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Policy and Procedure Name:
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Insurance Service Office
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Policy #:
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CP-09-04
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Code/Rule Reference:
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N/A
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Effective Date:
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05/06/19
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Approved:
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Kevin R. Abrams, Chief Operating Officer
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Origin:
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Claims Policy
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Supersedes:
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CP-09-04 effective 04/19/19
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History:
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CP-09-04
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Rev. 04/19/19; 11/14/16; New 07/10/13
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CP-09-04.PR1
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Rev. 08/09/13; New 07/10/13
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Insurance Service Office Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Insurance Services Office (ISO)
IV. POLICY
A. Investigation Tool
B. Disclosing ISO Report
Information
C. ISO Impact on Claim
Decisions
V. PROCEDURE
A. Standard Claim File
Documentation
B. ISO Report Requests
C. Utilization of ISO
Reports
D. Reviewing the ISO Report
E. Confidentiality and
Using the Information from ISO
F. Communications with ISO
Members
G. BWC Job Aid
The purpose of this policy is to ensure that BWC staff
properly obtain and utilize Insurance Services Office information during the
life of a claim.
This policy applies to all BWC staff.
Insurance
Services Office (ISO): A confidential data bank that contains bodily
injury claim information on automobile, workers’ compensation, homeowner,
general liability, product liability and disability insurance injury claims for
the last ten (10) years.
A.
Investigation Tool - It is the policy of
BWC to use ISO as an investigative tool to combat fraud, recognize and pursue
subrogation rights and reduce the overall cost of workers’ compensation claims.
B.
Disclosing ISO Report Information - Information from the ISO report
will not be disclosed to any individual or entity other than BWC staff involved
in investigating the claim, or the insurance company, or other entities that
provided the information.
C.
ISO Impact on Claim Decisions - A claim will not be denied based
solely on the information received from ISO, although BWC will consider all
evidence in the file to determine eligibility and compensability.
D. It is the
policy of BWC to run ISO reports on state fund and bankrupt self-insured claims
only.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note requirements; and
2. Shall
follow any other specific instructions for claim notes included in this
procedure.
1. Types of
ISO Report Requests
a. Automated
request – An ISO cross-match search that starts automatically once a new claim
is entered in the claims management system.
b. Manual
request – An ISO report request that is submitted manually in the claims
management system by BWC staff on a pre-existing claim.
c. Requested
ISO reports are automatically indexed into the claim document folder, under
“doc type confidential” in the document management system.
2. Timeframes
for Receipt
a. ISO reports
are viewable in the claim management system on the fourth (4th) day after the
request.
Example: If
claims services staff requests an ISO report on Monday, claims services staff
will not see the ISO report and work item in the claims management system until
the following Friday.
b. ISO report
timeframes include weekends.
Example: If
claims staff requests an ISO report on Friday, claims services staff will see
the ISO report and work item in the claims management system the following
Tuesday.
3. Storing of
Requested ISO Reports
a. The ISO
report will be automatically imaged into the confidential file of the claim;
and
i. If ISO
detects a hit, a work item will generate to the claims services staff member
assigned to the claim at the time of the hit; or
ii. If there
is not a hit, the ISO report will be imaged into the claim without a work item
being generated.
b. Claims
services staff may also review “Interface Requests” in the claims management
system to determine if an ISO report was generated.
1. Initial
Determination - During the initial investigation, claim services staff may
review the automatically generated ISO report to further investigate incidents
that may impact the claim such as duplicate claims filed in other jurisdictions,
separate accidents with related medical conditions, or potential third-party
involvement.
2. Additional
Allowance or Claim Reactivation – For a request for an additional allowance or
for claims reactivation, claims services staff may request an ISO report when:
a. There has
been no recent activity in the claim;
b. The
medical evidence or other documentation in the claim file identifies
intervening injuries that may not be related to the current worker’s
compensation claim; or
c. The
severity of the additional condition being requested appears to be greater than
what could have been caused by the current claim.
3. Lump Sum
Settlement (LSS)
a. The LSS
claims services staff may request an ISO report whenever LSS claims services
staff determines it may be useful in valuing and negotiating the settlement
agreement.
b. Please
refer to the Lump
Sum Settlement policy and procedures on COR for additional information.
