Common use of Claims Management Services Clause in Contracts

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 temporarily reassigned. (12) State Fund shall provide CalHR with the results of any audits performed on claims handling covered by this Agreement that have been completed by the Department of Industrial Relations (DIR), Bureau of State Audits, State Controller's Office (SCO) or Department of Finance (DOF). (13) Individual Adjuster caseload size shall be determined by State Fund management, and reported to CalHR on a quarterly basis. (14) State Fund will ensure that their claims personnel will be trained and have legally required claims certifications. (15) State Fund Adjusters will refer any claim(s) where fraudulent activity is suspected to State Fund's Special Investigations Unit (SIU). State Fund's SIU is responsible for the referral of cases to legal authorities, when appropriate. (16) Departments will have electronic access to State Fund provided safety materials. (17) Direct safety services, industrial hygiene services, and ergonomic evaluations may be available for an additional fee. (18) Departments shall establish, implement, and maintain uniform written policies for injury prevention, reporting of injuries when they occur, maintaining contact with injured employees, and returning injured employees to work per XXX Sections 2580 through 2581.2. (19) Departments shall provide to State Fund all pertinent information relevant to the adjustment of a workers' compensation claim promptly. This information may include relevant information regarding: California Public Employees' Retirement System, personnel files, adverse actions, performance issues, and EEO issues, including reasonable accommodation. (20) Departments shall comply with the applicable sections of the California Government Code, California Labor Code, California Code of Regulations, XXX and Executive Order D-48-85, regarding returning employees to work and shall actively seek employment opportunities for injured employees who have become disabled. (21) Departments shall ensure that the "Employer's Report of Occupational Injury or Illness" is completed and submitted to State Fund no later than the statutory timeframe from the employer's date of knowledge of injury, illness, or death. Departments are responsible for notifying the California Division of Occupational Safety and Health as required by law. (22) Departments shall ensure that the injured employee is provided with an "Employee's Claim for Workers' Compensation Benefits" form (SCIF e3301) and the guide to the State Fund medical provider network (MPN) within one (1) working day of the employer receiving notice of injury, illness, or death. The completed SCIF e3301 shall be routed to State Fund within one (1) working day of receipt from the injured employee or his/her representative. (23) The RTWC may schedule strategy meetings with State Fund once per quarter, which may include a legal strategy summary for litigated files upon request. These legal strategy summaries will be provided within a reasonable, mutually agreeable timeframe following communication of the request to the State Fund attorney. (24) The RTWC may contact State Fund to review their claim files. A review of the Department's file(s) may also be performed by a CalHR representative. The timing and location of the review will be mutually agreed upon. (25) Departments shall notify State Fund and CalHR of the name(s) of the RTWC(s) and their area of responsibility. Each Department shall have at least one RTWC who is the key contact with State Fund on claim files related to the Department. When there is a change in the RTWC assignment, the Department shall notify State Fund and CalHR of the name and contact information for the RTWC assigned. (26) At the request of the State Fund Adjuster or attorney, the RTWC shall attend case planning meetings, mandatory settlement conferences (MSC), and trials. If the RTWC cannot attend a case planning meeting out of town, alternatives to travel will be considered, such as conference calls or teleconferencing. (27) Departments are responsible for conveying information to State Fund regarding return to work, including but not limited to when an injured worker returns to work or the Department offers to return the injured worker to work, so that appropriate benefits can be provided. (28) Departments shall ensure that their RTWCs are properly trained in the areas of workers' compensation, disability management, etc. The RTWC shall take the Return-to-Work Training class given by CalHR, and/or an accredited or CalHR approved equivalent training program, within twelve (12) months of their appointment. Each year thereafter, the RTWCs shall take at least sixteen (16) hours of additional training (this can include the quarterly CalHR forums, seminars, webinars, or other relevant training). (29) Departments shall report any suspected fraudulent activity to State Fund. (30) CalHR will notify Departments of any changes to this Agreement. (31) CalHR, State Fund, and Departments shall attend monthly management level meetings. The purpose of these meetings is to facilitate greater performance and accountability under this Agreement. At these meetings the Parties will review performance results, work to resolve issues presented by this Agreement and the claims administration process, keep the Parties informed about the program and any changes thereto, and xxxxxx mutual accountability through improved communication. CalHR will schedule and facilitate the monthly management level meetings. (32) CalHR, in cooperation with State Fund and Departments, shall provide ongoing training programs for all RTWCs. Additional classes may be set up outside this Agreement and separate fees may be charged for attendance of these classes. (33) State Fund will provide CalHR with reports and information necessary for the administration of the State's workers' compensation program. In addition, State Fund and CalHR will work to improve the delivery of information to Departments with the intent of improving outcomes in the State's workers' compensation program. (B) Investigations: (1) State Fund has the authority to assign an investigator to complete an investigation on a claim, which may be performed by a Subcontractor. (2) State Fund or the vendor shall notify the RTWC when an investigator is assigned. Notification shall not delay commencement of the investigation. (3) The RTWC and other Department Personnel shall cooperate with State Fund's claims and/or fraud investigations. (4) The RTWC or appropriate Department Personnel may review an investigation with the approval of State Fund's Legal Department. The investigation shall be reviewed at a State Fund office. The RTWC may not make copies of any investigative materials, including, but not limited to, the report, documents/records obtained, or subrosa audio/video recordings. State Fund may refuse the review of an investigation if State Fund believes there is a conflict of interest in a particular case. (5) The RTWC may request State Fund assign an investigator to complete an investigation on a claim. In the event that State Fund determines there exists a compelling reason to deny ordering an investigation, State Fund will provide discussion and consultation to the requesting Department outlining the merits of the determination. The final decision regarding whether or not to order an investigation rests with State Fund. (C) Industrial Disability Leave; Labor Code Section 4800; Labor Code Section 4800.5: (1) State Fund shall notify Departments of periods of disability for Industrial Disability Leave (IDL), Labor Code (LC) 4800, and LC 4800.5 as appropriate, including the three (3) day waiting period. State Fund will provide temporary disability benefit payments as appropriate at the end of IDL, LC 4800, or LC 4800.5 upon notice of the ending date from the Department. (2) Departments will determine if the injured employee is eligible for IDL, Enhanced Industrial Disability Leave (EIDL) or LC 4800/4800.5 time in lieu of temporary disability. Departments will ensure timely payment of these benefits upon receipt of notification of periods of disability by State Fund. (3) Departments are responsible for tracking the eligible time period, including the waiting period.

