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Workers' Compensation Disputed Claims (March 2017)

Workers' Compensation Disputed Claims (March 2017)

Department

  1. Clearly mark appropriate box on Employers’ First Report of Injury (3067 or 121 or EFROI).
    a.  EFROI asks "Do you verify the injury?" indicate "No."

  2. Add clear explanation of WHY claim is questionable or disputed.
    a.  Within available comment section of 3067 or 121.
    b.  Within available comment section of EFROI or BIS (CDCR).
    c.  Separate email or fax directly to adjuster.

  3. Can also suggest next appropriate actions.
    a.  For example: "Please order investigation." Or "Please share this corrective memo with the treating physician."

  4. Discuss claim with adjuster.
    a.  Either party can initiate call/email discussion.
    b.  Document the discussion.
    c.  Set mutual diary date to follow up.

  5. Contact adjuster within agreed timeframe for update.

State Fund

  1. State Fund will make decision to put claim on delay if warranted.

  2. Discuss claim with RTWC.
    a.  Upon receipt of new claim, call department.
    b.  Discuss Departments’ requests for action.
         i.  Must check with legal before sending any non-medical information to the doctor.
    c.  Document claims file.
    d.  Set mutual diary date to follow up.

  3. Conduct appropriate discovery/investigation.

  4. Contact RTWC within agreed timeframe with update.

  5. Communicate decision making process with RTWC.

 

  Updated: 4/13/2017
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