ERISA
The time period under ERISA that begins upon receipt of a claim in which a claim specialist must make a decision unless an extension is warranted.
What is 45 days?
What is a Whole Person Analysis?
Key components of these skills include refraining from interrupting, placing opinions aside, active listening, acknowledgement of what claimants say, considering the claimant's feelings, and reserving judgement.
What are Effective Listening skills?
These two descriptions of a claimant's regular work duties are required for functional assessments.
What are physical and narrative job descriptions?
This condition duration limits benefits for certain conditions for all approved claims under that Plan. When a claimant has multiple claims under the same limited condition, the durations count towards the limited benefit period.
What are Lifetime condition durations?
This is the type of ERISA extension letter that would be utilized when no information is needed from the claimant.
What is a General Extension/ Extension Without Tolling?
Is the the claimant's responsibility to provide this information, which may include a completed medical authorization form, an Attending Physician Statement, and detailed medical information.
What is Proof?
This portion of the interview would include providing information regarding the LTD claim process, relevant plan provisions, benefit information, check frequency, etc.
What is providing plan and process information/education?
This definition of disability is based on the claimant's ability to perform the essential functions they regularly perform to provide their primary source of earned income. This could be from any employer in their Local or National Economy (depending on the Plan wording).
What is Own Occupation?
When the Plan lists a number of limitations together such as "For Disability Due to Mental and Nervous Disorders and Diseases; Neuromuscular, Musculoskeletal, or Soft Tissue Disorders; or Fibromyalgia", benefits paid under any of these limitations count towards the maximum Limited Disability Benefit benefits.
What are Combined limitations?
This is the time period under the Filing a Claim section of the Plan that defines the period allowable for the claimant to submit proof.
What is Proof of Loss/ Proof of Disability?
This is the specific sickness or injury causing the claimant's inability to work. This is generally based on clinical and diagnostic test results as well as symptoms.
What is diagnosis?
These two tools help to prepare for an interview.
What are the interview template and the Benefits and Offsets interview template?
When information regarding restrictions and limitations is vague, what two steps would the Claim Specialist take?
What are attempt to obtain clarification from health care provider(s) (HCPs), and refer to clinical if unable to obtain further clarification.
What are Self Reported Conditions?
Written notice for this type of communication must include the ERISA language, specify the reasons for the decision, explain any opinions CS did not agree with, and reference the relevant Plan provisions.
What are Adverse Decisions?
For these requests, Claim Specialist should determine the exact question that needs to be addressed, draft specific questions to obtain the necessary information, and limit the time period for the information to the time period under review.
What are health care provider/medical requests?
This type of question is designed to engage the claimant and obtain detailed responses.
What are open ended questions?
This process is part of ongoing claim management, the purpose of which is to determine whether there have been any changes in the claimant's functional with ongoing treatment.
What is re-evaluation of functional ability?
Under this limitation, benefits may be limited to only one period of disability during the claimant's lifetime while covered under that plan.
What is Alcohol, Drug or Substance Abuse or Addiction.
This communication should be sent to the claimant every 30 days after an extension until the decision is made.
What is the Initial Pending Claim Status letter/ 30 day status letter?
Payment responsibility when requesting an Attending Physician Statement (APS) and detailed medical information directly from the health care provider (HCP)?
What is shared responsibility?
During your initial interview, you should explain the need to apply for and the advantages of Social Security Disability Insurance (SSDI), as well as providing this information.
What are the advantages of working with a recommended vendor and offering a warm transfer?
When the definition of disability is Own Occupation and a Claim Specialist has clinically validated restrictions and limitations (R&Ls) that indicate a claimant has some work capacity, but the claimant cannot perform the duties of their own job, what is the next step?
What is referral to Vocational Rehabilitation Consultant (VRC) for an own occupation assessment?
This condition duration is limited for each approved LTD claim. Subsequent claims make the claimant eligible for a new limitation period.
What are Per Occurrence limitations?