workers compensation claims admin overview€¦ · administrative overview . chubb’s commitment...
TRANSCRIPT
Claims Services
Workers Compensation Claims Administrative Overview
Chubbrsquos 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 Chubbrsquos 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 Chubbrsquos associations with Preferred Provider Networks (PPNs) in many states
Reporting a Claim
Claims should be reported as soon as possible Delays in reporting work-related injuries can cause workers compensation claim costs to increase by up to 51 Claims with a delay of more than two weeks are more complex to settle take longer to close and involve a longer period before the injured worker can return to work As a rule of thumb you should report a claim to Chubb within 24 hours of the noticereport of a potential workers compensation loss from the employee Claims can be reported through several service channels
bull Online Chubbrsquos Website at wwwchubb com (see Exhibit A for directions)
bull Phone 1-800-699-9916 bull Fax 1-800-884-3946
Claim Assignment
Medical Only bull For minor injury Medical Only claims
our systems include sophisticated business rules that ensure timely claim resolution In the event ldquoescalationrdquo information is identified or as questions arise during the claim an adjuster will contact the insured Minor Medical Only claims are handled out of our Chicago New Haven and Atlanta core offices
bull Medical Only claims exceeding the minor injury threshold are assigned to Chubbrsquos 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 Chubbrsquos 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
2
descriptions completion of our Physical Demands Form accidentinvestigation reports the completion of a wage statement or other documents
Chubbrsquos 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 Chubbrsquos SIU conducts in-depth investigations on questionable claims which may include onsite insured visits in-person claimant statements and thorough claimant background checks If you suspect fraud notify your adjuster or report the activity by calling 1-800-35-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
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
Preferred Provider Networks Under Chubbrsquos 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 http www corvelcomprovider_lookup or by calling Corvel at 1-800-318-6668
Pharmacy Benefit Management Programs The Pharmacy Benefit Management Program (PBM) for Workers Compensation is administered by Express Scriptsreg (ESI) except in Texas where Chubb uses Corvelrsquos CorCareRX Some of the key benefits of a PBM include
bull Reduction of out-of-pocket expenses when injured workers obtain prescription drugs for compensable injuries
bull First Fill program where ID cards can be provided to injured workers to present to a participating pharmacy avoiding out of pocket expenditures from the start of a claim
bull ESI covers the cost of the first fill if the claim is not deemed compensable at no cost to the insured or to Chubb
bull Patient safety and injury-specific formulary where only those drugs that are appropriate for the injury are dispensed to the injured worker
bull Appropriate utilization of generic drugs versus brand name drugs where allowed
bull Mail order capability for long-term use of prescription medications ndash Express Scripts can be reached at 1-866-672-2482
Narcotic Management Program Within our Pharmacy Benefit Program is the Narcotic Management Program which entails
bull Point of sale edits utilized to address opioids prior to dispensing
bull Combining advanced analytics and investigative outreach to detect and deter potentially fraudulent activity
bull Proactively identifying and managing excessive use of opioids early in the claim
bull Engaging the appropriate resources to find the right balance between pain relief and the risks of dependency abuse and misuse This will contribute to improved clinical outcomes shorter disabilities and reduced overall medical costs
bull Focus on patient safety and recommendations for alternative approaches to pain management and clinical screening for potential high-risk claims
Medical Bill Re-pricing
Chubbrsquos bill review service re-prices every medical bill in accordance to each statersquos fee schedule and Preferred Provider Networkrsquos 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 return- to-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 Chubbrsquos Return-to- Work Program encourages a speedy recovery which can reduce workers compensation costs To learn more contact your local Chubb branch and see Exhibit C
3
Claim Reserving Litigation
Chubb is committed to the timely and When a claim is litigated an assigned accurate setting of reserves Reserves Chubb adjuster will engage one of are evaluated based upon the complete Chubbrsquos panel attorneys to represent loss profile the merits of each claim your company Our Litigation and probable outcome of the case Management Guidelines also specify Reserves are established as soon as that defense counsel should send your practical but no later than 90 days company copies of all appropriate from the date the loss is reported to litigation correspondence in accordance and received by Chubb with state law
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 is the marketing name used to refer to subsidiaries of Chubb Limited providing insurance and related services For a list of these subsidiaries please visit our website at wwwchubbcom Insurance provided by US based Chubb underwriting companies All products may not be available in all states Coverage is subject to the language of the policies as actually issued Surplus lines insurance sold only through licensed surplus lines producers Form 30-01-0035 (916)