Claims Management Services. (A) A General: (1) State Fund shall adjust Departments' ’ workers' compensation claim files in accordance with the California Labor Code (LC)Code, any other applicable Laws, and State Fund's ’s internal guidelines. (2) State Fund shall make the workers' ’ compensation liability decisions in regard regards 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 regulationsguidelines. (4) State Fund shall establish a new claim within one (1) business day of receipt of employer's ’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) 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 open, un-finalized 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 ’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 possiblepossibly, but no later than ten (10) days after the effective date of the change. This does not apply when cases are temporarily reassigned. (12) State Fund shall provide CalHR with the results of any audits performed on claims handling covered by this Agreement that have been completed by the Department of Industrial Relations (DIR), Bureau of State Audits, State Controller's ’s Office (SCO) or Department of Finance (DOF). (13) Individual Adjuster caseload size shall be determined by State Fund management, and reported to CalHR on a quarterly basis. (14) State Fund will ensure that their claims personnel will be trained and have legally required claims certifications. (15) State Fund Adjusters will refer any claim(s) where fraudulent activity is suspected to State Fund's Special Investigations Unit (SIU). State Fund's SIU is responsible for the referral of cases to legal authorities, when appropriate. (16) Departments will have electronic access to State Fund provided safety materials. (17) Direct safety services, industrial hygiene services, and ergonomic evaluations may be available for an additional fee. (18) Departments shall establish, implement, and maintain uniform written policies for injury prevention, reporting of injuries when they occur, maintaining contact with injured employees, and returning injured employees to work per XXX Sections 2580 through 2581.2. (19) Departments shall provide to State Fund all pertinent information relevant to the adjustment of a workers' compensation claim promptly. This information may include relevant information regarding: California Public Employees' ’ Retirement System, personnel files, adverse actions, and performance issues, and EEO issues, including reasonable accommodation. (20) Departments shall comply with the applicable sections of the California Government Code, California Labor Code, California Code of Regulations, XXX and Executive Order D-48-85, regarding returning employees to work and shall actively seek employment opportunities for injured employees who have become disabled. (21) Departments shall ensure that the "“Employer's ’s Report of Occupational Injury or Illness" ” is completed and submitted to State Fund no later than the statutory timeframe from the employer's date of knowledge of injury, illness, or death. Departments are responsible for notifying the California Division of Occupational Safety and Health as required by law. 7.1 A Continued: (22) Departments shall ensure that the injured employee is provided with an "“Employee's ’s Claim for Workers' ’ Compensation Benefits" ” form (SCIF e3301) and the guide to the State Fund medical provider network (MPN) within one (1) working day of the employer receiving notice of injury, illness, or death. The completed SCIF e3301 shall be routed to State Fund within one (1) working day of receipt from the injured employee or his/her representative. (23) The RTWC may schedule strategy meetings with State Fund once per quarter, which may include a legal strategy summary for litigated files upon request. These legal strategy summaries will be provided within a reasonable, mutually agreeable timeframe following communication of the request to the State Fund attorney. (24) The RTWC may contact State Fund to review their claim files. A review of the Department's ’s file(s) may also be performed by a CalHR representative. The timing and location of the review will be mutually agreed upon. (25) Departments shall notify State Fund and CalHR of the name(s) of the RTWC(s) and their area of responsibility. Each Department shall have at least one RTWC who is the key contact with State Fund on claim files related to the Department. When there is a change in the RTWC assignment, the Department shall notify State Fund and CalHR of the name and contact information for the RTWC assigned. (26) At the request of the State Fund Adjuster or attorney, the RTWC shall attend case planning meetings, mandatory settlement conferences (MSC), and trials. If the RTWC cannot attend a case planning meeting out of town, alternatives to travel will be considered, such as conference calls or teleconferencing. (27) Departments are responsible for conveying information to State Fund regarding return to work, including but not limited to when an injured worker returns to work or the Department offers to return the injured worker to work, so that appropriate benefits can be provided. (28) Departments shall ensure that their RTWCs are properly trained in the areas of workers' ’ compensation, disability management, etc. The RTWC shall take the Return-to-Work Training class given by CalHR, and/or an accredited or CalHR approved equivalent training program, within twelve (12) months of their appointment. Each year thereafter, the RTWCs shall take at least sixteen (16) hours of additional training (this can include the quarterly CalHR forums, seminars, webinars, forums or other relevant trainingseminars). (29) Departments shall report any suspected fraudulent activity to State Fund. (30) CalHR will notify Departments of any changes to this Agreement. (31) CalHR, State Fund, and Departments shall attend monthly management level meetings. The purpose of these meetings is to facilitate greater performance and accountability under this Agreement. At these meetings the Parties will review performance results, work to resolve issues presented by this Agreement and the claims administration process, keep the Parties informed about the program and any changes thereto, and xxxxxx mutual accountability through improved communication. CalHR will schedule and facilitate the monthly management level meetings. (32) CalHR, in