Flashcards in Quiz #2 Deck (20)
Objective Findings: “Objective findings in support of medical evidence are ___________ that may include but are not limited to _____________. “Objective findings” does not include physical findings or subjective responses to physical examinations that are not reproducible, measure, or observable.
- Verifiable indication of injury or disease
- range of motion, atrophy, muscle strength and palpable muscle spasm
An Occupation Disease is any disease or infection arising out of and in the course of employment caused by substances or activities to which an employee is not ordinarily subjected or exposed other than during a period of regular actual employment, therein which requires medical services or results in disability or death?
Omitted Condition: A condition that was present _____________ but was omitted from the ____________
- At the time of acceptance
When is the three day waiting period payable (select two)
- The worker is total disable for a period of 14 consecutive days
- The worker is admitted as an inpatient to a hospital within 14 days of the onset of total disability
What information is required before an adjuster can assess time loss benefits?
- Attending physician or authorized NP needs to verify the workers inability to work and authorize time loss
When is the first time-loss payment due to the worker per SAIF’s best practice?
13 days from the employers date of knowledge and of the workers disability
Which is NOT a Type A Medical provider who can serve as an attending physician in a claim?
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
How Many Days an and Authorized NP Authorize time loss benefits?
How many days do insurers have to pay medical bills in an accepted claim?
- 45 days from the receipt of the bill
How Many days prior to the IME appointment must the adjuster notify the injured worker of the scheduled exam?
Which of the following items of information must be included in the notice of acceptance? (3 of them)
- Compensable conditions
- disabling or non disabling status
- employment reinstatement rights
Which parties must receive a copy of the denial?
- The worker, Employer, WCD, Each medical provider, private health insurance if any, and the workers attorney f represented
In what situations can an insurer request suspension of benefits form WCD? (4 of them)
- Worker commits insanitary or injurious acts
- Worker fails to attend or cooperate with an IME
- Worker fails or refuses to cooperate with investigation
- Worker fails to refuse to accept recommended med tx
How many days does the insurer have to reclassify a claim from nondisabling to disabling?
- 14 days from the receipt of information that the claim is disabling or request from the worker to reclassify
When a worker is represented by an attorney, when does the insurer need to provide discoverable documents?
- 14 days from the receipt of the attorneys discovery request
In what areas are claims adjusters responsible for setting reserves? (4 of them)
- Temporary Disability (Time Loss)
- Permanent Partial Disability
- Legal costs ( Fees)
When a claim is appealed what are the levels of litigation (appeal) that can occur?( 4 of them)
- Oregon Supreme Court
- Oregon Court of Appeals
- Workers Comp Board
- WCB Hearings Division – ALJ
How many days does an insurer have to pay a Claims Disposition Agreement (CDA) once it has been approved?
- 14 days from the receipt f the approved form from WCB