|
Policy
and Procedure Name:
|
Duplicate Claims and Customers
|
|
Policy
#:
|
CP-04-05
|
|
Code/Rule
Reference:
|
None
|
|
Effective
Date:
|
11/05/2021
|
|
Approved:
|
Ann
M. Shannon, Chief of Claims
Policy and Support
|
|
Origin:
|
Claims
Policy
|
|
Supersedes:
|
Policy
# CP-04-05, effective 11/14/16
|
|
History:
|
Previous
versions of this policy are available upon request
|
Table
of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
IV. POLICY
V. PROCEDURE
A. General Claim
Note and Documentation Requirements
B. Identifying
Duplicate Claims
C. Investigating/Processing
Duplicate Customers
D. Investigating/Processing
Duplicate Claims
E. Duplicate claims
that have different accident types (injury, occupational disease, or death)
F. Combining and
Decombining Claims
G. Overpaid
Compensation and Medical Bills
VI. Appendix A:
Combining Duplicate Claims
The purpose of this policy is to ensure
that duplicate claims and customer records are properly identified and combined
in an efficient manner to prevent duplicate actions.
This policy applies to all BWC staff
and managed care organizations.
Alias Claim: The claim
that is combined into the surviving claim.
Duplicate Claim: When more
than one claim has the same injured worker name, social security number,
risk/policy number, and date of injury.
Surviving Claim: The claim
that remains once the alias claims are combined.
It is the policy of BWC to identify and
combine duplicate claims in a manner that avoids or corrects overpayments and
creates one complete and accurate claim.
1. BWC staff will
refer to the Standard
Claim File Documentation and Altered Documents policy and
procedure for claim note and documentation requirements; and
2. Must follow any
other specific instructions for claim notes and documentation included in this
procedure.
1. Claims may be
considered duplicate when they contain the following identical elements:
a. Injured worker’s
name;
b. Social security
number;
c. Risk/policy
number;
d. Date of occurrence.
2. Duplicate
claims may be identified as follows:
a. The claims
management system provides an alert of a duplicate or potential duplicate
claim;
b. An Industrial
Commission (IC) order identifies one or more claims as duplicate;
c. BWC staff
identifies a potential duplicate while conducting a name and social security
review;
d. Notification
from the MCO;
e. The
Automatic Claims Processing (ACP) Potential Dupe Same Policy flag;
f.
A duplicate claims report that has been posted to the IMS/EMS
SharePoint Cognos Reports folder; or
g. Parties
to the claim.
1. Prior
to resolving duplicate claims issues, claims service staff shall determine if a
duplicate customer record exists.
2. If
a duplicate customer is discovered, claims service staff shall determine which
customer’s information is correct and address the discrepancy.\
3. If
the customer record for the IW in which the error(s) occurred contains more
than one claim for the IW, claims service staff must review all claims attached
to that customer record and move all of the claims to the remaining viable
customer record before flagging the incorrect customer records as “DO NOT USE”.
4. Once
the discrepancies are reconciled, one customer record will be the surviving
customer and one shall be updated to reflect “Do Not Use” and have a Block set
for “invalid customer.”
5. The Duplicate
Claims and Customers CoreSuite job aid provides detailed steps on how to process
duplicate customer issues.
1. After resolving
duplicate customer issues, claims service staff shall investigate indicators of
potential duplicate claims as referenced in Section V.C. above.
2. When duplicate
claims have different employers, claims service staff shall investigate to
determine the correct employer for each claim.
3. If the
investigation reveals that two employers employed the IW and the accident
descriptions are different, then claims service staff shall process the claims
separately.
4. If the
investigation reveals that both claims should have the same employer, and the claims are duplicates in all other respects,
claims service staff shall:
a. Make the
employer correction following the procedures outlined in the Initial Claim Determination procedures
if the claim with the incorrect employer has not yet been determined; or
b. Make the
employer correction following the procedures outlined in the Changing the Employer and or
Policy Number after Initial Determination procedures if the
claim with the incorrect employer has been determined; then,
c. Refer to
Appendix A below to determine the appropriate action.
d. Notify the
identified employers of the findings.
1. If potentially
duplicate claims with different accident types have been allowed, BWC staff
shall discuss potential continuing jurisdiction with the BWC attorney.
2. If the
potentially duplicate claims with different accident types have not been
determined, BWC staff shall investigate to determine the appropriate accident
type, make a determination and then refer to Appendix A for further action.
3. If the
investigation does not clearly reveal the correct employer and the claims
appear to be duplicates in other respects, BWC staff shall staff the claim with
the BWC attorney for further direction.
1. BWC staff shall
combine verified duplicate claims or decombine claims in the claims management
system pursuant to the instructions in the CoreSuite Training manual and/or the
“Duplicate claims/duplicate customer” CoreSuite job aid available on the
Duplicate Claims policy page on COR.