cooperation with State Fund and Departments, shall provide ongoing training programs for all RTWCs. Additional classes may be set up outside this Agreement and separate fees may be charged for attendance of these classes. (33) State Fund will provide CalHR with reports and information necessary for the administration of the State's ’s workers' ’ compensation program. In addition, State Fund and CalHR will work to improve the delivery of information to Departments with the intent of improving outcomes in the State's ’s workers' ’ compensation program. (B) Investigations: (1) State Fund has the authority to assign an investigator to complete an investigation on a claim, which may be performed by a Subcontractor. (2) State Fund or the vendor shall notify the RTWC when an investigator is assigned. Notification shall not delay commencement of the investigation. (3) The RTWC and other Department Personnel shall cooperate with State Fund's ’s claims and/or fraud investigations. (4) The RTWC or appropriate Department Personnel may review an investigation investigative report with the approval of State Fund's ’s Legal Department. The investigation shall be reviewed at a State Fund office. The RTWC may not make any copies of any investigative materials, including, but not limited to, the report, documents/records obtained, or subrosa audio/video recordingsdocument. State Fund may refuse the review of an investigation a report if State Fund believes there is a conflict of interest in a particular case. (5) The RTWC may request State Fund assign an investigator to complete an investigation on a claim. In the event that State Fund determines there exists a compelling reason to deny ordering an investigation, State Fund will provide discussion and consultation to the requesting Department outlining the merits of the determination. The final decision regarding whether or not to order an investigation rests with State Fund. (C) Industrial Disability Leave; Labor Code Section 4800; Labor Code Section 4800.5: (1) State Fund shall notify Departments of periods of disability for Industrial Disability Leave (IDL), Labor Code (LC) 4800, and LC 4800.5 as appropriate, including the three (3) day waiting period. State Fund will provide temporary disability benefit payments as appropriate at the end of IDL, LC 4800, or LC 4800.5 upon notice of the ending date from the Department. (2) Departments will determine if the injured employee is eligible for IDL, Enhanced Industrial Disability Leave (EIDL) or LC 4800/4800.5 time in lieu of temporary disability. Departments will ensure timely payment of these benefits upon receipt of notification of periods of disability by State Fund. (3) Departments are responsible for tracking the eligible time period, including the waiting period.

Claims Management Services. (A) A General: (1) State Fund shall adjust Departments' ’ workers' compensation claim files in accordance with the California Labor Code (LC)Code, any other applicable Laws, and State Fund's ’s internal guidelines. (2) State Fund shall make the workers' ’ compensation liability decisions in regard regards 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 regulationsguidelines. (4) State Fund shall establish a new claim within one (1) business day of receipt of employer's ’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) 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 open, un-finalized 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 ’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 possiblepossibly, but no later than ten (10) days after the effective date of the change. This does not apply when cases are temporarily reassigned. (12) State Fund shall provide CalHR with the results of any audits performed on claims handling covered by this Agreement that have been completed by the Department of Industrial Relations (DIR), Bureau of State Audits, State Controller's Office (SCO) or Department of Finance (DOF). (13) Individual Adjuster caseload size shall be determined by State Fund management, and reported to CalHR on a quarterly basis. (14) State Fund will ensure that their claims personnel will be trained and have legally required claims certifications. (15) State Fund Adjusters will refer any claim(s) where fraudulent activity is suspected to State Fund's Special Investigations Unit (SIU). State Fund's SIU is responsible for the referral of cases to legal authorities, when appropriate. (16) Departments will have electronic access to State Fund provided safety materials. (17) Direct safety services, industrial hygiene services, and ergonomic evaluations may be available for an additional fee. (18) Departments shall establish, implement, and maintain uniform written policies for injury prevention, reporting of injuries when they occur, maintaining contact with injured employees, and returning injured employees to work per XXX Sections 2580 through 2581.2. (19) Departments shall provide to State Fund all pertinent information relevant to the adjustment of a workers' compensation claim promptly. This information may include relevant information regarding: California Public Employees' Retirement System, personnel files, adverse actions, performance issues, and EEO issues, including reasonable accommodation. (20) Departments shall comply with the applicable sections of the California Government Code, California Labor Code, California Code of Regulations, XXX and Executive Order D-48-85, regarding returning employees to work and shall actively seek employment opportunities for injured employees who have become disabled. (21) Departments shall ensure that the "Employer's Report of Occupational Injury or Illness" is completed and submitted to State Fund no later than the statutory timeframe from the employer's date of knowledge of injury, illness, or death. Departments are responsible for notifying the California Division of Occupational Safety and Health as required by law. (22) Departments shall ensure that the injured employee is provided with an "Employee's Claim for Workers' Compensation Benefits" form (SCIF e3301) and the guide to the State Fund medical provider network (MPN) within one (1) working day of the employer receiving notice of injury, illness, or death. The completed SCIF e3301 shall be routed to State Fund within one (1) working day of receipt from the injured employee or his/her representative. (23) The