Workers’ Compensation Quality Claim Review Expectations The NARS Way – Team Leader - Quality Claim Review Expectations Payments Leakage applies when lack of documentation to support payment of medical expenses or payment of loss wages. Medical bills need to be in the files to support payment of the medical expense. Duplicate payments can occur. There are also times where a claims specialist may not timely provide the injured worker with the required 30-day notice of termination of loss time benefits. There are also times where questions may arise if an alleged injury results from the work-related accident or if it is the result of other circumstances such as the result of an employee’s long-time hobby. Review of loss wages for accuracy and jurisdiction are a must at the present time. Questions to ask yourself while reviewing payments: • Have lost time benefits been issued accordingly? Were the benefits issued timely? • Do we owe the waiting period? • Was the appropriate jurisdiction used for wage calculations? • Were the appropriate state forms filed related to payment of benefits? Management Involvement • Management involvement in claims is dictated by the complexity of the claim and experience level or performance of The NARS Workers’ Compensation Team claim staff. • Questions to ask yourself while reviewing for management involvement: • Has direction been given in the claims file per best practices? • Has direction been followed? • If the claim direction has not been followed, is further follow up warranted? File Administration • Were all C3 Tabs completed per best practices? • Was the work comp type accurate? (Incident, MO, Indemnity) • Was the class code completed and is it accurate? • Were the injury codes confirmed and are they accurate? • Was Linked Claim marked when applicable? • Was the first Payment completed on time? • Were ongoing payments completed on time? • Were account handling instructions followed? • Were cards or flowers sent to the injured worker, when applicable? • Was the diary system used and followed? • Are metrics up to date? • Was Big 5 Data completed for Medicare? 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.