Workers’ Compensation Quality Claim Review Expectations The NARS Way – Team Leader - Quality Claim Review Expectations Coverage Upon assignment of a new claim, the claim specialist should perform a thorough review of the coverage and document the pertinent provisions in the file. When confirming coverage, the claim specialist needs to verify the effective dates of the policy, locations and states covered; deductibles (as appropriate) and employee listed on the policy. Questions to ask yourself when reviewing for coverage: • Was the date of loss confirmed? • Was the jurisdiction confirmed? • Was coverage properly reviewed/documented? • Were there coverage issues that needed investigation? • Were coverage issues properly investigated? • Were coverage issues resolved appropriately? • Was coverage applied with an analysis? Suggested recommendations for improvement with coverage: • Is the date of injury within the policy period? • Have we verified the injured worker is indeed an employee of the employer? • Has the claim specialist provided an analysis applying the information secured from the investigation to the policy? Review (Investigation) Upon receipt of a new claim, a thorough investigation should be immediately initiated. The claim specialist needs to first center on the question “Did the alleged accident arise out of and in the course of employment?” Gathering the facts from both the employer and the injured worker is important, not only in knowing how the accident occurred but to develop an understanding as to the injury and what type of medical treatment is being received presently and potentially will be in the future. If the investigation reveals the accident was caused by the negligence of others, it is essential the claim specialist be proactive to preserve the evidence to seek recovery against the third party. There is always the necessity to consider each loss individually and to exercise sound judgement as to what investigation is needed for a particular claim. Additional effort may be needed on more complex and serious losses. In those claims where the injured worker is reported to have suffered lost time because of the accident, the claim specialist needs to secure a recorded statement in a timely manner. (Recorded statements need to be obtained on all lost time, questionable, and subrogation claims in addition to client specific instructions.) Questions to ask yourself while reviewing for investigation: • Were the facts of the accident/injury gathered and documented? • Were recorded statements taken and documented? • Was an assessment of compensability accurate and clearly documented? (Clearly documenting how the injury related to the injured worker’s’ occupation, state jurisdiction, and applicability to the work.) • Was the first full day off and first date of disability documented? NARS’ Best Practices were created by and for the internal use of NARS and are confidential, proprietary and trade secret documents protected by the Uniform Trade Secrets Act and applicable state/federal law. They may not be copied, distributed, or reproduced, in whole or in part, without NARS’ express prior written authorization. Unauthorized use or distribution may be subject to civil and/or criminal penalties.