Client_Handling_Instructions.pdf

Special Claims Handling Instructions

County of San Mateo 500 County Center, 4th Floor, Redwood City, CA 94063

Claim File Set Up

• Review all reported claims including incidents which have been reported as potential claims

• Set up all files in the system within 3 working days

Three Point Contacts and Communication

Employer Contact:

- Initial contact attempt within 1 business day of receipt of claim.

- Three attempts for successful employer contact within the first 3 business days of receipt of claim.

- Contact the Department Supervisor listed on the First Report of Injury (5020).

- If unable to reach the Department Supervisor, contact the County WC Manager (WC Manager) for assistance.

- All communication with the WC Manager or anyone else at the County must be documented in the claim file/administrator electronic database. If communication is by email, the email should include all Attachments. Calls should also be documented in Notepad.

Employee Contact:

- Initial contact attempt within 1 business day of receipt of claim.

- Three attempts for successful employee contact within the first 3 business days of receipt of claim.

- Ongoing communication with the employee should be documented per a 10-14 day diary while the employee is off work.

- Communication with employees who remain at work should be on a maximum 30-day diary and whenever necessary to obtain or provide information.

Medical Contact:

- Initial contact attempt within 1 business day of receipt of claim, unless medical report addressing all issues (causation, diagnosis, treatment plan, work status, NOV) has been received.

- Three attempts for successful medical contact will be made within the first 3 business days of receipt of claim.

- PTP/provider should be contacted immediately upon receipt of a report that does not clearly describe the status of the injured workers’ injuries, treatment, work status, clear and medically necessary work restrictions and any other issue pertinent to the ongoing handling of the claim such as but not limited to next appointment date and duration of work restrictions.

Compensability

• Determination whether to accept, delay or deny a claim will be determined within the 14-day timeline of receipt of the claim or ER awareness of the claim, whichever is the shorter period.

- Send an email for all compensability decisions/claim determinations to the WC Manager, putting a copy in the claim file.

- Delayed or denied claims: Send an email to the WC Manager, putting a copy in the claim file.

• All Mental Stress Injuries are to be delayed and investigated unless the injury qualifies as a traumatic event.

• RSI claim protocol: All claims where the injured workers’ employment is under two years, should be delayed for further investigation. All claims in which there are personnel issues, or supervisors’ concerns should be reviewed and investigated/ placed on delay if needed. For RSI claims involving the upper extremities and neck, with no red flags, longer tenure and job duties that require repetitive work, as well as an opinion by the provider as industrial, can be moved to acceptance within the first 14 days. The exception for this is RSI claims involving the low back, hips, knees, and legs. In those cases, a discussion should be had with the supervisor on whether we have enough information to accept, or if we should delay for more discovery. For all RSI claims, all prior medical files should be requested immediately.

• AOE/COE investigations are to be initiated and/or completed within thirty (30) days of claim receipt, where warranted. If an investigation cannot be completed within the first thirty (30) days, document the claim file for the reason and outline the remaining investigation and a target date for completion.

• All presumptive cases are to be investigated. We have a shorter timeline for investigation of presumptive claims – now 75 days as opposed to 90 days.

• Hearing Loss Claims: The claim examiner must notify the County Occupational Health Coordinator of all hearing loss claims, so that she can verify that all audiograms are available in Origami. The examiner should refer the injured workers to Kaiser RWC Occupational Medicine Department for testing. Kaiser will refer to appropriate ENT provider, per the MPN, providing the test results and records (if any).

• Exposure Claims: The policy/procedure for the County’s TB exposure claims for hospital staff and the sheriff’s department is to accept the claim without delay or AOE/COE investigations. Employees are directed to Kaiser for labs/medications, and the claims are assigned to the medical only desk for handling. The Claim Examiner must notify the County Occupational Health Coordinator of BBFE (Blood and Body Fluids Exposure) injuries and provide additional information if requested, to identify, track and obtain source testing.

• Notification: The County WC Manager is to be notified of all compensability decisions, via email with the rationale for the decision. Please include the date you intend to issue the decision, absent any objections.

