner in. He might not be covered because of this endorsement.
What is the Sole Proprietors, Partners, Officers and Other Endorsement?
Control is the main factor in determining the difference between an employee and a(n) ________.
What is an independent contractor?
If an employee is injured while intoxicated, it would need to be determined that the alcohol was the ____ cause of the injury.
What is prevailing or proximate cause?
This is the name of our search tool used to find medical providers on our network.
What is Talispoint?
This time period must be met before Indemnity benefits would be owed.
What is the waiting period?
All incoming EDM should be handled in this timeframe.
What is 3-5 days?