SIU
A material misrepresentation of a matter of fact, whether by commission or omission, for the purpose of obtaining a benefit.
What is Fraud?
The acronym MSA stands for this.
What is Medicare Set-Aside?
The act of legally pursuing a third party that caused an insurance loss to an employer.
What is subrogation?
For CCU, the timeframe in which initial contacts with all parties needs to occur.
What is within 48 hours from claim activation?
This body part is made up of the Cervical, Thoracic and Lumbar Vertebrae.
What is the Spine?
A survey of medical providers who may have records of treatment to a claimant.
What is a medical/hospital sweep?
These 3 demographic fields need to verified for Medicare Reporting Requirements. All are in IIS.
What are Date of Birth, Gender and Social Security number?
The insurer will file this on the proceeds of any third party recovery to reimburse for a portion of what was paid on the claim.
What is a lien?
These three fields in IIS need to be updated when the injured party is represented by an attorney.
What are Atty/Auth Rep, Atty/Auth Rep Date and the Opposing Attorney in the Contacts Tab?
According to an Insurance Journal study from 2018, these are the most common type of workplace injuries. (non-body type specific).
What are Sprain/Strain injuries?
Identify suspected “Red Flags,” document their file and submit the referral to SIU.
What are the responsibilities of the Claims Adjuster?
This agency is part of the US Department of Health and Human Services and reviews MSA submissions that meet a certain criteria.
What is CMS?
This type of settlement occurs when a lien is waived or reduced in order to close a WC claim.
What is a global settlement?
The timeframes in which the initial Status/POA and subsequent Status/POA need to be entered by.
What are 14 days of claim assignment and every 90 days thereafter?
This body part is associated with Carpal Tunnel Syndrome.
What is the median nerve of the wrist?
60 days from when reasonable belief is established.
What timeframe does SIU have to file their Fraud Referral (eFD1)?
ORM stands for this.
What is Ongoing Responsibility for Medical?
When a third party settlement is more than the insurance carrier has already paid, this will help mitigate ongoing exposure of a claim.
What is a future credit?
The amount of time an adjuster has to process a medical bill in their mailbox.
What is 3 business days?
This is a scan uses a strong magnetic field and radio waves to create detailed images of the organs and tissues within the body.
What is an MRI?
Reasonable suspicion is a legal standard of proof in United States law that is less than probable cause, but more than a suspicion or 'hunch.'
What is Articulable Suspicion?
A payment that Medicare makes for services where another payer may be responsible.
What is a Conditional Payment?
This type of coverage under 1B of the WC policy often results in a waiver of subrogation.
What is Employers Liability (EL)?
These are the 5 NCCI reporting requirements that need to be verified.
What are the Jurisdiction, body part, accident code, loss code and class code?
This is a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury. (TBI)
What is a Traumatic Brain Injury?