• All emails to and from the County must be included in the claim file either as an attachment or embedded in Notepad/claim notes.

Medical Management

WC Manager approval-UR

• If not listed below as an approved treatment, service or prescription, claims examiners should reach out to the WC Manager to seek approval to authorize if they believe the request is appropriate based on facts of the current claim and medical history.

• Examiners should contact the requesting PTP for all requests from Kaiser or the Jayakar Medical Group, that are

NOT on the approved list below and that they have not already sought approval to authorize from the WC Manager, to determine if the request should be authorized or go through UR. If, after this conversation with the PTP, the examiner believes the request should be authorized, they should reach out to the WC Manager to seek approval to authorize the request.

• For all other MPN providers, the examiner should review the requests that are NOT on the approved list below and determine if, based upon the current facts of the claim and medical treatment history, they should seek approval from the WC Manager or reach out to the provider to discuss the request and then seek approval from the WC Manager or not.

UR/Prior Authorized Guidelines are as follows:

• Physical Therapy, Chiropractic or Acupuncture visits for flare-ups should be authorized if documented in the PR 4 or AME/QME report as included in future medical treatment for Stipulations with open medical Awards.

• The County approved medical providers (as listed in the San Mateo County MPN) are pre- authorized for the following medical services for accepted body parts:

Approved List

18 Physical Therapy visits (unless part of future medical Award, as stated above) 18 Chiropractic visits (unless part of future medical Award, as stated above) 18 Acupuncture visits (unless part of future medical award, as stated above) EMG/NCS with documented neurologic deficit on exam or after 30 days of conservative care with documented neurological deficit or without improved function MRI or CT after major trauma, progressive documented neurologic deficits or after 30 days of conservative care without functional improvement X-ray for trauma or suspected fracture or lesion Bone scan to rule out fracture after negative plain film Routine pre-operative testing, including cardiac testing (routine EKG, lab work, echocardiogram with ultrasound, Holter monitor, Zio packet, if medically indicated Consults & Transfer of Care referrals within the SMC MPN Outpatient knee and shoulder arthroscopies after abnormal MRI scan w/findings revealing tears in the rotator cuff in the shoulder or meniscal or ligament tears in the knee (after failed conservative care) All carpal tunnel surgeries (open) where EMG study is positive in moderate or severe cases when injured worker failed bracing, therapy, and steroid injections after 30 days of conservative care.

Inguinal hernia repair after positive ultrasound or CT scan 12 post-op Physical Therapy visits 30-day supply of Flexeril, Lyrica, Gabapentin, Meloxicam or Celebrex. RFA with medical report documenting improvement with use and continued medical necessity required for continued prescription Lidocaine patches 5% Over the counter medication, including, but not limited to: Tylenol, Ibuprofen, Lidoderm (Lidocaine) patches and ointment, Naproxen, Omeprazole, Voltaren gel, Flector (Diclofenac Epolamine) patches 1.3% etc.)

Antibiotics (oral and topical) Other prescription medication in compliance with MTUS and the Chronic Pain Medical Treatment Guidelines as adopted by the DWC Initial injections: medial and lateral epicondyle-one injection per guidelines, up to 2 trigger point, acromioclavicular and subacromial, De ’Quervain’s, carpal tunnel, trigger finger, knee, and for radiculopathy (demonstrated dermatomal pain) injections may be done after 30 days of conservative treatment have failed

One-time referral to a psychologist to determine compensability and/or to provide a recommended treatment plan

Cognitive therapy up to 6 visits Initial evaluation for pain management based on documented need by Primary Treating Physician (PTP).

All medically indicated durable medical equipment (slings, crutches, simple braces, wraps, splints, canes, etc.)

up to $500.00 per equipment TENS units for 30-day trial, unless for low back pain, which is not recommended per MTUS TENS purchase if documented improvement by physical therapist or PTP DME supplies such as electrodes and batteries CPM machines for post-operative knee care Cryotherapy (without compression) rental for post-operative care Podiatry referral for Plantar Fasciitis and other foot injuries; custom orthotics Epidurals -

1) Lumbar Epidural- One steroid injection at one level under fluoroscopy if there is MRI and EMG documentation of the nerve root involved

2) Cervical Epidural – One cervical interlaminar injection with documentation of cervical MRI showing nerve root compression and EMG abnormalities after failure of 3 months of conservative treatment

• Claims examiners can authorize the following for accepted body parts o Functional Capacity Evaluation (FCE) o Medication refills excluding opioids

• Non-medical requests (i.e.: Ergonomic evaluation and equipment) should be sent to County WC Manager for review and not sent through UR.