4. Death
Benefits
a. When
claims services staff receives a request or recommendation for death benefits,
claims services staff may request an ISO report, if a previous non-work-related
injury appears to be related to the IW’s death.
b. Example: A
person has a car accident on a Thursday and is diagnosed with a concussion. The
car insurance covers the accident and injury treatment costs. The person goes
back to work the following Monday and hits his/her head on a desk while falling
on the floor at work. The person dies immediately afterwards. The family of the
deceased files for workers’ compensation death benefits. In this case, claims
service staff may need an ISO report to uncover information about the car
accident and whether it was related to the ultimate death of the IW.
5. Fraud
a. Special
Investigations Department staff may manually request and receive ISO reports
when investigating:
i. Workers’
compensation claims fraud;
ii. Medical
provider fraud; and
iii. Premium
fraud.
b. Please
refer to the Fraud
Special/Investigations policy and procedures on COR for additional
information.
6. Subrogation
a. Claims
services staff may request an ISO report after the initial determination of the
claim if subsequent questions regarding potential subrogation issues are
identified in the claim.
b. Claims
services staff shall review any ISO reports received to identify any potential
for subrogation and make a referral to the Subrogation Department, if
appropriate.
c. Please
refer to the Subrogation
policy and procedures on COR for additional information.
7. Other – Claims
services staff may request an ISO report at any other time it is determined
that such report could provide useful information for claims management.
Example: sudden or significant increase in treatments has occurred that appear
unrelated to the claim.
When an ISO report
reflects a match, claims services staff responsible for managing the claim
shall review the report and:
1. Determine
if there are potential patterns to the types of claims filed by the IW;
a. Are there
multiple reported injuries?
b. Is there a
pattern to the type of injuries reported?
c. What types
of claims are reported?
2. Evaluate
the information to determine if the matched data does or could have an impact
on a current or past BWC claim;
a. If
there is an injury listed in ISO with a date of injury that could be reasonably
related to the workers’ compensation claim: Is the IW submitting medical bills
for the same injury to BWC and the other ISO member?
b. The
body parts affected in each claim: If the claims involve related body parts,
the claims services staff shall advise the managed care organization (MCO) of
the related accident date and injuries so the MCO may inform the provider.
3. Evaluate
the information to determine if there are red flags that warrant a fraud
referral (See the Fraud
Special/Investigations policy and procedure);
4. Evaluate
the information to determine if there are indicators that warrant a referral to
the BWC Subrogation Unit (See the Subrogation
policy and procedure); and
5. Consider
whether other information on the report may be relevant to a claim including,
but not limited to:
a. Workers’
compensation claims in another state;
b. Insurance
claims through other policies (i.e., auto, homeowners, liability, workers’
compensation or medical claims);
c. Causes of
other injuries and liability for those injuries; and
d. Treating
providers and/or representatives in the IW’s other claims.
1. Claims
services staff shall not share the ISO report itself with any party or entity
outside of BWC staff involved in investigating the claim.
2. Claims
services staff shall not deny a claim based solely on the information received
from ISO. Claims services staff shall weigh all the evidence in the claim when
determining eligibility and compensability.
3. Claims
services staff shall refer to the Sensitive
Paper Record Handling policy on
how to protect confidential hard copy ISO reports received via email, files,
printouts, electronic copy, etc.
1. Claims
services staff may contact other ISO members to obtain basic information
regarding a claim filed with that member. For general inquiries, claims
services staff may also email ISO at njsupport@iso.com
or call 1-800-888-4476.
2. As
applicable, claims services staff shall ask the ISO member:
a. What is
the current status of the ISO member’s claim and what type of claim is being
handled (e.g., auto, homeowner, workers’ compensation)?
b. Is the
claim still open? If the claim is open, has the IW recently requested an
additional allowance?
c. What is
the name of the doctor, hospital and attorney associated with the claim?
d. If the
claim is closed, how and when did it close? Was the claim closed through
settlement or due to the statute of limitations?
e. Was the
claim denied and if so, for what reason?
3. If claims
services staff is contacted by an ISO member for information, claims services
staff shall obtain a signed release from the IW before sharing any BWC claim
information.
4. Claims
services staff shall direct any questions regarding the use of ISO information
to a BWC attorney.
G.
BWC Job Aid - BWC staff shall refer to the ISO Claims Match Job Aid
located on Claims Online Resources (COR) for outlined processes to
manually request an ISO report.