WORKERS COMPENSATION CLAIMS ADMINISTRATIVE OVERVIEW

Transcription

1 WORKERS COMPENSATION CLAIMS ADMINISTRATIVE OVERVIEW

2 Welcome to Chubb Chubb s commitment to providing world-class service has earned us a reputation for claim service excellence that is evident in the speed, empathy and integrity with which we handle claims. Superior claim handling is made possible by Chubb s experienced and knowledgeable staff who have access to expert resources throughout the claim process. Additionally, our Workers Compensation Managed Care Program allows injured employees to receive timely and appropriate medical care while mitigating expenses due to Chubb s associations with Preferred Provider Networks (PPNs) in many states. Reporting a Claim Claims should be reported as soon as possible. As a rule of thumb, you should report a claim to Chubb within 24 hours of the notice/report of a potential workers compensation loss from the employee. Claims can be reported through several service channels: Online: Chubb s Website at (See Exhibit A for directions) Phone: Fax: Claim Assignment Medical Only Chubb s automated Medical Only FastTrack process expedites the assignment and processing of minor injury claims for timely case resolution. In the event escalation information is identified or as questions arise during the claim, an adjuster will contact the insured. FastTrack claims are handled out of our Chicago, New Haven and Atlanta core offices. Medical Only claims exceeding FastTrack thresholds are assigned to Chubb s Medical Only unit. Once the critical case facts are assessed at claim intake, an adjuster may contact the insured to discuss if further investigation is necessary to determine the case exposure. Claimant contact will be considered if the investigation reveals complicating claim factors. Lost Time Claims that involve lost time or litigation are assigned to Chubb s Lost Time unit. An adjuster will make contact with all parties and utilize specialized resources, when warranted, to achieve a favorable outcome on each claim. Claim Handling Initial Contact The insured may receive an initial call right after the claim is reported to determine optimal claim assignment. For Lost Time claims, we make every effort to have an adjuster contact the insured and claimant within 24 business hours. Requests for Information During the initial investigation, an adjuster may request documents from the insured that could include the following: medical reports, job descriptions, completion of our Physical Demands Form, accident/investigation reports, the completion of a wage statement, or other documents. Chubb s Special Investigation Unit It is the mission of the Chubb Special Investigation Unit (SIU) to identify, investigate, and pursue claims which indicate the potential for fraud. Chubb s SIU conducts in-depth investigations on questionable claims, which may include on-site insured visits, in-person claimant statements and thorough claimant background checks. If you suspect fraud, notify your adjuster or report the activity by calling CHUBB. Recovery Unit If a third party is involved in the claim, an adjuster specializing in subrogation management is assigned in addition to the claim adjuster. Examples of third party cases are motor vehicle accidents, off-premises injuries and equipment malfunction.