RTWC may schedule strategy meetings with State Fund once per quarter, which may include a legal strategy summary for litigated files upon request. These legal strategy summaries will be provided within a reasonable, mutually agreeable timeframe following communication of the request to the State Fund attorney. (24) The RTWC may contact State Fund to review their claim files. A review of the Department's file(s) may also be performed by a CalHR representative. The timing and location of the review will be mutually agreed upon. (25) Departments shall notify State Fund and CalHR of the name(s) of the RTWC(s) and their area of responsibility. Each Department shall have at least one RTWC who is the key contact with State Fund on claim files related to the Department. When there is a change in the RTWC assignment, the Department shall notify State Fund and CalHR of the name and contact information for the RTWC assigned. (26) At the request of the State Fund Adjuster or attorney, the RTWC shall attend case planning meetings, mandatory settlement conferences (MSC), and trials. If the RTWC cannot attend a case planning meeting out of town, alternatives to travel will be considered, such as conference calls or teleconferencing. (27) Departments are responsible for conveying information to State Fund regarding return to work, including but not limited to when an injured worker returns to work or the Department offers to return the injured worker to work, so that appropriate benefits can be provided. (28) Departments shall ensure that their RTWCs are properly trained in the areas of workers' compensation, disability management, etc. The RTWC shall take the Return-to-Work Training class given by CalHR, and/or an accredited or CalHR approved equivalent training program, within twelve (12) months of their appointment. Each year thereafter, the RTWCs shall take at least sixteen (16) hours of additional training (this can include the quarterly CalHR forums, seminars, webinars, or other relevant training). (29) Departments shall report any suspected fraudulent activity to State Fund. (30) CalHR will notify Departments of any changes to this Agreement. (31) CalHR, State Fund, and Departments shall attend monthly management level meetings. The purpose of these meetings is to facilitate greater performance and accountability under this Agreement. At these meetings the Parties will review performance results, work to resolve issues presented by this Agreement and the claims administration process, keep the Parties informed about the program and any changes thereto, and xxxxxx mutual accountability through improved communication. CalHR will schedule and facilitate the monthly management level meetings. (32) CalHR, in cooperation with State Fund and Departments, shall provide ongoing training programs for all RTWCs. Additional classes may be set up outside this Agreement and separate fees may be charged for attendance of these classes. (33) State Fund will provide CalHR with reports and information necessary for the administration of the State's workers' compensation program. In addition, State Fund and CalHR will work to improve the delivery of information to Departments with the intent of improving outcomes in the State's workers' compensation program. (B) Investigations: (1) State Fund has the authority to assign an investigator to complete an investigation on a claim, which may be performed by a Subcontractor. (2) State Fund or the vendor shall notify the RTWC when an investigator is assigned. Notification shall not delay commencement of the investigation. (3) The RTWC and other Department Personnel shall cooperate with State Fund's claims and/or fraud investigations. (4) The RTWC or appropriate Department Personnel may review an investigation with the approval of State Fund's Legal Department. The investigation shall be reviewed at a State Fund office. The RTWC may not make copies of any investigative materials, including, but not limited to, the report, documents/records obtained, or subrosa audio/video recordings. State Fund may refuse the review of an investigation if State Fund believes there is a conflict of interest in a particular case. (5) The RTWC may request State Fund assign an investigator to complete an investigation on a claim. In the event that State Fund determines there exists a compelling reason to deny ordering an investigation, State Fund will provide discussion and consultation to the requesting Department outlining the merits of the determination. The final decision regarding whether or not to order an investigation rests with State Fund. (C) Industrial Disability Leave; Labor Code Section 4800; Labor Code Section 4800.5: (1) State Fund shall notify Departments of periods of disability for Industrial Disability Leave (IDL), Labor Code (LC) 4800, and LC 4800.5 as appropriate, including the three (3) day waiting period. State Fund will provide temporary disability benefit payments as appropriate at the end of IDL, LC 4800, or LC 4800.5 upon notice of the ending date from the Department. (2) Departments will determine if the injured employee is eligible for IDL, Enhanced Industrial Disability Leave (EIDL) or LC 4800/4800.5 time in lieu of temporary disability. Departments will ensure timely payment of these benefits upon receipt of notification of periods of disability by State Fund. (3) Departments are responsible for tracking the eligible time period, including the waiting period.ten

