Common Worker's Comp Forms Flashcards Preview

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Flashcards in Common Worker's Comp Forms Deck (12)
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1

Form 801 - Report of Job Injury or Illness Purpose

The employer uses this form to report an on-the-job injury.

2

Timeframe for Form 801 - Report of Job Injury or Illness Purpose

It must be submitted to the insurer by the employer within five days of the employer’s date of knowledge of a claim being made.

3

Seven uses for the Form 827 - Workers and Health Care Provider's report for WC Claim

- First report of an injury or disease (must be sent to the insurer within 72 hours of the initial office visit)
- Request to accept a new or omitted medical condition
- Report of aggravation
- Notice of change of attending physician or nurse practitioner (must be sent to the insurer within 5 days of the office visit)
- Progress report
- Closing report
- Palliative care request

4

Reasons for sending form 1502 - Insurer's report

- insurer uses the form to report info (including the first report) to the WCD
- New or omitted condition reopening
- Aggravation decision
- reopening for voc training
- litigation ordered acceptance
- change in acceptance or disability status
- correction of previously submitted info
- MCO enrollment after a previously report

5

Time frame for sending 1502 - Insurers report?

14 days from the action that requires the reporting

6

1502 goes to the WCD when?

- Disabling Acceptance
- All Denials including partial denials
-ONLY for NON DISABILING CLAIM IS DENIED

7

Purpose of 1503 - Insurers Notice of Closure summary

- provide notice of claim closure
- provide time loss payment
- provide medical payments
- provide the workers return to work status

8

Timeframe for 1503- Insurers Notice of Closure summary

within 14 days of obtaining info to close claim

9

Purpose of 1644 - Notice of Closure

- Provide notice to the worker of claim closure
- includes extent of benefits, time loss payments, permanent disability (if any) and appeal rights

10

Timeframe for 1644 - Notice of Closure

within 14 days of obtaining info to close claim

11

Purpose of form 2807 - Insurer notice of closure worksheet

Form is used by insurers to calculate disability benefits before entering the info on the 1644

12

Timeframe for 2807 - Insurer notice of closure worksheet

14 days