Workers Compensation Claims Admin Overview - chubb.com

1 Claims Services Workers Compensation Claims Administrative Overview chubb s 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 chubb s 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 chubb s associations with Preferred Provider Networks (PPNs) in many states.

2 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 notice/report of a potential Workers Compensation loss from the employee. Claims can be reported through several service channels: Online: chubb s Website at com (see Exhibit A for directions).

3 Phone: 1-800-699-9916 Fax: 1-800-884-3946 Claim Assignment Medical Only For minor injury Medical Only Claims , our systems include sophisticated business rules that ensure timely claim resolution. In the event escalation 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. Medical Only Claims exceeding the minor injury threshold are assigned to chubb s Medical Only unit.

4 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 chubb s 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.

5 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, accident/investigation reports, the completion of a wage statement, or other documents.

6 chubb s 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. chubb s 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.

7 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 chubb s Workers Compensation Managed Care Program, employees receive medical care provided in accordance with approved techniques for specifying and monitoring treatment.

8 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. 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 Scripts (ESI), except in Texas where chubb uses Corvel s CorCareRX. Some of the key benefits of a PBM include: Reduction of out-of-pocket expenses when injured Workers obtain prescription drugs for compensable injuries.

9 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. ESI covers the cost of the first fill if the claim is not deemed compensable at no cost to the insured or to chubb . Patient safety and injury-specific formulary, where only those drugs that are appropriate for the injury are dispensed to the injured worker . Appropriate utilization of generic drugs versus brand name drugs where allowed.

10 Mail order capability for long-term use of prescription medications. 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: Point of sale edits utilized to address opioids prior to dispensing. Combining advanced analytics and investigative outreach to detect and deter potentially fraudulent activity. Proactively identifying and managing excessive use of opioids early in the claim.