Chubbrsquos 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 Chubbrsquos 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 Chubbrsquos associations with Preferred Provider Networks (PPNs) in many states
Reporting a Claim
Claims should be reported as soon as possible Delays in reporting work-related injuries can cause workers compensation claim costs to increase by up to 51 Claims with a delay of more than two weeks are more complex to settle take longer to close and involve a longer period before the injured worker can return to work As a rule of thumb you should report a claim to Chubb within 24 hours of the noticereport of a potential workers compensation loss from the employee Claims can be reported through several service channels
bull Online Chubbrsquos Website at wwwchubb com (see Exhibit A for directions)
bull Phone 1-800-699-9916 bull Fax 1-800-884-3946
Claim Assignment
Medical Only bull For minor injury Medical Only claims
our systems include sophisticated business rules that ensure timely claim resolution In the event ldquoescalationrdquo information is identified or as questions arise during the claim an adjuster will contact the insured Minor Medical Only claims are handled out of our Chicago New Haven and Atlanta core offices
bull Medical Only claims exceeding the minor injury threshold are assigned to Chubbrsquos 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 Chubbrsquos 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
2
descriptions completion of our Physical Demands Form accidentinvestigation reports the completion of a wage statement or other documents
Chubbrsquos 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 Chubbrsquos SIU conducts in-depth investigations on questionable claims which may include onsite insured visits in-person claimant statements and thorough claimant background checks If you suspect fraud notify your adjuster or report the activity by calling 1-800-35-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
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
Preferred Provider Networks Under Chubbrsquos 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 http www corvelcomprovider_lookup or by calling Corvel at 1-800-318-6668
Pharmacy Benefit Management Programs The Pharmacy Benefit Management Program (PBM) for Workers Compensation is administered by Express Scriptsreg (ESI) except in Texas where Chubb uses Corvelrsquos CorCareRX Some of the key benefits of a PBM include
bull Reduction of out-of-pocket expenses when injured workers obtain prescription drugs for compensable injuries
bull First Fill program where ID cards can be provided to injured workers to present to a participating pharmacy avoiding out of pocket expenditures from the start of a claim
bull ESI covers the cost of the first fill if the claim is not deemed compensable at no cost to the insured or to Chubb
bull Patient safety and injury-specific formulary where only those drugs that are appropriate for the injury are dispensed to the injured worker
bull Appropriate utilization of generic drugs versus brand name drugs where allowed
bull Mail order capability for long-term use of prescription medications ndash Express Scripts can be reached at 1-866-672-2482
Narcotic Management Program Within our Pharmacy Benefit Program is the Narcotic Management Program which entails
bull Point of sale edits utilized to address opioids prior to dispensing
bull Combining advanced analytics and investigative outreach to detect and deter potentially fraudulent activity
bull Proactively identifying and managing excessive use of opioids early in the claim
bull Engaging the appropriate resources to find the right balance between pain relief and the risks of dependency abuse and misuse This will contribute to improved clinical outcomes shorter disabilities and reduced overall medical costs
bull Focus on patient safety and recommendations for alternative approaches to pain management and clinical screening for potential high-risk claims
Medical Bill Re-pricing
Chubbrsquos bill review service re-prices every medical bill in accordance to each statersquos fee schedule and Preferred Provider Networkrsquos 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 return- to-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 Chubbrsquos Return-to- Work Program encourages a speedy recovery which can reduce workers compensation costs To learn more contact your local Chubb branch and see Exhibit C
3
Claim Reserving Litigation
Chubb is committed to the timely and When a claim is litigated an assigned accurate setting of reserves Reserves Chubb adjuster will engage one of are evaluated based upon the complete Chubbrsquos panel attorneys to represent loss profile the merits of each claim your company Our Litigation and probable outcome of the case Management Guidelines also specify Reserves are established as soon as that defense counsel should send your practical but no later than 90 days company copies of all appropriate from the date the loss is reported to litigation correspondence in accordance and received by Chubb with state law
