Claims

This chapter describes the ATS features that are
provided to help you manage claims as easily and efficiently as possible. Since
keeping notes is an integral part of the job, this feature is also covered in
this chapter.

Entering a New Claim

Users with the appropriate access rights may use the New Claim
item from a menu or click the New button on a Claim
Result List to begin entry.

The system will first ask you to select an employee.
Entering a last name that starts with “smith” will generate a list of employees
with names like Smith, Smithy, Smithies, and Smithers. A first name or any of
the other options may be entered to limit the choice list.

Figure 5‑1: Claim Search Criteria

A record for the employee must exist before you can
enter a claim. If one cannot be found, click New. When you Save
and Close the Employee data entry page, you will be automatically
returned to the Claims page and asked for the State of Jurisdiction for the claim.

Figure 5‑2: State of Jurisdiction Dialog

Click the Select button
and the Claim data input page will appear. The screen shown below is the
standard one provided by ATS. It contains all of the fields necessary to submit
subsequent Reports of Injury to the State of Jurisdiction for both IAIABC Release 1 and 3.

The required fields appear in yellow by default.  A system administrator may have set others as
required. The default labels for the levels in your company’s hierarchy are
Division,
Dept and Sub. Those on your screen have
probably been changed using the Application Parameters page.

Figure 5‑3: Claim Page – General Section (New)

All
of the information displayed above was taken from the employee’s record. The
personal information may not be edited from within the claim. If you need to
make a change, click the Ellipsis … button next to the Last
Name.

It is important to note that the name the employee is
known as in the ATS system may not be the person’s legal name.  If that is the case, be sure to enter the
name as known by the Social Security Administration in the employee record when
the claim will be submitted to the CMS.

The fields in the General section that are not
read from the employee’s record are described as follows.

Field Name

Description

Adjuster

The
user entering the claim is assigned as the adjuster by default.

Claim Type

Valid claim types are indemnity, medical,
first aid which is treated as a medical claim on most reports, and notation
which may be used to track an incident that has not become a claim.
(Notations are not included in the standard ATS reports.)

If
there  are  indemnity
reserves,  the
claim  type  will
be  changed  to “INDEMNITY” when the claim is saved.

Injury
Date

The
date the injury or illness occurred is required.  A warning is displayed if the date is over
six months ago.  When there is an
existing claim for that date, review the pertinent information on the other
claim to determine whether you are entering a duplicate claim.

If
the Policy module is in use, the program will search
for one that covers the fiscal year in which the injury occurred. When the
Administer-Configuration- Module Parameters menu has been used to enter a
Policy Form, but the Policy Format field is empty, the program will search
for a policy for a specific level, starting with the employee’s level 3
through 1, that covers the date the injury occurred (e.g. L101-2010).

If
a policy is not found for a level, the program will attach the first one it
finds that covers the date. The Tools-Policy menu may be used to select a different one
if necessary.

The
following Policy Formats may also have been used to specify
which policy should be assigned to the claim:

1.    @YR-L1 or @L1-YR: Searches for a policy
for the specified year and level 1 (e.g. 2010-L101).

2.    @ST-YR<L#: Uses the state code from
the specified level (1 thru 3) and the year to search for a policy (e.g.
FL-2010).

3.    @ST-YR: Uses the code for the state of
jurisdiction and the year to search for a policy.

When
a policy is found, the program will display the code in the window’s title
bar and write the Deductible on the Financial page.

If
a policy is not found, a message will appear to indicate that the claim
cannot be saved.

Injury
Time

The
(military) time the injury occurred in an HHMM format. This data is not
required, but if it is entered a special claim analysis may be run from the
Reports-Statistical menu.

CMS Date of Injury

The
CMS expects the date of accident or the first
exposure, ingestion, or implant. This may not be the date after which you are
legally responsible. The CMS needs the actual date for any recovery claims.
An approximate date is OK as long as it’s before the person’s date of
entitlement to Medicare. If this field is
empty, the program will automatically export the Injury Date.

First
Report

The
date the employer submitted the First Report of Injury.

Report
Date

The
date the employer was notified of the injury. This is usually referred to as
the knowledge date.

Death
Date

The
date of death should be entered when relevant. Note that in fatality cases,
we recommend that the employee’s beneficiary be set up as a dependent to facilitate the payment process.

Cause of Death

Indicate
if the death was due to the injury, not related to the injury or unknown.

Full
Denial Date

The
date the claim was denied.  This date
is required when submitting a SROI for a full denial to the state.