Nurse Case Management

Documentation of written approval from the County is required prior to making any referral for NCM/TCM services. The examiner must include the rationale for the referral in the request for approval.

Modified Duty

• Contact the employee’s supervisor to discuss availability of temporary modified duty and copy the County WC Manager.

• Track modified duty assignments upon receipt of updated medical report with work status to ensure progress towards full duty release is occurring. Take action to address any delays in progression. Clearly document your activities, including any obstacles delaying progression.

• Examiner should support continued return to work and should advise the County WC Manager should any of the following occur:

Employee is released to his/her usual and customary position without restrictions.

It is determined that the employee is unlikely to return to work in his/her usual and customary position with or without accommodation based on medical opinion. (Permanent restrictions or permanent and stationary status)

• The County WC Manager will advise TPA when:

o Employee retires, resigns, or is terminated from County service.

o It is determined that continued transitional work would put undue hardship on the Department.

o There is not enough work to offer the employee to make the return to work meaningful and mutually beneficial.

Indemnity Benefit Coordination

• Examiner to contact the Payroll Specialist for each department for wage statement requests.

Examiner will coordinate with the County WC Manager when converting an accepted claim after a delay/denial.

• Salary continuation and temporary disability voucher payment entries will be determined in coordination with the County WC Manager.

• Claim Supervisor assures that timely TTD reports are sent to the Controller’s Office and specified individuals.

• The County’s Salary Continuation must be included with all temporary disability start/resume benefit notices.

Indemnity Claims

• Examiner will contact and document bi-weekly calls (on 10-14 day diary) to the claimant while they are receiving lost time benefits.

• If treating doctor continues with excessive TTD (60 days or more with no objective findings), the examiner will send a letter inquiring why TTD continues and provide a job description, if needed.

• Examiner will notify the County WC Manager when employee becomes MMI and will provide:

- accepted body parts

- physician name and role (AME/QME/Primary)

- date of MMI status

- permanent work status (limitations or full duty)

- due date (if any) for offer of regular or permanent modified/alternative work or supplemental job displacement benefit voucher will become due

- last day of TD eligibility (if any)

• If the doctor needs additional information to determine work restrictions, or the injured worker’s ability to continue working in their U&C position, the examiner will take immediate action to provide the necessary information.

• The WC Manager will initiate the interactive process (if needed) and advise the examiner of the outcome in order for the examiner to document the claim file.

Reserving

• All reserves will be set per the state requirements as found in 8 CCR 15300.

• Comprehensive reserve reviews will be completed as needed and every 90 days, documenting the rationale for any changes in the POA to ensure reserving accuracy in response to changes in claim status.

• Examiners will notify the WC Manager by email, with a copy put into the claim file, when posting a reserve over

$25,000, providing a breakdown of the reserves added and their rationale

Diaries and Plan of Action Reviews

• The initial POA is due in the first 30 days

• All active indemnity claims must be reviewed every ninety (90) days and will include a full plan of action. This notepad template is CSM action plan review. In addition, all active indemnity claims must be reviewed every 45 days for an interim review. This notepad template is CSM 45 Day Interim Summary Review.

• Whenever there is a TD claim, examiner must review for updated work status and attempt contact with the EE every two weeks.

• Any time there is a reserve change, there must be an accompanying action plan – even if it is before the 90 day or 180-day timeline.

• The Supervisor completes an initial review within 30 days of claim set up and sets the diary for subsequent reviews.

• Subsequent supervisory diaries must not exceed one-hundred-twenty (120) days on active indemnity files and 180 days on future medical files thereafter. Supervisor diary review on claims with incurred in excess of $100,000 will be completed on or before ninety (90) days.

