SUMMARY
This chapter provides an overview of claims processing and highlights common issues that arise during claims processing. PDF Download - After purchase go to My Content to retrieve your digital file(s).
DESCRIPTION
Chapter 6
CLAIMS PROCESSING
Linh T. Vu
§ 6.1 SCOPE OF CHAPTER
§ 6.2 CLAIMS-PROCESSING OUTLINES AND ISSUES
§ 6.2-1 Original Claim for Industrial Injury or Occupational Disease
§ 6.2-1(a) Claim by Worker
§ 6.2-1(a)(1) Injury
§ 6.2-1(a)(2) Exceptions to 90-Day Written Notice Requirement
§ 6.2-1(a)(3) Occupational Disease
§ 6.2-1(a)(4) Presumption of Timely Notice
§ 6.2-1(b) Insurer Investigation, Assessment, and Response
§ 6.2-1(b)(1) Acceptance or Denial
§ 6.2-1(b)(2) Interim Compensation
§ 6.2-1(b)(3) Investigation
§ 6.2-1(b)(4) Required Medical Examinations
§ 6.2-1(b)(5) Notice of Acceptance
§ 6.2-1(b)(6) Notice of Denial
§ 6.2-1(b)(7) Employer-Reimbursed Medical Services Costs
§ 6.2-2 Aggravation Claims for Injury or Occupational Disease
§ 6.2-2(a) Claim by Worker
§ 6.2-2(a)(1) Written Notice or Knowledge
§ 6.2-2(a)(2) Physician’s Report
§ 6.2-2(a)(3) Nondisabling Claim Becomes Disabling
§ 6.2-2(b) Insurer Processing Obligations
§ 6.2-3 Claim for New or Omitted Medical Condition
§ 6.2-3(a) Difference between New and Omitted Conditions
§ 6.2-3(b) Filing the Claim
§ 6.2-3(c) Processing of a New or Omitted Medical Condition Claim
§ 6.2-3(c)(1) Interim Compensation or Temporary Disability
§ 6.2-3(c)(2) Insurer’s Response
§ 6.2-3(c)(3) Acceptance
§ 6.2-3(c)(4) Denial
§ 6.2-4 Responsibility Disputes
§ 6.2-4(a) Raising Responsibility Issue
§ 6.2-4(b) Designation of Paying Agent
§ 6.2-4(c) Hearings on Responsibility
§ 6.2-5 Accepted Claims
§ 6.2-5(a) Disabling versus Nondisabling Claim Classification
§ 6.2-5(b) Duty to Provide Payment and Written Explanation
§ 6.2-5(c) Payment of Temporary Total Disability (TTD)
§ 6.2-5(c)(1) First Payment
§ 6.2-5(c)(2) Duration and Frequency
§ 6.2-5(c)(3) Rate of Temporary Total Disability
§ 6.2-5(c)(4) Supplemental Temporary Disability
§ 6.2-5(d) Payment of Temporary Partial Disability (TPD)
§ 6.2-5(d)(1) Time
§ 6.2-5(d)(2) Duration
§ 6.2-5(d)(3) Rate
§ 6.2-5(d)(4) Notice to Worker
§ 6.2-5(e) Payment for Medical Services
§ 6.2-5(e)(1) Limitations on Medical Care
§ 6.2-5(e)(2) Time for Payment or Response
§ 6.2-5(e)(3) Loss of Time from Work for Medical Services
§ 6.2-5(e)(4) Choice of Physician
§ 6.2-5(e)(5) Related Services
§ 6.2-5(f) Vocational and Other Rehabilitation Services
§ 6.2-5(f)(1) Insurer’s Duty to Assess and Provide
§ 6.2-5(f)(2) Types and Conditions
§ 6.2-5(f)(3) Temporary and Permanent Disability during Vocational Assistance
§ 6.2-5(f)(4) Appeal and Review of Vocational Decisions
§ 6.2-5(f)(5) Ending Vocational Services and Claim Closure after Vocational Rehabilitation Program
§ 6.2-5(g) Claim Closure and Permanent Disability
§ 6.2-5(g)(1) Worker Is Medically Stationary
§ 6.2-5(g)(2) Worker Is Not Medically Stationary
§ 6.2-5(g)(3) Worker’s Request for Closure
§ 6.2-5(g)(4) Appeal from Notice of Closure
§ 6.2-5(g)(5) Appeal from Order on Reconsideration
§ 6.2-5(g)(6) Payment of Permanent Partial Disability (PPD)
§ 6.2-5(g)(7) Permanent Total Disability (PTD)
§ 6.2-6 Insurer Rights, Remedies, and Penalties
§ 6.2-6(a) Right to Medical Records and Reports
§ 6.2-6(b) Independent Medical Examinations
§ 6.2-6(b)(1) Insurer Required Medical Examinations
§ 6.2-6(b)(2) Worker Requested Medical Examinations (WRME)
§ 6.2-6(c) Elective-Surgery Rules
§ 6.2-6(d) Review of Medical Treatment, Reporting, and Billing
§ 6.2-6(e) Major Contributing Cause Denials
§ 6.2-6(f) Suspension of Benefits
§ 6.2-6(g) Offsets and Recovery of Overpayments
§ 6.2-6(h) Consequences of Failure to Comply with Claims-Processing Requirements
§ 6.2-7 Requests for Hearing
§ 6.2-7(a) Jurisdictional Issues
§ 6.2-7(b) Time for Requesting a Hearing
§ 6.2-7(b)(1) Denied Claims
§ 6.2-7(b)(2) Order on Reconsideration
§ 6.2-7(b)(3) Appeal from Notice of Refusal to Close
§ 6.2-7(b)(4) Director’s Order Regarding Vocational Assistance
§ 6.2-8 Claim Disposition Agreements and Disputed Claim Settlements
§ 6.2-8(a) Claim Disposition Agreements
§ 6.2-8(b) Disputed Claim Settlements
§ 6.2-9 Board’s Own-Motion Jurisdiction
§ 6.2-9(a) Scope of Board’s Authority
§ 6.2-9(b) Benefits Available
§ 6.2-9(c) Initiation of Own-Motion Claim
§ 6.2-9(d) Insurer Response
§ 6.2-9(e) Responsibility Disputes
§ 6.2-9(f) Workers’ Compensation Board’s Order
§ 6.2-9(g) Closure
§ 6.2-9(h) Judicial Review of Own-Motion Orders
Appendix 6A Abbreviations