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


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
-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.


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

14 days from the request from the attorney


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


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.


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

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


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


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