Standard Claim
File and Altered Documents General Information Checklist
a. Injured
worker (IW) demographics, such as, but not limited to:
i. Name;
ii. Address
and phone number;
iii. Social
security number;
iv. Gender;
v. Date
of birth;
vi. Marital status;
vii. Number of dependents;
viii. Length of employment;
ix. Secondary
employment; and
x. Date
of injury, disease, or death, as applicable.
b. Employer
demographics, such as, but not limited to:
i. Name
(primary and doing business as);
ii. Policy
number;
iii. Address,
contact name, phone, and fax number;
iv. NCCI manual
classification code; and
v. Certification.
c. MCO
demographics, such as, but not limited to:
i. Name;
ii. MCO identification number and effective date; and
iii. Address,
contact name, phone, and fax number.
d. Provider
demographics, such as, but not limited to:
i. Name;
ii. Provider
identification number and effective date; and
iii. Address,
contact name, phone, and fax number.
e. IW
Representative and Employer Representative Information:
i. Representative
identification number;
ii. Address,
contact name, phone, and fax number; and
iii. Effective
date of authorization as a representative.
2. Claim
Level Information
a. Accident
or illness demographics, such as, but not limited to:
i. Narrative
description of accident or illness;
ii. Part
of body injured;
iii. Filing
date; and
iv. Narrative
description of diagnosis and ICD code.
b. Documents
and reports related to the claim, including, but not limited to:
i. Applications
(e.g., C-84, C-86, Medco14, C-92);
ii. Job
description;
iii. Medical
summaries and diagnostic test results;
iv. Rehabilitation
information;
v. Light
duty and transitional work availability and other information;
vi. Claim notes; and
vii. Any other information
that assists in managing the claim.
3. Compensability
Information:
i. Benefit
type code;
ii. AWW;
iii. FWW;
iv. MMI date; and
v. RTW
date.