Workers’ Compensation Claims Handling Guidelines • Compensability must be established within 10 - 14 days of claim receipt by clearly identifying status as accepted, deferred, or denied with supportive justification. Suppose the claim is being placed into a deferred status. The Workers' Compensation Claim Specialist must render an opinion once information has been secured. The Workers' Compensation Claims Workers' Specialist must notify the injured worker and the client of a deferred decision. o All files must contain a "Compensability" note and completion in the Loss Details section of the tree. o The note must clearly and concisely describe the reason for either a denial, deferred or accepted status. o The file must also clearly and concisely describe the loss under the loss description of the Loss Info section of the tree. o The compensability rationale shall include a detailed explanation and must be thoroughly documented and well supported with all the following applicable components: AOE/COE, ER/EE relationship, going and coming rule, injury by accident, pre-existing conditions, injury description inconsistencies, employer level investigation, intoxication, the proximate cause of injury and any applicable case law or statute to support when necessary. o Denials: All claim denials and/or delays must have Unit Manager approval documented in the claim system, and the Workers' Compensation Claim Specialist must obtain client approval when applicable. Unit Managers must keep a reoccurring 45-day diary on all denied files until file resolution and closure. • The Workers' Compensation Claim Specialist should document the file notes discussion of explanation of benefits with the injured worker. The Workers' Compensation Claim Specialist should also send appropriate benefit letters to the injured worker and medical authorizations. Medical Management • The Workers' Compensation Claim Specialist shall take a proactive approach and comply with the applicable jurisdictional rules and regulations. The Workers' Compensation Claim Specialist must direct care in those states where it is permitted. • The Workers' Compensation Claim Specialist must obtain the injured worker's medical documentation and appointment dates and document the file. • The file must reflect a medical treatment plan with a file note "Treatment Plan" to include the diagnosis, prognosis, and any co-morbidities that may impact the treatment plan. • The file note can be completed simultaneously as the Medical Management section of the tree by documenting the treatment plan within that section. • The Medical Management section must also contain the projected Maximum Medical Management target date. The Workers' Compensation Claim Specialist must obtain projected target dates from either ongoing disability guidelines or the physician. This document contains North American Risk Services – Workers’ Compensation proprietary information that is privileged and confidential. It is to be used exclusively by the individual to whom it was given and is not to be copied in full or in partial or the information herein communicated in any manner to anyone who is not employed by North American Risk Services.