3 Medical and Disability Management Nurse Case Managers Nurse Consultants provide oversight of the case management process and assign Telephonic Nurse Case Managers (TCMs) or Field Nurse Case Managers (FCMs), as needed, to Medical Only and Lost Time cases. The case manager will work in collaboration with the assigned Claim Adjuster to assist with medical management and timely return to work. Pharmacy Benefit Management Programs The Pharmacy Benefit Management Program (PBM) for Workers Compensation is administered by Express Scripts (ESI), except Preferred Provider Networks Under Chubb s Workers Compensation Managed Care Program, employees receive medical care provided in accordance with approved techniques for specifying and monitoring treatment. Chubb has affiliations with Preferred Provider Networks in many states to help injured employees receive quality care at a reasonable cost. Providers within the PPO network can be located at: corvel.com/provider_lookup or by calling Corvel at Medical Bill Re-pricing Chubb s bill review service re-prices every medical bill in accordance to each state s fee schedule and Preferred Provider Network s discounts. Quarterly reports showing the medical savings and the fees for re-pricing can be provided. Return-to-Work Program One of the fundamental tenets of the workers compensation system is to treat injured employees and help them return to work in a timely and cost-efficient manner. In support of that, a returnto-work (RTW) program helps injured workers return to gainful employment by providing them with modified job responsibilities that take into consideration physical restrictions, skills and abilities. Chubb s Return-to-Work Program encourages a speedy recovery which can reduce workers compensation costs. To learn more, contact your local Chubb branch. Claim Reserving in Texas where Chubb uses Corvel s CorCareRX. Some of the key benefits of a PBM include: Reduction of out-of-pocket expenses when injured workers obtain prescription drugs for compensable injuries Patient safety and injury-specific formulary, where only those drugs that are appropriate for the injury are dispensed to the injured worker Appropriate utilization of generic drugs versus brand name drugs where allowed Mail order capability for long-term use of prescription medications Express Scripts can be reached at Chubb is committed to the timely and accurate setting of reserves. Reserves are evaluated based upon the complete loss profile, the merits of each claim and probable outcome of the case. Reserves are established as soon as practical but no later than 90 days from the date the loss is reported to and received by Chubb. Litigation When a claim is litigated, an assigned Chubb adjuster will engage one of Chubb s panel attorneys to represent your company. Our Litigation Management Guidelines also specify that defense counsel should send your company copies of all appropriate litigation correspondence, in accordance with state law.

4 At Chubb, we believe the best way to manage a claim is through a coordinated engagement with our customers, agents and brokers. Each claim is unique, and our claim handling approach is tailored to the situation with an unwavering commitment to provide world class claim service. Should you have any questions or need assistance contact your local Chubb settling office. Chubb refers to the insurers of the Chubb Group of Insurance Companies. This literature is descriptive only. Whether or to what extent a particular loss is covered depends on the facts and circumstances of the loss and the actual coverage of the policy as issued. It is offered as a resource to be used together with your professional insurance advisor in maintaining your insurance program. No liability is assumed by reason of the information this document contains. Not all insurers do business in all jurisdictions. Chubb, Box 1615, Warren, NJ Form (Rev. 3/15)

5 ONLINE CLAIM REPORTING Exhibit A Simple, Online Reporting Instructions Designed with the user in mind. Click Report a Claim STEP 1: Click Report a Claim on Chubb s Homepage: STEP 2: Select Online from the list of claim reporting options Click Chubb s Online Claim Reporting application

6 STEP 3: Unless instructed otherwise, continue as an Unregistered User. Most Business Insurance customers should use the Unregistered User path. Unregistered Users: Everyone can submit a claim as an unregistered user. For an improved experience, check Remember My Information to save contact and policy detail for future claim reporting. Business insurance customers, who are frequent users, may find the unregistered user path most beneficial. Registered Users: Personal insurance customers who have registered their accounts online and agents or business insurance customers IDs will have the option to log-in. Logged in users, with valid policy numbers, will have the ability to populate the form with select policy level information. Questions related to log-in credentials: Personal Insurance Customers & Agents Business Insurance Customers & Agents STEP 4: Follow the onscreen instructions and complete the form Navigation Keys: ÁIndicates a required field Indicates a field that while not required will speed up claim processing (Workers Compensation only) Indicates addditional information is available, click on the icon to reveal the detail

7 STEP 5: Review the claim summary click edit to make changes to a section Identify who should receive an confirmation and who should be contacted by the adjuster Upload documents Save information for future claim notices Submit the claim Check this box to save time when reporting future claims Click Submit Claim

8 STEP 6: Print a confirmation with claim number & summary The confirmation page Registered users can access Chubb s Property & Auto Vendors All Worker s Compensation Claims can access the Corvel Medical Network Chubb refers to the insurers of the Chubb Group of Insurance Companies. This literature is descriptive only. Whether or to what extent a particular loss is covered depends on the facts and circumstances of the loss and the actual coverage of the policy as issued. It is offered as a resource to be used together with your professional insurance advisor in maintaining your insurance program. No liability is assumed by reason of the information this document contains. Not all insurers do business in all jurisdictions. Chubb, Box 1615, Warren, NJ