Flashcards in Claims Tenets, Communication and Adjuster Certification Deck (9)
What are the Three Tenets?
What are the claims tenets?
- Claims adjusters will decide the compensability of claims by using available resources and administer timely and appropriate benefits.
- Claims adjusters will strive to manage claims to the most appropriate conclusion for workers and employers by facilitating early return to work and claim closure.
- Claims employees will promptly communicate significant claim developments by partnering with injured workers, employers, and providers to work toward the best possible outcome.
- Claims employees will guarantee current and future benefits to workers by managing reserves, administering compensable benefits, and aggressively managing litigation to ensure corporate financial stability.
- Claims employees will be mindful of the changing business climate and workers' compensation landscape to positively influence a culture of change that anticipates the future needs of Oregon's workforce and the state's economy.
What are the Reserving Tenets?
- All claims will be reserved for their ultimate probable cost, recognizing that claims seldom develop in best- or worst-case scenarios.
- Claims reserves require periodic reassessment, documentation, and management review.
- Keep policyholders informed regarding reserves on the claim.
What are the Settlement Tenets?
- Settlements should reduce uncertainty for the worker, the employer, and SAIF.
- Parties affected by settlements must be fully informed.
- The settlement value of a claim is the present value of probable claim benefits discounted by the uncertainty of entitlement.
- Claims employees have an affirmative responsibility for anticipating and preparing for litigation and for considering settlement only after adequate preparation.
- Disputed claim settlements should be employed where issues lack clarity as to compensability, or benefit entitlement.
What is considered timely contact?
A verbal dialogue with the injured worker, which includes an explanation of the claims process, and asking and answering questions.
- Two reasonable attempts by phone, at varying times, and considering their work schedule, to reach the injured worker.
- If no response is received following the attempts by phone, an interactive email that is a business-style communication of letter-quality or a call adjuster letter should be sent.
What are the Claims Division communication standards?
Every worker receives the Claim Acknowledgement Letter.
• Contact within 24 hours of adjuster’s receipt on all disabling claims and within four days of a nondisabling claim.
• When appropriate, take a recorded statement within four days of receipt of a new disabling claim, or a significant nondisabling claim.
• Contact on the day of any claim status decision (accept/deny, agg, palliative care).
• Contact on the day of a change in rate of compensation or payment alteration.
• Contact prior to scheduling an appointment with the IME provider to discuss the purpose of the appointment and address any scheduling conflicts, potential travel concerns, or transportation needs the worker may have.
• Contact by the next adjuster within three days of reassignment.
• Contact within ten days of a surgery.
• Contact within two weeks of receipt of medically stationary status or at claim closure.
• Contact within two weeks of receipt of any reopen request.
What elements must be demonstrated by the claims examiner certification exam?
- Familiarity with ORS chapter 656;
- Ability to navigate OAR chapter 436;
- Ability to perform claims processing activities - Understanding of all components in OAR 436-055-0085(1) (IME training).
What is the minimum percentage needed to pass the claims adjuster certification exam?