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Flashcards in Claims Management - Open Claims Deck (8)
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1

What two questions should adjusters ask themselves every time they review an open claim?

- What do I need to do to bring this claim to resolution?
- Are my reserves adequate?

2

How many days does the insurer have to reclassify a claim from nondisabling to disabling?

- The insurer has 14 days from receipt of information that the claim is disabling
or
-A request from the injured worker to reclassify the claim.
-If it is more than one year from date of acceptance, the injured worker must file an aggravation claim.

3

When a worker is represented by an attorney, when do you need to provide discoverable documents?

14 days from the request from the attorney

4

When a worker is represented by an attorney How often and for how long do you need to provide updates?

provide updates every 30 days for 180 days

5

Why is it important to set reserves on a claim?

-It enables SAIF to estimate future liabilities.
- Reserves are used in ratemaking and calculation of the employer’s modification rate.
- It is used to calculate premium for retrospective policies.
- Reserves facilitate underwriting decisions.
- It meets statutory requirements.

6

In what four areas is a claims adjuster responsible for setting reserves?

- Medical,
- Temporary Disability (Time loss),
-Permanent Partial Disability,
- Legal Costs (Fees)

7

When is an adjuster required set reserves on a claim?

- Within 30 days of the receipt of the request for hearing on a denied claim or condition.
- Within 30 days of acceptance of a disabling claim.
-On accepted, nondisabling claims, when medical paid costs exceed $5,000

8

What are examples of significant events that would prompt you to review the reserves on a claim?

- A change in the time loss authorization (starting or stopping)
- A change in the work release or work status
- Receipt of medical information such as a surgery
- Claim closure information
- A request to reopen a claim
- A request to accept new, omitted, consequential, or combined conditions
- The passage of time without further treatment or activity in the claim