Compensability. 1. The initial compensability determination (accept claim, deny claim or delay acceptance pending the results of additional investigation) and the reasons for such a determination shall be made and documented in the file within 14 calendar days of the filing of the claim with the employer. In the event the claim is not received by the third party administrator or self-administered entity within 14 calendar days of the filing of the claim with the employer, the third party administrator or self-administered entity shall make the initial compensability determination within 7 calendar days of receipt of the claim.
2. Delay of benefit letters shall be mailed in compliance with the Division of Workers’ Compensation (DWC) guidelines. In the event the employer does not provide notice of lost time to the third party administrator or self-administered entity timely to comply with DWC guidelines, the third party administrator or self-administered entity shall mail the benefit letters within 7 calendar days of notification.
3. The final compensability determination shall be made by the claims examiner or supervisor within 90 calendar days of employer receipt of the claim form.
Compensability. Compensability of leave shall be according to RCW 28B.50.553.
Compensability. There is a need for finality in the litigation, and □ Defendants have admitted Plaintiff’s claims for compensation □ Defendants have reasonably denied Plaintiff’s claims for compensation □ Defendants have admitted in part, and reasonably denied in part, Plaintiff’s claims for compensation
Compensability. Where compensability is disputed and the City is denying responsibility for the payment of medical treatment, the injured member is not required to obtain treatment by an authorized provider, pending the resolution of compensability.
Compensability. Within 14-days of assignment, a compensability determination should be noted on all indemnity claims to outline the rationale for claim acceptance or denial. In the event a claim decision must be delayed due to investigation, further investigative action steps should be outline in the claim file notes. The range of acceptable performance is 90% or above. The contactor shall document an initial action plan within 30 days of assignment for all indemnity claims. Updated action plans shall be completed thereafter at 60 and 90 days from the assignment date. After 90 days from assignment an action plan shall be completed at a minimum of every 90 days. The action plan shall include any information that relates to the direction of the claim as well as further work to be done and target date for completion of said work. The range of acceptable performance is 90% or above. The Contractor shall document initial supervisor review in the claim file notes within 30 days of assignment of the claim. Subsequent supervisor reviews shall be documented every 90 days until file closure. Supervisor reviews shall include information that relates to the direction of the claim and further work to be done. The range of acceptable performance is 90% or above. The Contractor shall issue all undisputed indemnity payments in a timely manner. Timeliness is determined according to statutory limits. The range of acceptable performance is 90% or above.
Compensability. The claims adjuster will conduct a thorough investigation of the facts of the claim – including any necessary statements, on-site investigations, or other fact finding methods of substantiating compensability issues, including pursuit of personnel records, prior medical records, ISO, police reports, and court reports. These investigative steps will be documented in claim notes. • Within 10 days, the claims adjuster will complete full investigation, obtain initial medical report(s), determine compensability (officially accept or deny the claim), evaluate the adequacy of initial reserves, and evaluate the file to assure that all appropriate documentation has been entered. • Within 14 days, the adjuster will approve payment for accepted claims • In complex claim investigations where a decision just cannot be made by the 10th day, the State can actually allow up to 90 days for a decision to be made. In these special circumstances, the adjuster will discuss with Xxxxxxx Xxxxxx. APPROVALS • Death claims; • Heart attack/hypertension claims (HHL Claims); • National Guard claims APPROVAL NOTICES • Send a notice of compensability approval to the claimant on every approved claim (LT, MO and WCEXP). • Send a copy of every compensability approval notice (via e-mail) to the following contacts from the State's group insurance division: o Xxxxxxx Xxxxxxx xxxxxxx.xxxxxxx@xx.xxx o Xxxxxx Xxxxxxx xxxxxx.xxxxxxx@xx.xxx o Xxxxxx Xxxxxx xxxxxx.xxxxxx@xx.xxx • Send a copy of every compensability approval notice to the employee's designated HR contact(s) via e-mail.
Compensability
