Claims Management Services. The Association agrees to provide the following services, and may elect to do so through the engagement of a professional claim management firm:
a) Maintain records on each assigned Washington State claim and regularly manage and review all workers’ compensation claims which adversely affect the plan year results of the Member and the Association;
b) Represent the Member’s interest and take appropriate action to minimize charges against the Member’s L&I industrial insurance account;
c) Verify the facts surrounding each time loss claim and arrange for medical, vocational or other expert review as necessary;
d) Conduct interviews, and/or take statements from, the claimant, witnesses, medical providers, vocational counselors, and other experts or representatives as necessary;
e) Monitor the treatment programs of claimants as necessary;
f) Assist the Member in arranging claimant rehabilitation, retraining, or light duty as appropriate;
g) Provide regular statistical and narrative reports concerning the status of industrial insurance claims which impact Program results;
h) Provide services that are in compliance with Washington statutes and administrative codes;
i) ERNW shall not provide services that are deemed to be the practice of law.
Claims Management Services. In satisfaction of its obligations to assist the Insurer with the processing of claims arising under policies reinsured in connection with the Group Short Term Disability Reinsurance Treaty (“the Treaty”), the Reinsurer designates Claims Service International, Inc. (“CSI”) to perform claims management services in connection with the Treaty as set forth herein. The Insurer shall not be liable to CSI for the services rendered under the Claims Management Agreement and shall not bear any of the expenses incurred by CSI in connection with CSI’s performance of services hereunder, except as may be expressly set forth herein. The obligation of CSI to perform administrative services in connection with the Treaty shall continue until such time as all reinsured claims have been paid, unless other agreement is reached and becomes a written part of this Agreement.
Claims Management Services. (A) General:
(1) State Fund shall adjust Departments' workers' compensation claim files in accordance with the California Labor Code (LC), any other applicable Laws, and State Fund's internal guidelines.
(2) State Fund shall make the workers' compensation liability decisions in regard to claims adjusted under this Agreement. This authority shall not extend to California Labor Code Section 132a issues, Serious and Willful misconduct, or liability of the Department for civil issues that may arise from the same facts as the workers' compensation claim.
(3) State Fund shall maintain electronic and paper files according to State Fund internal guidelines and applicable regulations.
(4) State Fund shall establish a new claim within one (1) business day of receipt of employer's first report of injury submitted electronically using the electronic first report of injury (EFROI) system provided by State Fund.
(5) When a Department has identified a new claim as disputed with respect to industrial causation, State Fund will contact the Return-to- Work Coordinator (RTWC) to discuss the claim at case make up. The Adjuster or Assistant Claims Manager (ACM) will contact the RTWC with an explanation if the decision is made to accept the claim.
(6) State Fund shall establish a case summary or case plan on all open claims.
(7) State Fund will provide the RTWC with copies of all benefit notices sent to the injured employee or their representative.
(8) All statutory forms necessary for the reporting of claims and administering the State's Return-to-Work Program will be available electronically.
(9) State Fund shall provide courtesy notice to Departments whenever outstanding liens on an individual case total more than $10,000. State Fund will notify the Department within five (5) days whenever an individual xxxx xxxxxxx for more than $10,000.
(10) State Fund Adjusters shall be available to prepare a claims summary and meet with a Department's representative on a case within a reasonable time period. The location of the meeting will be mutually agreed upon.
(11) State Fund will provide staff contact information (e-mail, phone, and fax) and caseload assignment. When there is a change in Adjuster caseload assignment, State Fund shall notify the affected Department of the change and provide the new staff name(s) and contact information as soon as reasonably possible, but no later than ten (10) days after the effective date of the change. This does not apply when cases are temporaril...