Claims Management Services. (A) A In General: (1) State Fund shall adjust Departments' ’ workers' compensation claim files in accordance with the California Labor Code (LC)Code, any other applicable Laws, and State Fund's ’s internal guidelines. (2) State Fund shall make the workers' ’ compensation liability decisions in regard regards 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 regulationsguidelines. (4) State Fund shall establish a new claim within one (1) business day of receipt of employer's ’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) 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 open, un-finalized 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 ’s Return-to-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 possiblepossibly, but no later than ten (10) days after the effective date of the change. This does not apply when cases are temporarily reassigned. (12) State Fund shall provide CalHR with the results of any audits performed on claims handling covered by this Agreement that have been completed by the Department of Industrial Relations (DIR), Bureau of State Audits, State Controller's ’s Office (SCO) or Department of Finance (DOF). (13) Individual Adjuster caseload size shall be determined by State Fund management, and reported to CalHR on a quarterly basis. (14) State Fund will ensure that their claims personnel will be trained and have legally required claims certifications. (15) State Fund Adjusters will refer any claim(s) where fraudulent activity is suspected to State Fund's Special Investigations Unit (SIU). State Fund's SIU is responsible for the referral of cases to legal authorities, when appropriate. (16) Departments will have electronic access to State Fund provided safety materials. (17) Direct safety services, industrial hygiene services, and ergonomic evaluations may be available for an additional fee. (18) Departments shall establish, implement, and maintain uniform written policies for injury prevention, reporting of injuries when they occur, maintaining contact with injured employees, and returning injured employees to work per XXX Sections 2580 through 2581.2. (19) Departments shall provide to State Fund all pertinent information relevant to the adjustment of a workers' compensation claim promptly. This information may include relevant information regarding: California Public Employees' ’ Retirement System, personnel files, adverse actions, and performance issues, and EEO issues, including reasonable accommodation. (20) Departments shall comply with the applicable sections of the California Government Code, California Labor Code, California Code of Regulations, XXX and Executive Order D-48-85, regarding returning employees to work and shall actively seek employment opportunities for injured employees who have become disabled. (21) Departments shall ensure that the "“Employer's ’s Report of Occupational Injury or Illness" ” is completed and submitted to State Fund no later than the statutory timeframe from the employer's date of knowledge of injury, illness, or death. Departments are responsible for notifying the California Division of Occupational Safety and Health as required by law. (22) Departments shall ensure that the injured employee is provided with an "“Employee's ’s Claim for Workers' ’ Compensation Benefits" ” form (SCIF e3301) and the guide to the State Fund medical provider network (MPN) within one (1) working day of the employer receiving notice of injury, illness, or death. The completed SCIF e3301 shall be routed to State Fund within one (1) working day of receipt from the injured employee or his/her representative. (23) The RTWC may schedule strategy meetings with State Fund once per quarter, which may include a legal strategy summary for litigated files upon request. These legal strategy summaries will be provided within a reasonable, mutually agreeable timeframe following communication of the request to the State Fund attorney. (24) The RTWC may contact State Fund to review their claim files. A review of the Department's ’s file(s) may also be performed by a CalHR representative. The timing and location of the review will be mutually agreed upon. (25) Departments shall notify State Fund and CalHR of the name(s) of the RTWC(s) and their area of responsibility. Each Department shall have at least one RTWC who is the key contact with State Fund on claim files related to the Department. When there is a change in the RTWC assignment, the Department shall notify State Fund and CalHR of the name and contact information for the RTWC assigned. (26) At the request of the State Fund Adjuster or attorney, the RTWC shall attend case planning meetings, mandatory settlement conferences (MSC), and trials. If the RTWC cannot attend a case planning meeting out of town, alternatives to travel will be considered, such as conference calls or teleconferencing. (27) Departments are responsible for conveying information to State Fund regarding return to work, including but not limited to when an injured worker returns to work or the Department offers to return the injured worker to work, so that appropriate benefits can be provided. (28) Departments shall ensure that their RTWCs are properly trained in the areas of workers' ’ compensation, disability management, etc. The RTWC shall take the Return-to-Work Training class given by CalHR, and/or an accredited or CalHR approved equivalent training program, within twelve (12) months of their appointment. Each year thereafter, the RTWCs shall take at least sixteen (16) hours of additional training (this can include the quarterly CalHR forums, seminars, webinars, forums or other relevant trainingseminars). (29) Departments shall report any suspected fraudulent activity to State Fund. (30) CalHR will notify Departments of any changes to this Agreement. (31) CalHR, State Fund, and Departments shall attend monthly management level meetings. The purpose of these meetings is to facilitate greater performance and accountability under this Agreement. At these meetings the Parties will review performance results, work to resolve issues presented by this Agreement and the claims administration process, keep the Parties informed about the program and any changes thereto, and xxxxxx mutual accountability through improved communication. CalHR will schedule and facilitate the monthly management level meetings. (32) CalHR, in cooperation with State Fund and Departments, shall provide ongoing training programs for all RTWCs. Additional classes may be set up outside this Agreement and separate fees may be charged for attendance of these classes. (33) State Fund will provide CalHR with reports and information necessary for the administration of the State's ’s workers' ’ compensation program. In addition, State Fund and CalHR will work to improve the delivery of information to Departments with the intent of improving outcomes in the State's ’s workers' ’ compensation program. (B) . B Investigations: (1) State Fund has the authority to assign an investigator to complete an investigation on a claim, which may be performed by a Subcontractor. (2) State Fund or the vendor shall notify the RTWC when an investigator is assigned. Notification shall not delay commencement of the investigation. (3) The RTWC and other Department Personnel shall cooperate with