Denial
Rescinded

The
date the denial was rescinded.

Open
Date

The
date the claim was opened is a required field.  By default, the program will enter the
current date.

Closed
Date

The
date the claim is closed.  Refer to the
Closing a Claim section for details on using this feature and how the reserves are affected.

Reopen
Date

A
closed claim may be reopened by deleting the Closed Date and saving the record. The current date will
automatically be displayed as the Reopened Date.

Start
TD

The
program will determine the date of compensation from the first indemnity or
rehab payment where the Grouper contains TD.  The date will be adjusted if the payment is
voided later.

This
date cannot be edited as it may be used in determining the number of lost
days to report on the OSHA log.

If
you plan on entering TD payments manually instead of using the AutoPay module, the Administer-Configuration-Diary/Scan menu may be
used to set up diaries to let the adjuster know when the payments are due.

Stop
TD

The
date temporary disability benefits end.

Start
PD

The date of the first indemnity payment where the Grouper contains “PD”.

The
date will be adjusted if the payment is voided later.

If
PD payments are issued manually, the Diary Scan utility may be used to set up diaries
to notify the adjuster when they are due.

Stop
PD

The
date permanent disability benefits end.

Dependents

The
number of dependents added to the claim with the Tools-Dependents menu is displayed for informational
purposes.  Since this feature is used
in states where dependents affect the benefit rate, the Benefits dialog will
appear whenever this number changes so the rate may be adjusted accordingly.

Basic
Pay

The
employee’s salary without any fringe benefits.

Average Weekly Wage

The program will calculate and display the
average weekly wage based on the information in the employee's record.

The
Wage View flag may have been set with the
Administer-Configuration- Module Parameters menu to hide either the wage for
all claims or all except for indemnity.

Wage Effective

The
date the specified wage became effective.
This may be a required field when submitting a SROI in IAIABC Release 3.

Benefit Type

This value determines which rate table is
used to calculate the benefit.

Typically,
the choices are TD (temporary disability), PD (permanent disability) or VR (vocational
rehabilitation), but others may be available depending on the state of
jurisdiction.  If blank, TD benefits are calculated by
default.

Note
that this field is required in order to use the auto feature when making a
new payment.

Benefit

The weekly comp benefit rate for the state
of jurisdiction may be entered manually or calculated by
clicking the button to display the Benefit Calculator. Items such as the number of
dependents entered with the Tools- Dependents menu, Other Income, the COLA amount, and the
Benefit Adjustment are taken into consideration depending on the state’s
guidelines. (See the Benefit Type description for more information.)

In some states such as Virginia, a COLA
Requested box will appear in the top, right-hand corner. If the box is
checked to indicate that the employee wants COLA to be included in the
benefit payments, you may redisplay the dialog to see the date it was
requested by clicking the Ellipsis button.

<<GRAPHIC:
Benefit Calculator Dialog>>

The
following illustrates how the calculations are made:

Original
Weekly Amt  =
Weekly Wage x Benefit rate

587.48
= 766.28 x 76.667

Final
Weekly Amt = Original Weekly Amt
x Increase Multiple

613.92=
587.48 x 1.048

Weekly
Increase = Final Weekly Amt - Original Weekly Amt

26.44 = 625.68 - 587.48

Alternate Claim Number

When you save a claim for which auto
payments have been scheduled and the benefit rate has been adjusted, you will
be asked if those payments should be changed. If so, use the Tools-AutoPay option and adjust the amount. When the
state’s benefit rates change, you may run the BENFITUP program to update the
claim and payments scheduled with AutoPay
accordingly.

This
field may contain a claim number that was used in a prior workers'
compensation package. ATS refers to it as the alternate claim number which is
available for lookup purposes.

Medicare Beneficary

A
check will indicate that the employee is a Medicare beneficiary. Note that this box may be
checked while processing a Query Response from the CMS.

HICN

Medicare’s health insurance
claim number.

ORM Assumed

A check indicates that the Responsible
Reporting Entity (RRE) has assumed
ongoing responsibility for medicals (ORM).  It’s important to understand the reference
to "ongoing" is not related to "ongoing reporting" but
rather the RRE’s responsibility to pay on an ongoing basis for the injured
party’s medicals associated with the claim. This typically only applies to
no-fault and workers’ compensation claims.

You
will not have this box on your screen if all your claims are adjudicated in a
state such as New York that mandates that employers assume ORM for the claimant’s lifetime. (The CMS Export program will check the state record
to determine if ORM applies to all claims in that jurisdiction.)