Claims Management Services including (i) receipt, processing, settlement and payment of claims in states other than Alaska, Idaho, Montana, Oregon and Washington under the policies and contracts of workers compensation insurance issued by Agency Markets pursuant to requests from Agency Markets (the “Portfolio”); (ii) acknowledgement of the receipt of notices received from policyholders in connection with any claims; (iii) investigation of any claim, as necessary, to determine its validity and compensability, including verification of coverage and status information and utilization of any relevant documents and/or information made available to Liberty Mutual and advice to the appropriate person of the results of such investigation; (iv) notification to policyholders of declined claims and the reasons for such declinations; (v) response to any inquiry, complaint or request received from any policyholder, agent, broker, regulator or other interested party pertaining to or regarding any such claim, and recordation of such complaints in complaint logs to be maintained by Liberty Mutual on Agency Markets’ behalf; (vi) compliance with claims file maintenance, record retention and reconciliation requirements in conformity with the standards for performance set forth in this Service Agreement or as otherwise agreed by the parties; (vii) engagement and direction, as necessary, of attorneys, consultants or other professionals in connection with the processing, defense and handling or any such claims; (viii) defense of disputed claims; (ix) delivery of notices and other communications to policyholders; and (x) generally, all such other acts and things as are reasonably necessary or otherwise required in the administration of all such claims relating to the Portfolio;
Claims Management Services. Database and System Access (No restriction on number of users) Data Transfer Manual Claims Input Document Storage $ .10 per record per month $ .10 per creditor $ .25 per claim (plus hourly rates) Waived Standard Call Center Setup Call Center Operator Voice Recorded Message Support/Maintenance $2,500 $75 per hour $0.19 per minute $200 per month Additional call center services not specifically covered by this proposal will be charged at hourly rates or at a unit price to be determined. Specifically, such tasks as reviewing and managing traffic reports, assigning and supervising staff, call auditing, quality control testing, training and the like will be billed at the applicable hourly rate.
Claims Management Services a. Assist the Judicial Council in management of claims, to their conclusion, for no additional fees by providing the full range of claims services.
b. Assist in the development of a well-coordinated claims program between the Contractor, insurers, the Judicial Council and contractors of all tiers;
c. Assist in the development and procurement of a favorable claims service agreement.
d. Establish special handling procedures to ensure proper recognition of each claim as an OCIP related claim, with its unique characteristics;
e. Develop claim and accident reporting procedures for each major line of coverage. Distribute and make available to all OCIP participants;
f. Establish a local network of healthcare providers for each project;
g. Develop OCIP claims management and coordination procedures to minimize the cost of claims;
h. Arrange for the recommendation or utilization of any identified medical providers or services near each project site. Negotiate fees with medical providers;
i. Coordinate the timely filing of workers’ compensation and general liability reports to insurance carriers and governmental agencies;
j. Provide oversight of the adjustment and settlement of claims and losses including insurance carrier allocated expense activities by the insurer or its authorized third- party administrator;
k. Monitor claims management activities and adherence to the claim service agreement;
l. Analyze OCIP insurers’ claims and loss reserves and negotiate appropriate changes as recommended by the Judicial Council;
m. Provide recommendations for cost containment, structured settlements and other areas to reduce claims costs;
n. Review the accuracy, adequacy and timeliness of all loss runs and reports and make changes as needed, including the proper designation of claims;
o. Provide expert assistance on coverage, policy and claim interpretation;
p. Assist the Judicial Council in the resolution of all outstanding claim disputes and to obtain timely payments on all claims. Provide explanations as needed regarding denied or uncovered claims;
q. Audit OCIP insurer’s claims management prior to quarterly claims meetings about the adequacy of insurer’s handling of each open claim with reserves in excess of $10,000;
r. Conduct quarterly claims review meetings with the Judicial Council and insurer representatives;
s. Serve as liaison between the Judicial Council and the OCIP insurers for OCIP claims;
t. Maintain accurate claim data by accident date, by contractor, and such ...
Claims Management Services including (i) receipt, processing, settlement and payment of claims under the policies and contracts of insurance issued by Wausau pursuant to requests from PIC (the “Portfolio”); (ii) acknowledgement of the receipt of notices received from policyholders in connection with any claims; (iii) investigation of any claim, as necessary, to determine its validity and compensability, including verification of coverage and status information and utilization of any relevant documents and/or information made available to Wausau and advice to the appropriate person of the results of such investigation; (iv) notification to policyholders of declined claims and the reasons for such declinations; (v) response to any inquiry, compliant or request received from any policyholder, agent, broker, regulator or other interested party pertaining to or regarding any such claim, and recordation of such complaints in complaint logs to be maintained by Wausau; (vi) to the extent required by law, provision to policyholders of reports on taxable benefits, and the amounts withheld on account of FICA, federal, state and/or local income taxes, both as payments of benefits are made, and as of the end of each calendar or fiscal year; (vii) compliance with claims file maintenance, record retention and reconciliation requirements in conformity with the standards for performance set forth in this Service Agreement or as otherwise agreed by the parties; (viii) engagement and direction, as necessary, of attorneys, consultants or other professionals in connection with the processing, defense and handling or any such claims; (ix) defense or disputed claims; (x) delivery of notices and other communications to policyholders; and (xi) generally, all such other acts and things as are reasonably necessary or otherwise required in the administration of all such claims relating to the Portfolio;