State Fund's ’s claims and/or fraud investigations. (4) The RTWC or appropriate Department Personnel may review an investigation investigative report with the approval of State Fund's ’s Legal Department. The investigation shall be reviewed at a State Fund office. The RTWC may not make any copies of any investigative materials, including, but not limited to, the report, documents/records obtained, or subrosa audio/video recordingsdocument. State Fund may refuse the review of an investigation a report if State Fund believes there is a conflict of interest in a particular case. (5) The RTWC may request State Fund assign an investigator to complete an investigation on a claim. In the event that State Fund determines there exists a compelling reason to deny ordering an investigation, State Fund will provide discussion and consultation to the requesting Department outlining the merits of the determination. The final decision regarding whether or not to order an investigation rests with State Fund. (C) Industrial Disability Leave; Labor Code Section 4800; Labor Code Section 4800.5: (1) State Fund shall notify Departments of periods of disability for Industrial Disability Leave (IDL), Labor Code (LC) 4800, and LC 4800.5 as appropriate, including the three (3) day waiting period. State Fund will provide temporary disability benefit payments as appropriate at the end of IDL, LC 4800, or LC 4800.5 upon notice of the ending date from the Department. (2) Departments will determine if the injured employee is eligible for IDL, Enhanced Industrial Disability Leave (EIDL) or LC 4800/4800.5 time in lieu of temporary disability. Departments will ensure timely payment of these benefits upon receipt of notification of periods of disability by State Fund. (3) Departments are responsible for tracking the eligible time period, including the waiting period.

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 temporarily reassigned. (12) State Fund shall provide CalHR with the results of any audits performed on claims handling covered by this Agreement that have been completed by the Department of Industrial Relations (DIR), Bureau of State Audits, State Controller's Office (SCO) or Department of Finance (DOF). (13) Individual Adjuster caseload size shall be determined by State Fund management, and reported to CalHR on a quarterly basis. (14) State Fund will ensure that their claims personnel will be trained and have legally required claims certifications. (15) State Fund Adjusters will refer any claim(s) where fraudulent activity is suspected to State Fund's Special Investigations Unit (SIU). State Fund's SIU is responsible for the referral of cases to legal authorities, when appropriate. (16) Departments will have electronic access to State Fund provided safety materials. (17) Direct safety services, industrial hygiene services, and ergonomic evaluations may be available for an additional fee. (18) Departments shall establish, implement, and maintain uniform written policies for injury prevention, reporting of injuries when they occur, maintaining contact with injured employees, and returning injured employees to work per XXX Sections 2580 through 2581.2. (19) Departments shall provide to State Fund all pertinent information relevant to the adjustment of a workers' compensation claim promptly. This information may include relevant information regarding: California Public Employees' Retirement System, personnel files, adverse actions, performance issues, and EEO issues, including reasonable accommodation. (20) Departments shall comply with the applicable sections of the California Government Code, California Labor Code, California Code of Regulations, XXX and Executive Order D-48-85, regarding returning employees to work and shall actively seek employment opportunities for injured employees who have become disabled. (21) Departments shall ensure that the "Employer's Report of Occupational Injury or Illness" is completed and submitted to State Fund no later than the statutory timeframe from the employer's date of knowledge of injury, illness, or death. Departments are responsible for notifying the California Division of Occupational Safety and Health as required by law. (22) Departments shall ensure that the injured employee is provided with an "Employee's Claim for Workers' Compensation Benefits" form (SCIF e3301) and the guide to the State Fund medical provider network (MPN) within one (1) working day of the employer receiving notice of injury, illness, or death. The completed SCIF e3301 shall be routed to State Fund within one (1) working day of receipt from the injured employee or his/her representative. (23) The RTWC may schedule strategy meetings with State Fund once per quarter, which may include a legal strategy summary for litigated files upon request. These legal strategy summaries will be provided within a reasonable, mutually agreeable timeframe following communication of the request to the State Fund attorney. (24) The RTWC may contact State Fund to review their claim files. A review of the Department's file(s) may also be performed by a CalHR representative. The timing and location of the review will be mutually agreed upon. (25) Departments shall notify State Fund and CalHR of the name(s) of the RTWC(s) and their area of responsibility. Each Department shall have at least one RTWC who is the key contact with State Fund on claim files related to the Department. When there is a change in the RTWC assignment, the Department shall notify State Fund and CalHR of the name and contact information for the RTWC assigned. (26) At the request of the State Fund Adjuster or attorney, the RTWC shall attend case planning meetings, mandatory settlement conferences (MSC), and trials. If the RTWC cannot attend a case planning meeting out of town, alternatives to travel will be considered, such as conference calls or teleconferencing. (27) Departments are responsible for conveying information to State Fund regarding return to work, including but not limited to when an injured worker returns to work or the Department offers to return the injured worker to work, so that appropriate benefits can be provided. (28) Departments shall ensure that their RTWCs are properly trained in the areas of workers' compensation, disability management, etc. The RTWC shall take the Return-to-Work Training class given by CalHRXxxXX, and/or an accredited or