 |
 |
| Tuesday, May 21, 2013 |
Claims Coordinator Responsibilities
The claims coordinator is responsible for receiving notices of
injury from employees and serves as the liaison between an injured
employee and SORM. The claims coordinator is responsible for submitting
the required injury reports and notices to SORM and collecting statements
from witnesses.
The Claims Coordinator Role as Liaison
When SORM receives notice that a state employee has been injured,
a SORM adjuster immediately contacts the injured employee, the employee’s
physician, and the employing agency. The claims coordinator is the
primary point of contact between the adjuster and the agency. An adjuster
will call the claims coordinator soon after receiving the injury report
to verify that all the information on the report is correct.
Early contact by the adjuster helps establish the facts of the on-the-job
injury in complicated cases and aids in prompt medical treatment and
payment of benefits that may be due. Early personal contact may also
help to determine the possibility of third-party liability.
The adjuster will call the claims coordinator periodically to obtain
additional information or to verify that the employee has returned
to work. It is important that the claims coordinator immediately notify
SORM when the employee has lost time or returns to work. Timely notification
ensures that benefits are correctly paid to the employee.
An adjuster may ask for work schedules or other information about
the employee’s injury that is available from the agency timekeeper
or the employee’s supervisor. The claims coordinator is responsible
for obtaining this information from their agency and providing it
to SORM.
The Claims Coordinator Role in Claim Processing
The claims coordinator is responsible for supplying SORM with the
appropriate information and forms so that SORM adjusters can properly
process claims. There are various forms that the claims coordinator
must file with SORM to ensure that the adjuster can manage the claim
appropriately and remain in compliance with the law and DWC rules.
There are very important time guidelines that must be adhered to when
filing these forms. The forms and instructions for processing and
submission are summarized in a checklist format in Section VIII of
this manual.
Occupational Diseases
The employing agency is required to file a First Report of Injury
with SORM for occupational diseases, even if the employee has lost
no time from work.
For occupational disease claims with a date of injury occurring on
or after September 1, 1995, the injured employee’s eligibility for
income benefits terminates 401 weeks after the date benefits are first
accrued.
DWC provides the following classifications for occupational diseases/cumulative
injuries through the Electronic Data Interchange (EDI) requirement.
- Dust Disease NOC (All Other Pneumoconiosis)
- Asbestosis
- Black Lung
- Byssinosis
- Silicosis
- Respiratory Disorders (Gases, Fumes, Chemicals, etc.)
- Poisoning - Chemical
- Poisoning - Metal
- Dermatitis
- Mental Disorder
- Radiation
- All Other Occupational Disease
- Loss of Hearing
- Contagious Disease
- Cancer
- AIDS
- VDT-Related Disease
- Mental Stress
- Carpal Tunnel Syndrome
- All Other Cumulative Injuries
Medical Only Claim
When the injured employee has a medical only claim and is not losing
time from work, there are four critical forms that the claims coordinator
must submit to SORM. However, SORM adjusters may request subsequent
forms or additional information if needed.
The Employer’s First Report of Injury or Illness (DWC-1S) must be
received by SORM not later than the 5th calendar day after the first
notice of injury is reported to the employing agency. A copy of the
DWC-1S is included in this handbook.
The claimant must complete the Employee’s Report of Injury (SORM-29)
immediately after an injury occurs and the form must be received by
SORM no later than the third calendar day of the filing of the first
notice of injury. The form must be legible, and signed and dated by
the claimant.
The Witness Statement (SORM-74) form must be completed for each witness
to the injury or incident. The claims coordinator is responsible for
collecting the completed forms and making sure that they are completed
accurately. These forms must be received by SORM not later than the
third calendar day after the first notice of injury is reported to
the agency.
The claimant must complete the Authorization for Release of Information
(SORM-16) immediately after sustaining a work-related injury. The
claimant must sign and date the form. The form must be received by
SORM not later than the third calendar day after the first notice
of injury is filed.
Lost Time Claim
When an injured employee is losing time from work, there are additional
forms that must be submitted to SORM. The Employer’s First Report
of Injury or Illness (DWC-1S) must be received by SORM not later
than the 5th calendar day after the first notice of injury
is reported to the agency. A copy of the DWC-1S is included in this
handbook.
The Employee’s Report of Injury (SORM-29)
must be completed by the claimant immediately after an injury occurs
and should be received by SORM not later than the 5th calendar
day of the filing of the first notice of injury. The form must
be legible and the claimant must sign and date the form.
Injured employees must choose whether they will utilize sick leave
before receiving workers’ compensation income benefits on the Employee’s
Election Regarding Utilization of Sick Leave (SORM-80). This form
must be received by SORM not later than the 5th calendar day
after the first day of lost time.
If the employee experiences one full day of lost time, not including
the date of injury, the claims coordinator must submit the Employer’s
Wage Statement (DWC-3) to SORM. This form should be received
by SORM not later than the 5th calendar day after the first
full day of lost time. If the employer suspends health insurance,
the employer must file an amended DWC-3 with SORM within three days
reporting the date of suspension.
The claims coordinator must complete a Witness Statement (SORM-74)
for each witness to the injury or incident. The claims coordinator
is responsible for collecting the completed forms and making sure
that they are completed accurately. These forms must be received by
SORM not later than the 5th calendar day after the first notice
of injury is reported to the agency.
The claims coordinator must submit the Supplemental Report of Injury
(DWC-6) to SORM for any of the following five different scenarios.
Because this information is crucial to the timely stopping and starting
of benefits, we request that the claims coordinator call the adjuster
as soon as possible and follow up by faxing a DWC-6 to SORM.
1. When the employee returns to work, the form must be received by
SORM not later than the third calendar day after the employee returns
to work.
2. When an employee returns to work and experiences an additional
day(s) of disability as a result of the injury, the form must be received
by SORM not later than the third calendar day after employee
loses the first additional day.
3. If the employee experiences a change in weekly earnings (increase
or decrease) after the injury, the form must be received by SORM not
later than the third calendar day after the end of the pay
period in which this occurs.
4. If the employee resigns or is terminated, the form must be received
by SORM not later than the third calendar day after that event.
The claims coordinator must submit the Notification of Additional
Information (SORM-90) to SORM, not later than the next working
day after any additional leave has been granted. We recommend that
this form be faxed.
The claimant must complete the Authorization for Release of Information
(SORM-16) form immediately after sustaining a work-related injury.
The claimant must sign and date the form. The form must be received
by SORM not later than the 5th calendar day after the first
notice of injury is filed with SORM.
Other Forms
If there is a change in an agency’s claims coordinator, the Change
in Designation of Claims Coordinator (SORM-100) form must be received
by SORM not later than 10 calendar days after the change.
The claimant must complete the Travel Reimbursement Form (DWC-48)
when seeking reimbursement for travel expenses for medical care relating
to work-related injuries. This covers authorized reimbursements for
mileage, lodging, and meals. The claimant or claims coordinator must
submit this form. It must be received by SORM not later than 30 calendar
days after the date of travel. |
|
|
|