2. Claims shall be
combined into the earlier filing date, unless:
a. Compensation
has been, or is being paid in one claim and not the other, then the claims
shall be combined into the claim in which compensation has or is being paid;
b. The IC has
issued an order outlining how BWC shall combine the claims;
c. Both claims
were filed within the statute of limitations and circumstances make it more
efficient to combine the claim into the later filed claim. E.g., one claim has
more information than its duplicate; the claim may be combined into the claim
with the most complete information.
d. Compensation is
paid in more than one claim.
i.
If
duplicate records exist, claims services staff shall select the claim that has
the most compensation paid as the surviving claim.
ii. Claims services
staff shall stop compensation in the alias claim(s), send a subsequent order
and adjust compensation in accordance with the Adjustment of Overpaid Compensation policy and procedure.
3. When
combining duplicate claims, claims services staff shall confirm that the alias
claim(s) is properly associated with the surviving claim.
4. Claims services staff
shall decombine claims when either of the following occurs:
a. The IC orders
it; or
b. Claims services
staff combines claims in error. In this case, a BWC order is not required.
1. If claims
services staff identifies an overpayment of compensation because of claim
duplication, claims services staff shall follow the procedures set forth in the
Adjustment of Overpaid Compensation policy and procedure. Claims services staff shall
not combine duplicate claims until the subsequent order is issued and the
appeal period expires.
2. If claims
services staff identifies an overpayment of medical bills because of claim
duplication, claims services staff shall follow the procedure set forth in the Claim Cost Adjustments policy and procedure.
|
Claims
are considered duplicate when they have the same:
- Injured
worker name;
- Policy
number;
- Date
of injury; and
- Accident
description.
Claims
services staff must also review the customer records on the possible
duplicate claims prior to determining if the claims should be combined. It
may also be necessary to combine the customer records. If each claim has its
own customer record, the customer records must be updated and combined prior
to combining the claims.
|
|
Claims
Statuses
|
Action
Required
|
|
Pending
and Pending
|
If
the claims meet the criteria in the introduction section above, claims
service staff will combine the claims. If each claim has its own customer
record, the customer records must be updated and combined prior to combining
the claims.
|
|
Accepted
and Pending
|
An
investigation must be conducted to determine if the accident and time of
injury are the same. If the claims meet the criteria in the introduction
section above, claims service staff will combine the claim in pending status
into the accepted claim. If each claim has its own customer record, the
customer records must be updated and combined prior to combining the claims.
|
|
Accepted
and Denied
|
Claims
services staff must staff with BWC attorney for continuing jurisdiction when
both claims are in a final status, and one is allowed, and the other is
denied.
|
|
Accepted
and Accepted
|
If
the parties agree and it meets the criteria in the introduction above, in
addition to being allowed for the same conditions, claims services staff may
combine the claims. If each claim has its own customer record, the customer
records must be updated and combined prior to combining the claims.
If
both claims are not allowed for the same conditions, staff the claims with a
BWC attorney.
If
the parties do not agree, the claims must be staffed with a BWC attorney for
continuing jurisdiction.
|
|
Accepted
and Accept/Appeal
|
If
no appeal has been filed to the claim in accept/appeal, the parties agree, it
meets the criteria in the introduction section above, and the allowed
condition(s) are the same, claims services staff may combine the claims. If
each claim has its own customer record, the customer records must be updated
and combined prior to combining the claims.
If
no appeal has been filed to the claim in accept/appeal, the parties agree, it
meets the criteria in the introduction section above, but the allowed
condition(s) are the different, claims services staff must staff the claims
with your supervisor and, if necessary, a BWC attorney.
If
an appeal has been filed to the claim in accept/appeal or the parties do not
agree, the claims must be staffed with a BWC attorney.
|
|
Accepted
and Deny/Appeal
|
When
one claim in accepted status and one is deny/appeal status the claims must be
staffed with your supervisor and a BWC attorney.
|
|
Denied
and Pending or Accept/appeal
|
Staff
with a BWC attorney. The subsequent pending application may be a request for
reconsideration of claim allowance. If the accident and time of injury are
the same, then the claims may fit the “Greene Court Case” fact
pattern.
|
|
Accept/appeal
and Denied/appeal
|
When
one claim in accept/appeal status and one is deny/appeal status the claims
must be staffed with your supervisor and a BWC attorney.
|
|
Dismissed
and Pending
|
See
the detailed instructions regarding re-filing
a dismissed claim in the Initial Claim Determination
policy.
|
|
Dismissed
and Accepted or Denied
|
An
investigation must be conducted to determine if the accident and time of
injury are the same. If the claims meet the criteria in the introduction
section above, combine the dismissed claim into the claim that has been
determined. If each claim has its own customer record, the customer records
must be updated and combined prior to combining the claims.
|
|
Dismissed
and Accept/appeal or Deny/appeal
|
An
investigation must be conducted to determine if the accident and time of
injury are the same. If the claims meet the criteria in the introduction
section above, if no appeals are filed, claims service staff must review all
evidence in each claim to determine if information in the dismissed claim
would impact the pending decision that was made. The claims must be staffed
with your supervisor and a BWC attorney.
|
|
Hearing
and any other status
|
Staff
with the BWC attorney.
|