First Half

Question 1

What is OAR Division 35

Answer 1

Disability Rating Standards

Question 2

What is OAR Division 9

Answer 2

Oregon Medical Fee and Payment Rules

Question 3

What is OAR Division 10

Answer 3

Medical Services Rules

Question 4

What is OAR Division 110

Answer 4

Preferred worker Program Rules

Question 5

What is OAR Division 105

Answer 5

EAIP

Question 6

List 5 reason why an insurer would use the form 1502 - Insurer’s Report

Answer 6

1. When accepting a disabling claim
2. When denying a NonDisabling claim
3. When accepting a new or omitted condition
4. When accepting an aggravation
5. Correction of previous information

Question 7

How many days does the insurer have to send the 1502?

Answer 7

14 days from the date of denial or acceptance

Question 8

Define Attending Physician

Answer 8

The doctor who is primarily responsible for overseeing the treatment of a worker during a workers compensation injury.

Question 9

Define Claim

Answer 9

Is a written request for compensation from a subject worker, or on a subject workers behalf, from which a subject worker had knowledge of an injury/incident which caused a need for treatment.

Question 10

Define Combined Condition

Answer 10

When a compensable injury combines with a qualified preexisting condition to create a need or prolong the need for treatment

Question 11

Define a Qualifying Preexisting Condition?

Answer 11

When an worker has been previously diagnosed or previously sought treatment for the area or the condition or has arthritis or an arthritic condition.

Question 12

List 4 situations in which you can stop paying timeloss?

Answer 12

1. The claim has been denied
2. The claim is closed
3. The worker returns to regular work
4. The worker returns to modified work at full hours/wages
5. The terminated worker process has been completed.
6. BJO has been sent but the worker refuses.

Question 13

What is the legal standard for determining compensability in an occupation disease claim?

Answer 13

Major contributing cause of the condition

Question 14

In what situations could you issue a backup denial once a claim has been accepted?

Answer 14

If there is any fraud, misrepresentation, illegal activity or if the insurers receives information that proves the initial injury was not compensable or if the new information changes who is responsible for the injury.

Question 15

List 5 items that need to be included on the denial?

Answer 15

1. The reason behind the denial - the factual evidence/objective findings
2. The workers right to request their own medical exam (WRME)
3. The workers right to appeal
4. Info on the expedited claim service
5. If the AP agreed with the decision

Question 16

Which settlement settles all benefits in the claim?

Answer 16

Disputed Claims Settlement

Question 17

How many days prior to the IME appointment must you notify the IW?

Answer 17

10 days

Question 18

Name a situations an IME report could be given deference over a report of the AP?

Answer 18

When the IME doctor is a specialist in the particular area compared to the AP.

If the IME doctor has clearer, concise, well reasoned or provides a better explanation

Question 19

According to the claims communication standards, what is considered a contact with the IW?

Answer 19

A verbal dialogue between the IW and the adjuster. The adjuster needs to make 2 attempts by phone at varying times of the day. If the above doesn’t work then send a letter requesting an specific interview time.

Question 20

What are 5 types of 3rd Party Claims?

Answer 20

Dog Bites
Assaults
MVA
Negligence
Product Liability
Premises Liability

Question 21

What are the 4 situation which you can as the WCD to suspends workers benefits?

Answer 21

1. Worker Fails to attend and IME.
2. Worker refuses to respond or cooperate with investigation.
3. Worker refuses to follow or continue with medical treatment plan
4. Worker commits insanitary or injurious acts

Question 22

What does HIP stand for? Explain the info on a HIP?

Answer 22

History, Issues, Plan

Question 23

What other issues must an adjuster consider before making a decision on a claim?

Answer 23

Responsibility

Question 24

How many days does a worker have to appeal a claim denial?

Answer 24

60 days from the date of the mailing of the denial.

Question 25

List type A providers

Answer 25

Medical Doctor Osteopathic Doctor Podiatric Doctor or Surgeon Oral or Maxillofacial Surgeon

Question 26

Which section of the ORS covers statues related to workers comp?

Answer 26

ORS 656

Question 27

List 7 uses of the Form 827

Answer 27

1. To first report an injury or disease 2. To requite a new or omitted condition 3. To report an aggravation. 4. To change a AP or ANP 5. For a progress report 6. For a closing exam 7. To request palliative care

Question 28

What is the legal standard for determining compensability of an injury claim?

Answer 28

It is the material contributing cause for the need for treatment

Question 29

Describe an injury vs OD

Answer 29

An injury occurs over a discrete period of time and has a sudden and acute onset, where an OD occurs over a longer period of time as a result of the type of work, conditions or environment the worker is subject too.

Question 30

Define Compensable Injury

Answer 30

An accidental injury or accidental injury to a prosthetic appliance, arising out of and during the course of employment requiring medical treatment resulting in disability or death. Must be established by medical evidence supported by objective findings.

Question 31

What triggers the start of the timeframe for insurers to accept or deny a claim?

Answer 31

60 days from the EDOK

Question 32

What 3 activities are generally not compensable?

Answer 32

Injury is from an active participant in an assault or combat that is not a part of the general job requirements or a deviations from daily duties. The injury occurred while the worker engaged in or performing a social or recreational activity for the workers pleasure. If the major cause of the injury was the result of the workers consumption of drugs or alcohol. Must have medical evidence to prove drugs/alcohol was the cause of the injury.

Question 33

What information is required before an adjuster can pay time loss

Answer 33

Must be authorized from an AP or ANP, stating that the IW is disabled or unable to return to their regular job duties.

Question 34

Write out the Claim Tenets (5)

Answer 34

Compensability, Manage, Communicate, Financial Stability, Climate.