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Flashcards in Knowledge quizes Deck (67)
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1

What does the acronym EDOK stand for at SAIF Corporation?

Employer date of knowledge

2

What does the acronym EAI stand for at SAIF Corporation?

Employer at injury

3

What does the acronym MOI stand for at SAIF Corporation?

Mechanism of injury

4

Which section number of the Oregon Revised Statues (ORS) covers the laws concerning workers' compensation?

ORS 656

5

Which chapter of the Oregon Administrative Rules (OAR) covers the laws concerning the processing of workers' compensation claims?

OAR 436

6

Which Oregon Administrative Rule division number covers Claims Administration Rules?

Division 60

7

Which TWO divisions under the Department of Consumer and Business Services regulate the workers' compensation process?

WCB- Workers' Compensation Board

WCD- Workers' Compensation Division

8

Which Form is used by the worker and the employer to report an injury to the insurer?

801

9

What are the uses for Form 827- Workers' and Health Care Provider's report of Workers' Compensation Claim?
(7)

-Report of aggravation
-First report of an injury or disease
-Request for a new or omitted medical condition
-Notice of change of attending physician or nurse practitioner
-progress report
-closing report
-palliative care request

10

What are the uses for Form 1502? and who is it sent to?

WCD

-Acceptance or denial of the claim
-Aggravation
-New or omitted condition reopening

11

How much time does a physician have to send the Form 827 to the insurer if it is being sent as the first report of an injury?

72 hrs of the initial office visit

12

How much time does the employer have to send Form 801 to the insurer?

5 days from the date of the employers knowledge that a claim is being made

13

When must the notice of change of attending physician or nurse practitioner be sent to the insurer using Form 827?

5 days of the office visit

14

A doctor or physician who is primarily responsible for the treatment of a workers' compensable injury or illness

ATTENDING PHYSICIAN

15

written request for compensation from a subject worker or someone on the worker's behalf, or compensable injury of which a SUBJECT EMPLOYER has notice or knowledge

CLAIM

16

An accidental injury or accidental injury to prosthetic appliances, arising out of and in the course of employment requiring medical services or resulting in disability or death established by medical evidence supported by objective findings.

COMPENSABLE INJURY

17

What are the legal standards for determining compensability in an injury claim ?

material contributing cause of the need for treatment or disability

18

What are the instances when a claim would most likely NOT be compensable?

Injury occurs:
-to an active participant in ASSAULTS OR COMBATS not connected to the job assignment and are a deviation for customary duties
-while engaging in or performing any social or recreational activity primarily for the WORKER'S PLEASURE
- Major contributing cause of the injury is caused by the worker's consumption of DRUGS OR ALCOHOL. Major cause must be demonstrated by a preponderance of the medical evidence

19

What does the phrase "COURSE AND SCOPE" mean?

"arising out of"---causal relationship to work
" in the course of"--- time, place, and circumstances

20

What are these called

Claims adjusters will:

-Decide the compensability of claims by using available resources and administer timely and appropriate benefits

-Strive to manage claims to the most appropriate conclusion for works and employers facilitating early return to work and claim closure

-promptly communicate significant claims developments

-guarantee current and future benefits by managing reserves.

-Be mindful of the changing business to positively influence a culture of change

The five Claims tenets

21

When is the three day waiting period payable?

(2)

-The worker is totally disabled for a period of 14 consecutive days

-IW is admitted as an inpatient to a hospital within 14 days of the onset of total disability

22

What information is required before an adjuster can assess time loss benefits?

Attending physician or authorized nurse practitioner needs to verify the worker's inability to work and authorize time loss

23

When is the first-time loss payment due to the worker per SAIF's best practice?

13 days from the employer's date of knowledge and of the worker's disability

24

Which one is NOT a type A medical provider who can serve as an attending physician in a claim?


-medical doctor

-Dr of osteopathic medicine
-Oral & maxillofacial surgeon
-nurse Practitioner
Podiatric physician & surgeon

Nurse practicioner

25

How many days or office visits can a type B medical provider provide medical services?

60 days or 18 office visits from the date of the first visit on the initial claim

26

How many days can an authorized nurse practitioner authorize time loss benefits?

180 days from the date of the first visit on the initial claim

27

Which one is NOT a type A medical provider who can serve as an attending physician in a claim?


-medical doctor

-Dr of osteopathic medicine
-Oral & maxillofacial surgeon
-nurse Practitioner
Podiatric physician & surgeon

Nurse practitioner

28

How many days do insurers have to pay medical bills in an accepted claim

45 from the receipt of the bill

29

How many days prior to the IME appointment must the adjuster notify the injured worker of the scheduled exam?

10 days

30

What must be included in a notice of acceptance

-Compensable conditions
-Disabling non disabling status
-Employment reinstatement rights