WC Basics
What is a waiting period, and where are they listed?
The amount of time a worker must "wait" before being eligible for TTD benefits. They are listed on the Waiting Periods & Panels tab of the WC spreadsheet.
What does "DNR" mean in an employee's profile?
"Do Not Recruit" - this may be for a particular facility, a health care system, or for any position with Aya.
What is the preferred format for medical documents uploaded to the ticket?
Medical documents should be uploaded to the ticket as PDF.
How can you check who is handling a claim?
Name the 2 state agencies that make determination about claims in Washington and Ohio.
What is a retroactive period?
If a worker remains off work after reaching the retroactive period, they will receive "retroactive" benefits for the original waiting period.
How do you check an employee's sick time balance?
Sick time balances are listed on paystubs, found within Dayforce.
Name the 3 places where we log the claim information.
1. In the WC ticket
2. In the EE's profile
3. On the WC YTD Spreadsheet
What does "MMI" mean?
"MMI" stands for "maximum medical improvement" and is the point where further medical improvement is not possible.
Name one monopolistic state other than Ohio or Washington.
What does it mean if a claim is "Medical Only"?
Worker received medical treatment but there was no lost time beyond the waiting period, claim does not require investigation, and the medical costs are under the MO threshold.
What is Anthem EAP and who can access it?
Anthem EAP is an Employee Assistance Program that can be accessed by any Aya employee (regardless of benefits). Services include helpful online tools, resources, and access to professionals such as licensed therapists and legal advisors.
Who can you task to request additional documentation related to a claim from the facility?
If there is a PM for this facility, they should be the first one to ask for documentation related to a claim. If there is no PM, task the AM.
Name at least one responsibility of a Resolution Manager.
Possible answers: Authorize treatment, ensure WC billing information is provided to treating provider(s), and administer TTD benefits when the worker is out of work.
In which state we will not be able to view any claim notes in Gallagher Bassett?
Montana
What is TTD and how is it calculated?
Total Temporary Disability is compensation while the worker is medically unable to work. It is calculated using their wages and earnings according to state guidelines.
What is a per diem traveler, and how are their schedules, earnings, and benefits different from a traveler?
Per Diem employees do not have a contracted number of hours to work each week. Number of days & hours worked each week may vary depending on facility need and employee's schedule. Per Diem employees are not eligible for stipends or health benefits.
Give an example of a situation where a WC ticket may have been created, but wouldn't be handled by WC?
Possible examples:
- Injuries sustained at home
- Personal medical conditions
- Car accidents (for non-home health providers)
- Damage to personal property (e.g. clothes, shoes) caused by patient or weather
Can a claimant continue PT if they have been cleared for full duty?
Yes, they can continue PT if it has been authorized by their RM. They may also have follow-up appointment(s) with their treating provider or even get imaging after being cleared for full duty.
In which state must the employee provide their medical notes to Aya/GB (they cannot be obtained directly from the treating provider)?
Oregon
1. Lost time exceeds the state waiting period.
2. Medical costs exceed the MO threshold.
3. Investigation is needed.
4. Claim becomes litigated.
Name 3 red flags you might notice from a worker's profile and/or work history.
- Professional conduct concerns or CXL
- Previous WC claim(s) for bodily injury
- Pre-existing injury to same body part
- Unhappy at facility, planning to self-CXL, etc.
When is a ticket GTC?
Clearance, Cancelled, or Completed!
If the employee was cancelled or completed their assignment prior with restrictions in place, they will need work advisory in place.
What is an "IME" and when might you need one?
"IME" is an Independent Medical Exam. We might need an IME in cases where we need to confirm the MMI according to the patient’s medical history and a medical examination, especially litigated or questionable claims.
What is unique about injury claims in North Carolina?
In NC, if there was no 'accident' (worker was injured doing their regular duties), the claim is likely to be denied. An exception to this would be spinal injuries. NC bodily injuries should be reviewed by Senior RM and flagged for Dana/Nicole.