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 is the marketing name used to refer to subsidiaries of Chubb Limited providing insurance and related services For a list of these subsidiaries please visit our website at wwwchubbcom Insurance provided by US based Chubb underwriting companies All products may not be available in all states Coverage is subject to the language of the policies as actually issued Surplus lines insurance sold only through licensed surplus lines producers Form 30-01-0035 (916)
descriptions completion of our Physical Demands Form accidentinvestigation reports the completion of a wage statement or other documents
Chubbrsquos 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 Chubbrsquos SIU conducts in-depth investigations on questionable claims which may include onsite insured visits in-person claimant statements and thorough claimant background checks If you suspect fraud notify your adjuster or report the activity by calling 1-800-35-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
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
Preferred Provider Networks Under Chubbrsquos 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 http www corvelcomprovider_lookup or by calling Corvel at 1-800-318-6668
Pharmacy Benefit Management Programs The Pharmacy Benefit Management Program (PBM) for Workers Compensation is administered by Express Scriptsreg (ESI) except in Texas where Chubb uses Corvelrsquos CorCareRX Some of the key benefits of a PBM include
bull Reduction of out-of-pocket expenses when injured workers obtain prescription drugs for compensable injuries
bull First Fill program where ID cards can be provided to injured workers to present to a participating pharmacy avoiding out of pocket expenditures from the start of a claim
bull ESI covers the cost of the first fill if the claim is not deemed compensable at no cost to the insured or to Chubb
bull Patient safety and injury-specific formulary where only those drugs that are appropriate for the injury are dispensed to the injured worker
bull Appropriate utilization of generic drugs versus brand name drugs where allowed
bull Mail order capability for long-term use of prescription medications ndash Express Scripts can be reached at 1-866-672-2482
Narcotic Management Program Within our Pharmacy Benefit Program is the Narcotic Management Program which entails
bull Point of sale edits utilized to address opioids prior to dispensing
bull Combining advanced analytics and investigative outreach to detect and deter potentially fraudulent activity
bull Proactively identifying and managing excessive use of opioids early in the claim
bull Engaging the appropriate resources to find the right balance between pain relief and the risks of dependency abuse and misuse This will contribute to improved clinical outcomes shorter disabilities and reduced overall medical costs
bull Focus on patient safety and recommendations for alternative approaches to pain management and clinical screening for potential high-risk claims
Medical Bill Re-pricing
Chubbrsquos bill review service re-prices every medical bill in accordance to each statersquos fee schedule and Preferred Provider Networkrsquos 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 return- to-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 Chubbrsquos Return-to- Work Program encourages a speedy recovery which can reduce workers compensation costs To learn more contact your local Chubb branch and see Exhibit C
3
Claim Reserving Litigation
Chubb is committed to the timely and When a claim is litigated an assigned accurate setting of reserves Reserves Chubb adjuster will engage one of are evaluated based upon the complete Chubbrsquos panel attorneys to represent loss profile the merits of each claim your company Our Litigation and probable outcome of the case Management Guidelines also specify Reserves are established as soon as that defense counsel should send your practical but no later than 90 days company copies of all appropriate from the date the loss is reported to litigation correspondence in accordance and received by Chubb with state law
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 is the marketing name used to refer to subsidiaries of Chubb Limited providing insurance and related services For a list of these subsidiaries please visit our website at wwwchubbcom Insurance provided by US based Chubb underwriting companies All products may not be available in all states Coverage is subject to the language of the policies as actually issued Surplus lines insurance sold only through licensed surplus lines producers Form 30-01-0035 (916)
Claim Reserving Litigation
Chubb is committed to the timely and When a claim is litigated an assigned accurate setting of reserves Reserves Chubb adjuster will engage one of are evaluated based upon the complete Chubbrsquos panel attorneys to represent loss profile the merits of each claim your company Our Litigation and probable outcome of the case Management Guidelines also specify Reserves are established as soon as that defense counsel should send your practical but no later than 90 days company copies of all appropriate from the date the loss is reported to litigation correspondence in accordance and received by Chubb with state law
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 is the marketing name used to refer to subsidiaries of Chubb Limited providing insurance and related services For a list of these subsidiaries please visit our website at wwwchubbcom Insurance provided by US based Chubb underwriting companies All products may not be available in all states Coverage is subject to the language of the policies as actually issued Surplus lines insurance sold only through licensed surplus lines producers Form 30-01-0035 (916)