Flashcards in Claims Management - Closure and Closed Claims Deck (28)
How many days do insurers have to close a claim?
How many days do injured workers have to appeal the Notice of Closure (NOC)?
60 days from mailing date
How many days to insurers have to appeal the Notice of Closure (NOC)?
Seven days from the mailing date of the NOC.
How many days do insurers have to pay additional time loss ordered by a Notice of Closure (NOC)?
Within 14 days of the mailing date of the NOC.
How many days do insurers have to pay a PPD award granted by a Notice of Closure (NOC)?
30 days from the mailing date of the NOC.
When can a claim be closed administratively?
-When the worker has not sought medical treatment for more than 30 days,
-When a warning letter (known as the “bug letter”) has been sent to the worker explaining that the worker needs to seek medical treatment within 14 days of the mailing date of the letter. If there is no response after 14 days, or the worker responds and indicates no further plans for medical treatment, the claim can be closed.
What information is needed before closing a claim?
- Medically stationary status
- Work release and work status information, including dates
- Information concerning permanent impairment, if any
What date qualifies a claim for closure (the qualification date)?
- the date SAIF receives the final piece of medical info needed to close the claim
- administrative closures use 30 days from the date of the last medical treatment received by the injured worker.
What forms are required for claim closure?
- Insurer’s Notice of Closure Summary – Form 1503
- Insurer’s Notice of Closure Worksheet – Form 2807
- Insurer’s Notice of Closure – Form 1644
- Updated Notice of Acceptance
- Medically stationary letter
If an injured worker has permanent impairment and is not released by his attending physician to return to his regular job, what additional factoring is included in his permanent partial disability award?
The injured worker will receive both a rating for the physical impairment as well as work disability.
What is the injured worker’s specific vocational preparation (SVP) based upon?
The jobs the injured worker has successfully performed in the five years prior to the date of issuance of the notice of closure.
What is chronic condition impairment? What is the percent value for chronic condition impairment?
This is when the worker is significantly limited in repetitive use of one or more of the following body parts: cervical spine, thoracic spine, lumbar spine, chest, shoulder, arm, forearm, hip, or leg.
The percent value is 5 percent.
What is the first level of appeal if a worker is unhappy with the NOC? Which agency performs that appeal?
The first level is reconsideration and it’s performed by the WCD.
What are the subsequent levels of appeal if the parties are unhappy with the Order on Reconsideration?
- An administrative hearing before an Administrative Law Judge (ALJ) at the WCB Hearings Division; usually done in writing versus an in-person hearing.
- Board review of the ALJ’s opinion by the Workers’ Compensation Board.
- Review by the Oregon Court of Appeals.
- Review by the Oregon Supreme Court.
How many days do insurers have to submit documents when reconsideration has been requested?
14 days from receipt of the director’s notice of the start of the reconsideration process.
Who determines impairment at the reconsideration level?
Medical arbiter physician or the attending physician if there is no medical arbiter exam.
For dates of injuries on or after January 1, 2002, how many days does the adjuster have to accept or deny a new or omitted condition?
60 days from the receipt of request to accept a new or omitted condition.
For dates of injuries prior to January 1, 2002, how many days does the adjuster have to accept or deny a new condition?
90 days from receipt of the request to accept.
For dates of injuries prior to January 1, 2002, how many days does the adjuster have to accept or deny an omitted condition?
30 days from receipt of the request to accept.
How long does a worker retain rights to receive medical treatment related to the accepted claim?
For the injured worker’s lifetime.
Which types of post-closure medical services are covered under ORS 656.245?
- Prescription medication
- Repair or replacement of prosthetic devices
- Office visits
- Diagnostic tests
-Life preserving modalities
- Palliative care
What questions should you ask yourself when determining whether to pay for palliative care?
- Was palliative care contemplated at the time of closure?
- Is the worker currently employed?
- Is the care palliative or curative in nature?
- Does the documentation explain how the care is related to the accepted condition?
- Does it indicate who will provide the care?
- Does it specific modalities, frequency, and duration?
How much time does an insurer have to respond to the attending physician’s request for palliative care?
30 days from the receipt of the request from the attending physician.
What are the elements of a compensable aggravation claim?
- An actual worsening,
- After the last arrangement of compensation,
- Of an accepted condition,
- Established by medical evidence,
- Supported by objective findings.
How many years does an injured worker have to file an aggravation on a disabling claim?
Five years from the date of the first notice of closure.
How many years does an injured worker have to file an aggravation on a nondisabling claim?
Five years from the date of injury.
When is the first time loss payment due on an aggravation claim?
14 days from receipt of a written report verifying the worker’s inability to work due to a worsening.