Coverage
What should a coverage analysis confirm?
That the injury occurred during an active period of coverage, at a covered location, and that the claimant was a covered employee on the date of injury.
How long do you have to contact the employer and injured worker after claim assignment?
Within one business day.
What should the compensability analysis include?
A documented rationale explaining which body parts are accepted or denied.
When should initial reserves be set?
Within 14 days of assignment
When should wage information be requested from the employer?
During initial employer contact.
Should the coverage determination be made before or after the compensability decision?
Before the compensability decision.
In California, when must contact be made with claimant counsel if the claimant is represented and a DWC-1 has been received?
Within ten calendar days.
When should compensability decisions be issued?
Timely and accurately, per jurisdictional requirements. (Within 14 days)
When should reserves be reviewed after new information is received?
Within 30 days of receiving new information impacting exposure.
How many attempts are required to obtain a wage statement?
A minimum of three attempts, or more per jurisdiction.
Give two examples of items not covered under the policy that must be escalated.
Civil pleadings and Labor Code 132a or Serious & Willful (S&W) claims in California.
How many follow-up attempts must be documented if initial contact is unsuccessful?
A minimum of three follow-up attempts within five days.
What is required before issuing a claim denial?
Supervisor Approval
How often must reserves be reviewed during the claim’s life?
Every 90 days, with up to 14 days’ grace.
What must accompany benefit payments?
State-required notices with accurate payment and benefit information.
What should be done if co-defendants are identified in a California cumulative trauma (CT) claim?
They should be identified and documented in the claim file.
How soon must records like medical or surveillance reports be reviewed once received?
Within 30 days, or sooner if needed for a critical claim event.
What screen and data points need to be updated once compensability has been determined?
Loss Details, Body Parts Details
What should reserves reflect?
The Most Probable Outcome of the claim.
What should benefit rate calculations be based on?
Accurate wage statements and jurisdictional formulas.
What is required if the claimant is an officer or independent contractor?
The coverage analysis must confirm whether they were covered under the policy at the time of injury.
What must be documented before assigning surveillance?
An articulable suspicion, scope of assignment, and supervisor approval.
Why must compensability notices be timely?
To meet jurisdictional requirements and ensure compliance with state laws.
What must be documented when reserves change?
What materially changed in the file that necessitated the adjustment.
What should be done if duplicate or overpayments occur?
Document recovery efforts and pursue reimbursement until resolved.