Source: http://www.wvinsurance.gov/ClaimsServices.aspx
Timestamp: 2015-04-21 02:55:18
Document Index: 167792955

Matched Legal Cases: ['§ 23', '§ 23', '§23', '§23', '§23', '§23']

The Claims Services Division is a team of dedicated employees providing quality oversight and support to various programs. Our oversight includes monitoring the claims administration of the West Virginia State Agency Workers’ Compensation Program (SAWC), Old Fund claims with a date of last exposure prior to July 1, 2005, Coal Workers Pneumoconiosis claims with a date of last exposure prior to January 1, 2006, and established Uninsured Employer Fund (UEF) claims. The Claims Services Staff strives to maintain efficiency and compliance via monthly quality assurance reviews, quarterly large loss claims staffing, and on-site semi-annual claims best practice reviews. Our staff is also responsible for reviewing and approving benefits payments set up by the Third Party Administrators’ (TPA), reviewing and approving reserves of $25,000 or greater, and reviewing and approving settlements of $25,000 or greater. We work with the West Virginia State Auditor’s Office to establish Electronic Fund Transfers (EFTS) for injured workers or their dependents who receive benefits. In addition to our claims staff, we have a nurse on-site to review pharmacy reports for trends, conduct internal medical reviews of claims with complicated medical conditions or issues, and to assist the claims staff in determining appropriate medical oversight of claims. We also have Insurance Program Specialists, who are responsible for monthly and yearly reporting, trending based on those reports, IT testing and workflow development, Electronic Data Interchange (EDI), and automation of our claims review processes. In addition, we will implement a medical audit project in the near future. The Claims Services Division is currently working with, or is responsible for the oversight of the following programs:
1) West Virginia State Agency Workers’ Compensation (SAWC)
2) Electronic Data Interchange (EDI)
3) Uninsured Employer Fund (UEF)
4) Old Fund Claims
5) New Claims Applications
6) Occupational Pneumoconiosis (OP) Board
7) Permanent Total Disability Review Board (PTDRB)
8) West Virginia Workers’ Compensation Claims Index NOTE: The 5th Annual West Virginia Workers' Compensation Educational Conference will be held at the Charleston Marriott Hotel on May 7th & 8th, 2015.
West Virginia Workers’ Compensation Educational Conference Brochure - 2015
The Claims Services Division contracts with TPAs to administer claims on its behalf. The three TPAs currently under contract are:
Sedgwick CMS, which administers the largest portion of the Old Fund Trauma and UEF claims; HealthSmart Disability Management, which administers the majority of State Occupational Pneumoconiosis (OP) and Federal Black Lung (FBL) claims; Zurich, which administers the State Agency Workers’ Compensation (SAWC) program. To maintain efficiency and compliance within the multiple programs, the Claims Services staff conducts monthly quality assurance reviews, quarterly large loss claims staffing, and on-site semi-annual claims best practices reviews. In addition, there is interaction between the Claims Services staff and the TPAs daily.
WV State Agency Workers’ Compensation Program (SAWC)
The SAWC program has a $250,000.00 deductible policy with Zurich, which was initially effective on October 1, 2011. The Claims Services Staff conducts ongoing quality assurance reviews, coordinates and participates with large loss claims staffing, and travels to Pittsburgh, PA when conducting on-site semi-annual claims best practices reviews that ensure compliance and claims handling efficiency. The West Virginia state agencies, boards and commissions have been combined under one workers' compensation policy covering all state employees. Specific policy information is provided below:
Member Listing - SAWC Members PDF
Workplace Posting Notice - Posting Notice PDF
SAWC Safety Policy Statement - SAWC Safety Policy Statement PDF
Claims Reporting – Employer Manual HealthSmart Wallcard Zurich - Important Information Employee Manual HealthSmart Employee ID TTD Wage Calculator Employee Brochure Agency and Location Site Codes Election of Option Form Customer Letter
Zurich FAQ Forms – Application for Fatal Dependent Benefits Employees and Physicians Report of Occupational Injury/Disease [OIC-WC-1]
Report of OP - Employer Attending Physicians Report Employer’s Report of Occupational Injury/Disease [OIC –WC-2]
Report of OP - Physician Change of Address Notification Functional Job Description Report of OP - Physician Interpretation Change of Physician Pharmacy Invoice Service Invoice Claimant Travel Voucher Physician Statement of Physical Capabilities Transitional Employment Agreement Claim Reopening Form Report of Hearing Loss Wage Report Diagnosis Update Report of OP - Employee Request for Change or Opt-Out
Tonya Montez (claims questions)
Email: tonya.montez@wvinsurance.gov
Rick Fisher (claims questions)
Phone: (304)-558-1966, ext. 3028
Email: rick.fisher@wvinsurance.gov
Email Inquiry – SAWC@wvinsurance.gov
Tom Judy, Program Manager (policy inquiries)
Email: thomas.judy@wvinsuarnce.gov
The Claims Services Division has a Workers’ Compensation System Specialist who assists the new carriers and self-insured employers with their EDI issues. Claims Services is currently developing a comprehensive EDI program to monitor regulatory compliance of all Workers’ Compensation carriers. The program will include the following tasks:
Quality Control Collection of reported data Analysis of required reporting data Implementation of fines and penalties Utilizing improvement processes for electronic data reporting Using National EDI standards as established by IAIABC Improving and maintaining processes for First Report of Injury (FROI) and Second Report of Injury (SROI) Following the statutory requirement for EDI Monitoring carriers and their reporting practices Following and implementing National Standards as they are developed Educating the carriers on the process and applicable policies Additional Information:
WV OIC EDI
If you have questions concerning the EDI program, you may contact:
Ralph Farmer, Claims Specialist
Email: ralph.farmer@wvinsurance.gov
UEF claims are filed initially with the Employer Coverage Division. The Claims Services Division monitors the UEF claims that are administered by Sedgwick CMS. The UEF pays awards for injured workers when non-insured employers default in payments. In addition, the UEF maintains a solvent fund balance from which to pay claims via the collection of fines, assessments, and any applicable benefit recoveries. All efforts are made to identify the chargeable employer(s). All UEF claims must be completed and sent to the address provided on the application below:
Uninsured Employer Fund Application Old Fund Claims
The Claims Services Division provides oversight of the Old Fund for the Offices of the Insurance Commissioner (OIC), which is the state’s claims liability following the privatization of Workers’ Compensation. The Old Fund consists of injury claims, occupational disease claims, occupational pneumoconiosis claims, and dependent claims with a date of injury or date of last exposure prior to July 1, 2005. We are also responsible for the oversight of Coal Workers’ Pneumoconiosis Fund claims with a date of last exposure prior to January 1, 2006.
Sedgwick CMS P.O. Box 14490 Lexington, KY 40512
Phone: 1-(877)-925-5580 Fax: 1-(866)-828-8550
HealthSmart Disability Management P.O. Box 3389 Charleston, WV 25333-3389
All claims are reviewed for applicable dates of last exposure and the responsible employer. Upon determination that a claim belongs to the Old Fund or CWPF, it is processed to obtain a Jurisdictional Claim Number (JCN), and assigned to a TPA for administration. Claims filed after the specified dates must be filed with new carriers. Employee’s and Physicians Report of Occupational Injury or Disease [OIC-WC-1]
Occupational Pneumoconiosis (OP) Board Occupational Pneumoconiosis claims may be referred to the Occupational Pneumoconiosis Board by the Carrier/Self-Insured Employer/TPA for matters concerning exposure and the degree of pulmonary function. Claims Services is responsible for providing support to the Occupational Pneumoconiosis (OP) Board who conducts these examinations. Support includes the receipt and tracking of requests for OP Board examinations, ensuring that all required information is included with the request, scheduling the examinations, issuing related correspondence, communication with pertinent parties, and reviewing OP Board invoices for payment approval. W.Va. Code § 23-4-8a.
All requests must be submitted to the following address:
Claims Services Division PO Box 50541
Email: deborah.bryant@wvinsurance.gov
The West Virginia Workers’ Compensation Claims Index was statutorily created to be established by the West Virginia Industrial Counsel. W.Va. Code § 23-2C-5(c) The Claims Services Division is responsible for reviewing and approving applications for access to the Claims Index. Approval may be given to Workers’ Compensation insurance carriers or TPAs. The Claims Index contains basic demographic data to assist insurers in obtaining information from other insurers regarding previously filed Workers’ Compensation claims filed by a specific claimant. Completed and signed applications must be sent to the Offices of the Insurance Commissioner Claims Services Division. A release signed by the claimant must be included with the application.
West Virginia Workers’ Compensation Claims Index Application for Access
The following Notices to Dependents under W.Va. Code §23-4-10(f) are to be used by the WV Offices of the Insurance Commissioner, self-insured employers, private carriers, and TPAs to inform dependents receiving 104-week awards that they may be eligible for benefits under W.Va. Code §23-4-15, and to explain how to apply for such benefits. Please refer to Informational Letter No. 176 found on the Insurance Commissioner’s website at http://www.wvinsurance.gov for additional information regarding these notices. Notices to Dependents Links:
Notice Under WV Code §23-4-10(f) To Recipients Of 104-Week Award Paid In A Lump Sum Second Notice Under WV Code §23-4-10(f) To Recipients Of 104-Week Award Paid In Monthly Payments Application for 104-Week Dependent’s Benefits – [OIC-WC-202]
Request for Settlement Review Settlement Application
Controlled Substances Form Attending Physician Benefits Form Diagnosis Update Direct Deposit Form 1-04-11
Old Fund Claim Re-Opening Application for Permanent Partial Disability
Every individual is responsible for helping ensure his or her work environment is safe and free of hazards. Let us all work to eliminate potential risk. When an unavoidable accident does happen, and there is a compensable injury, please assist the injured worker in receiving timely and adequate indemnity and medical care for the compensable injury. If you do not have a return to work program, consider the options your company has available to assist an injured worker with returning to work. *If you have an issue accessing any of the information or forms via the links on this webpage, please contact:
Insurance Program Specialist & Webpage Developer
Email: paul.dixon@wvinsurance.gov