CalHR approved equivalent training program, within twelve (12) months of their appointment. Each year thereafter, the RTWCs shall take at least sixteen (16) hours of additional training (this can include the quarterly CalHR forums, seminars, webinars, or other relevant training). (29) Departments shall report any suspected fraudulent activity to State Fund. (30) CalHR will notify Departments of any changes to this Agreement. (31) CalHR, State Fund, and Departments shall attend monthly management level meetings. The purpose of these meetings is to facilitate greater performance and accountability under this Agreement. At these meetings the Parties will review performance results, work to resolve issues presented by this Agreement and the claims administration process, keep the Parties informed about the program and any changes thereto, and xxxxxx mutual accountability through improved communication. CalHR will schedule and facilitate the monthly management level meetings. (32) CalHR, in cooperation with State Fund and Departments, shall provide ongoing training programs for all RTWCs. Additional classes may be set up outside this Agreement and separate fees may be charged for attendance of these classes. (33) State Fund will provide CalHR with reports and information necessary for the administration of the State's workers' compensation program. In addition, State Fund and CalHR will work to improve the delivery of information to Departments with the intent of improving outcomes in the State's workers' compensation program. (B) Investigations: (1) State Fund has the authority to assign an investigator to complete an investigation on a claim, which may be performed by a Subcontractor. (2) State Fund or the vendor shall notify the RTWC when an investigator is assigned. Notification shall not delay commencement of the investigation. (3) The RTWC and other Department Personnel shall cooperate with State Fund's claims and/or fraud investigations. (4) The RTWC or appropriate Department Personnel may review an investigation with the approval of State Fund's Legal Department. The investigation shall be reviewed at a State Fund office. The RTWC may not make copies of any investigative materials, including, but not limited to, the report, documents/records obtained, or subrosa audio/video recordings. State Fund may refuse the review of an investigation if State Fund believes there is a conflict of interest in a particular case. (5) The RTWC may request State Fund assign an investigator to complete an investigation on a claim. In the event that State Fund determines there exists a compelling reason to deny ordering an investigation, State Fund will provide discussion and consultation to the requesting Department outlining the merits of the determination. The final decision regarding whether or not to order an investigation rests with State Fund. (C) Industrial Disability Leave; Labor Code Section 4800; Labor Code Section 4800.5: (1) State Fund shall notify Departments of periods of disability for Industrial Disability Leave (IDL), Labor Code (LC) 4800, and LC 4800.5 as appropriate, including the three (3) day waiting period. State Fund will provide temporary disability benefit payments as appropriate at the end of IDL, LC 4800, or LC 4800.5 upon notice of the ending date from the Department. (2) Departments will determine if the injured employee is eligible for IDL, Enhanced Industrial Disability Leave (EIDL) or LC 4800/4800.5 time in lieu of temporary disability. Departments will ensure timely payment of these benefits upon receipt of notification of periods of disability by State Fund. (3) Departments are responsible for tracking the eligible time period, including the waiting period.

Claims Management Services. (A) A In General: (1) State Fund shall adjust Departments' ’ workers' compensation claim files in accordance with the California Labor Code (LC)Code, any other applicable Laws, and State Fund's ’s internal guidelines. (2) State Fund shall make the workers' ’ compensation liability decisions in regard regards 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 regulationsguidelines. (4) State Fund shall establish a new claim within one (1) business day of receipt of employer's ’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) 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 open, un-finalized 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 ’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 possiblepossibly, but no later than ten (10) days after the effective date of the change. This does not apply when cases are temporarily reassigned. (12) State Fund shall provide CalHR with the results of any audits performed on claims handling covered by this Agreement that have been completed by the Department of Industrial Relations (DIR), Bureau of State Audits, State Controller's Office (SCO) or Department of Finance (DOF). (13) Individual Adjuster caseload size shall be determined by State Fund management, and reported to CalHR on a quarterly basis. (14) State Fund will ensure that their claims personnel will be trained and have legally required claims certifications. (15) State Fund Adjusters will refer any claim(s) where fraudulent activity is suspected to State Fund's Special Investigations Unit (SIU). State Fund's SIU is responsible for the referral of cases to legal authorities, when appropriate. (16) Departments will have electronic access to State Fund provided safety materials. (17) Direct safety services, industrial hygiene services, and ergonomic evaluations may be available for an additional fee. (18) Departments shall establish, implement, and maintain uniform written policies for injury prevention, reporting of injuries when they occur, maintaining contact with injured employees, and returning injured employees to work per XXX Sections 2580 through 2581.2. (19) Departments shall provide to State Fund all pertinent information relevant to the adjustment of a workers' compensation claim promptly. This information may include relevant information regarding: California Public Employees' Retirement System, personnel files, adverse actions, performance issues, and EEO issues, including reasonable accommodation. (20) Departments shall comply with the applicable sections of the California Government Code, California Labor Code, California Code of Regulations, XXX and Executive Order D-48-85, regarding