• The Supervisor will run a monthly report identifying any files off diary and take action to ensure that these files are on diary and the necessary work is completed.

• All open Future Medical claims must be reviewed every 180 days. FM claims with active treatment or litigation will be reviewed by the claim examiner on a 90-day basis, with supervisor review at 180 days or less, as determined by the supervisor.

Litigation Management

▪ The County WC Manager must approve all referrals to defense counsel and subrogation counsel including the attorney assignment. When requesting authority, Examiners must include the rationale for the referral.

▪ Examiners will enter all (workers’ compensation and subrogation) matters on calendar in the litigation screen.

A Litigation report that documents all upcoming appearances is provided to the County weekly.

• Examiners will put all defense counsel and subrogation counsel communications, pleadings and documents in the

Attachment section of the claim file.

• Examiners will provide all pertinent claim information to the subrogation counsel, including, but not limited to monthly claim payment reports, AME and QME reports, medical records, investigative reports, WCAB Hearing reports and any and all information needed to resolve the subrogation case.

• Examiners will keep both defense counsel and the subrogation counsel advised of all developments on the wc claim and subrogation claim.

• The County should be copied on all substantive/strategic correspondence to and from defense counsel and from subrogation counsel. These copies should include but not be limited to all correspondence, pleadings, med-legal reports, analysis, depositions, 132a/S&W filings, mediation briefs, arbitration briefs and settlement discussions .

• Copies of all Awards and Orders issued by the WCAB and civil court on subrogation cases shall be sent to the County WC Manager along with all supporting documents.

• All other communication involving civil law (other than subrogation), employment law, or any legal action at a forum other than the WCAB should be reported to the County WC Manager.

• Examiners are responsible for timely obtaining from the defense attorney and subrogation attorney the following:

- The initial case evaluation, recommendations and litigation budget within 10 business days of case assignment.

- Copies of regular correspondence with recommendations for actions and actions taken towards resolution of disputes and claims.

- Copies of all necessary pleadings and documents filed at the WCAB and in the civil forum for subrogation cases, including, but not limited to, Applications, Answers, Petitions, Pleadings, DORs, Notices, Appeals, settlement documents, etc.

- Copies of all discovery as needed.

- Timely updates and summaries within 3 business days of any appearance at the board or in civil court and within 4 business days for depositions or other notable occurrences.

- The SAR seeking authority to settle all litigated cases, including subrogation.

Investigation

• Written approval from the County must be documented for any investigation or surveillance. Examiners request for authority must include the following:

- Rationale for the referral (including reasonable cause)

- Vendor recommendation

- Type and duration of services recommended

• Examiner is to notify the Risk Manager, Risk Management Program Manager, Worker’s Comp Manger and assigned District Attorney of any FD-1 filing.

• Investigator is to copy the County Risk Manager, Risk Management Program Manager, Worker’s Comp Manger on all investigation reports.

Subrogation

Subrogation claims will be referred to counsel, using the Litigation Management guidelines above. If the examiner determines that counsel is not needed to obtain the recovery and the credit from the WCAB, County WC manager authorization to proceed without counsel must be documented in the file.

A list of all subrogation cases and a benefit printout for each case will be provided to the County quarterly and upon request. The TPA will send benefit printouts to the handling attorney monthly and upon request.

• Authority to settle a subrogation claim with the third party should be requested from the County by a settlement authority request (SAR) that includes information regarding both the civil settlement and the Petition for Credit.

This includes settlement authority to waive subrogation or seek authority to waive part of the subrogation claim, with an explanation as to why the County will not be recovering all of their allowable civil damages as part of the settlement.

• For litigated claims, the SAR will be completed by counsel and sent to the WC Manager, Risk Manager and Risk Management Program Manager, with a copy to the TPA.

• For non-litigated claims the claim examiner will complete the SAR, including the information required above and send to the County representatives noted above to request authority. A Petition for Credit must be filed in all cases where the injured worker receives any settlement from a third party.

The County is to be notified when settlement proceeds are received and when the Petition for Credit is granted by the WCAB with a copy of the Order provided to the County.

Settlement

• Examiners have zero settlement authority. A settlement authority request (SAR) should be submitted to the WC Manager for review and approval for all settlement requests. The SAR will include the formal template.

- For 0% Stipulation with Request for Award, a full SAR does not need to be completed, but an email with request for authority with settlement rationale to the WC Manager is required.

• Settlements over $50,000 require Board of Supervisors approval and require County Counsel involvement. This process may take up to 90 days. The SAR will be sent to the WC Manager, Risk Manager and Risk Management Program Manager.

• For litigated claims, a SAR will be completed by Defense Counsel and sent to the County representatives listed above for review and approval. Defense Counsel will copy the TPA on this communication.

• The County is to be notified of all settlement payments by email to the WC Manager.

File Closure

All files will be closed per the requirements of CCR Chapter 8 Section 15400.2 Maintenance of Records. No claim files shall be destroyed. Claim files with awards for future benefits may be closed two years after the date of the last provision of workers' compensation benefits as defined in Labor Code Section 3207, if there is no reasonable expectation that future benefits will be claimed or provided.

Excess Coverage

Examiner to refer to the excess carrier list to determine carrier identity, coverage and reporting requirements which are controlled by date of loss.

The current carrier, as of 5/22/09 date of loss and continuing, is Safety National.

• First Notice of Loss (FNOL) should be filed when policy threshold levels for reporting have been met.

Safety National thresholds for filing FNOL:

- $500,000 reserve

- Fatalities

- Paraplegics and quadriplegics

- Serious burns, defined as 2nd or 3rd degree burns involving 25% or more of the body

- Brain injury

- Spinal cord injury

- Amputation of a major extremity Any Occurrence, which results in a serious injury to two or more Employees.

• Subsequent report will be sent every 90 days, unless policy/carrier indicates otherwise. File documentation of the subsequent reporting change will be documented with correspondence and in the POA under excess status, which is to be documented in the claim file.

• Reimbursement requests will be added to the subsequent reporting once SIR layer has been pierced for paid amount and will follow the policy terms. Any default in reimbursement requests will be escalated to the claims supervisor for intervention. If continued default occurs, the County will be notified to assess further plan of action.

Claim Reviews

The County will conduct the following file reviews at specific intervals as indicated and will require attendance by claims team:

• Claim File Reviews: Bi-annual or as needed

- Claims will be identified by claims team and the County.

- 30-day notice will be provided on the approved list of claims to be reviewed.

• Medical Case Management (Kaiser On-the-Job and Jayakar Medical Group): Bi-annual

- Claims will be identified by the provider and claims team and approved by the County.

• Legal File Review with LFLM: Bi-annual

- Claims will be identified by the Firm/County

- Other firms if retained

Check Issuance/Funding

• The County will maintain the bank account. Contact the County WC Mgr for any stop pays, voids or notifications for any returned checks.

• Any credits or recoveries will be deposited into the account or may be refunded to the County upon receipt.

• The County WC Manager must be notified of all payments $10,000 or higher upon issuance.

• The Risk Manager must also be included on any notification at or above $50,000, with the date of anticipated payment.

• Indemnity overpayments: Claims examiner to issue notice to employee when overpayment occurs requesting reimbursement. When funds are recovered (in part or in whole), the examiner will send an updated overpayment notice notifying employee of remaining balance due and also send notice when overpayment is fully recovered.

Overpayment should be adequately tracked in the plan of action until fully recovered through repayment and/or settlement of the claim.

Reports TPA will provide the following reports to the County (Risk Manager, WC Program Manager, WC Managers and Special Projects Coordinator):

1. Bordereau-loss run – quarterly

2. Settlement report – quarterly

3. Excess report – quarterly

4. Large Loss report – quarterly

5. Subrogation report – quarterly

6. SIU report – quarterly

7. Litigation reporting- weekly

8. Delayed Claims Report- weekly

9. Claims with compensability determinations- weekly

10. TD Claims payments- weekly (rolling month data)

11. TD Payments Financial Ledger- weekly

12. UR Report

13. Scorecard Report

Revised 3/8/2026

Subject to change based on updated policy, contracts & MOU’s