returning employees to work and shall actively seek employment opportunities for injured employees who have become disabled. (21) Departments shall ensure that the "Employer's Report of Occupational Injury or Illness" is completed and submitted to State Fund no later than the statutory timeframe from the employer's date of knowledge of injury, illness, or death. Departments are responsible for notifying the California Division of Occupational Safety and Health as required by law. (22) Departments shall ensure that the injured employee is provided with an "Employee's Claim for Workers' Compensation Benefits" form (SCIF e3301) and the guide to the State Fund medical provider network (MPN) within one (1) working day of the employer receiving notice of injury, illness, or death. The completed SCIF e3301 shall be routed to State Fund within one (1) working day of receipt from the injured employee or his/her representative. (23) The RTWC may schedule strategy meetings with State Fund once per quarter, which may include a legal strategy summary for litigated files upon request. These legal strategy summaries will be provided within a reasonable, mutually agreeable timeframe following communication of the request to the State Fund attorney. (24) The RTWC may contact State Fund to review their claim files. A review of the Department's file(s) may also be performed by a CalHR representative. The timing and location of the review will be mutually agreed upon. (25) Departments shall notify State Fund and CalHR of the name(s) of the RTWC(s) and their area of responsibility. Each Department shall have at least one RTWC who is the key contact with State Fund on claim files related to the Department. When there is a change in the RTWC assignment, the Department shall notify State Fund and CalHR of the name and contact information for the RTWC assigned. (26) At the request of the State Fund Adjuster or attorney, the RTWC shall attend case planning meetings, mandatory settlement conferences (MSC), and trials. If the RTWC cannot attend a case planning meeting out of town, alternatives to travel will be considered, such as conference calls or teleconferencing. (27) Departments are responsible for conveying information to State Fund regarding return to work, including but not limited to when an injured worker returns to work or the Department offers to return the injured worker to work, so that appropriate benefits can be provided. (28) Departments shall ensure that their RTWCs are properly trained in the areas of workers' compensation, disability management, etc. The RTWC shall take the Return-to-Work Training class given by CalHR, and/or an accredited or CalHR approved equivalent training program, within twelve (12) months of their appointment. Each year thereafter, the RTWCs shall take at least sixteen (16) hours of additional training (this can include the quarterly CalHR forums, seminars, webinars, or other relevant training). (29) Departments shall report any suspected fraudulent activity to State Fund. (30) CalHR will notify Departments of any changes to this Agreement. (31) CalHR, State Fund, and Departments shall attend monthly management level meetings. The purpose of these meetings is to facilitate greater performance and accountability under this Agreement. At these meetings the Parties will review performance results, work to resolve issues presented by this Agreement and the claims administration process, keep the Parties informed about the program and any changes thereto, and xxxxxx mutual accountability through improved communication. CalHR will schedule and facilitate the monthly management level meetings. (32) CalHR, in cooperation with State Fund and Departments, shall provide ongoing training programs for all RTWCs. Additional classes may be set up outside this Agreement and separate fees may be charged for attendance of these classes. (33) State Fund will provide CalHR with reports and information necessary for the administration of the State's workers' compensation program. In addition, State Fund and CalHR will work to improve the delivery of information to Departments with the intent of improving outcomes in the State's workers' compensation program. (B) Investigations: (1) State Fund has the authority to assign an investigator to complete an investigation on a claim, which may be performed by a Subcontractor. (2) State Fund or the vendor shall notify the RTWC when an investigator is assigned. Notification shall not delay commencement of the investigation. (3) The RTWC and other Department Personnel shall cooperate with State Fund's claims and/or fraud investigations. (4) The RTWC or appropriate Department Personnel may review an investigation with the approval of State Fund's Legal Department. The investigation shall be reviewed at a State Fund office. The RTWC may not make copies of any investigative materials, including, but not limited to, the report, documents/records obtained, or subrosa audio/video recordings. State Fund may refuse the review of an investigation if State Fund believes there is a conflict of interest in a particular case. (5) The RTWC may request State Fund assign an investigator to complete an investigation on a claim. In the event that State Fund determines there exists a compelling reason to deny ordering an investigation, State Fund will provide discussion and consultation to the requesting Department outlining the merits of the determination. The final decision regarding whether or not to order an investigation rests with State Fund. (C) Industrial Disability Leave; Labor Code Section 4800; Labor Code Section 4800.5: (1) State Fund shall notify Departments of periods of disability for Industrial Disability Leave (IDL), Labor Code (LC) 4800, and LC 4800.5 as appropriate, including the three (3) day waiting period. State Fund will provide temporary disability benefit payments as appropriate at the end of IDL, LC 4800, or LC 4800.5 upon notice of the ending date from the Department. (2) Departments will determine if the injured employee is eligible for IDL, Enhanced Industrial Disability Leave (EIDL) or LC 4800/4800.5 time in lieu of temporary disability. Departments will ensure timely payment of these benefits upon receipt of notification of periods of disability by State Fund. (3) Departments are responsible for tracking the eligible time period, including the waiting period.ten