Note:
Once a claim with ORM has been submitted, the box must remain
checked when sending subsequent reports.

ORM Terminated

The date when ALL responsibility for
medicals has ended and there is no possibility that the claimant will
submit/apply for payment of additional medicals related to the claim.
See Sections 11.8 and 11.9 of the CMS User Guide for information concerning
extensions/exceptions regarding reporting ORM.

Note
that future dates will be accepted, but the date must not be more than six
months from the date of injury. A claim with ORM may be closed in the ATS system, but CMS regards it as still open until an update
report is sent with the ORM Termination Date. Normally, you would need to
continue to monitor claims when the state of jurisdiction mandates ORM benefits for the claimant’s
lifetime, but the CMS will recognize a statement from the treating physician
stating that no further medicals are expected. In that case, the ORM claim
can be terminated.

CMS Batched

ATS
keeps a history of all reports that have been batched and/or sent for a
claim. This history can be viewed from the CMS Batch option on the Bridge menu. This check box is
only on the screen for your reference.

The standard Details section is shown below with a
sample record. Although your screen may have been tailored to meet your needs,
most of the fields will probably be the same.

Figure 5‑4: Claim Page – Details Section

Normally, the Cause, Nature and Body Site fields are the only ones that are required
since the information is needed on many state-mandated forms. (The labels for
the loss codes may have been changed on your screen using the
Application Parameters screen.)

If
the Employer’s Report module is in use, some of this information
such as the loss codes and the county/state where the injury or
illness occurred will have been transferred when the report of injury was
promoted to a claim.

The fields on this screen are described as follows. It
should be noted that a number of fields on the page pertain to the OSHA 300 log. A document that covers this feature
in detail is available from ATS support.

Field Name

Description

Agency

The
source of the injury or illness such as slippery floor. This data is not
required, but may be entered to break down the injury in more detail.

Cause

The
cause or reason for the injury such as slip and fall is normally required.

ICD-9 Cause

This is the ICD-9 classification code for the cause of injury.
There is a very detailed list with
more than 1,200 codes from which to choose.
Since we can’t make it shorter, we suggest that you contact ATS
support, request a copy of the list, find the codes you normally use, and
make a quick reference chart.

This
code is required when reporting to the CMS after January 1, 2011.

Nature

The
nature of the injury such as sprain or fracture.

Body
Site

The
FIRST part of the body that was injured.
Use the Multi Body Parts button to enter additional body parts.

ICD-9 Diagnosis

This is the ICD-9 diagnosis code for the first body part that
was injured.  Up to 19 codes may be
exported.  Use the Multi Body Parts feature to enter the other parts and the
associated ICD-9 diagnosis codes.  Note
that only the Site and ICD-9 codes will be exported.  The nature and impairment percentage is
optional.

<<GRAPHIC: Multiple Body Parts Dialog>>

To
modify an entry, highlight it, update the data, and click Save
to move the item back to the grid. To remove an entry, highlight it, and
click the red X.

PERI Cause Code

There
are up to four elements in a PERI cause code. If you are a public entity that
uses this feature, click the Ellipsis button to enter the codes in order:
level 1 through level 4.

Location

The
code for the location of the accident may be selected from a list of items
entered with the Maintain-Industry-Location menu. (This is the Location that
appears in one of the columns on the OSHA 300 log.)

County
/ State

The
county and state where the injury or illness occurred. Note that the State is
required when using the ISO Export utility.

Last
Worked

The
last day the employee worked before the current disability began.

Current Disability Started

The first day the employee was off work due
to the injury or illness. This date will be read when using the Auto
Compensation button to schedule payments with the AutoPay module.

This
date and the RTW date will also be used to determine the
number of lost OSHA days for medical only claims and time loss
cases where the employee returned to work before the waiting period ended
(and payments would have been issued).

RTW Date

The
date the employee returned to work. (See the OSHA note above.)

RTW Type

Valid
entries are actual or return to work to indicate
whether the RTW Date is the actual date the employee
returned to work or was released to return to work.

RTW with Restrictions

A
check indicates that the employee returned to work with restrictions.

Restricted
Work Days

The number of restricted or light duty days
may be entered using the Tools- Restricted Work Days menu option. Save the details in the dialog
and the program will update this field automatically. (This feature is
covered in the Tools Menu section.)

Note that according to the OSHA 300 guidelines, all restricted work days are
recordable. Transfers to another job due to the injury or illness must be
added to the restricted days for reporting purposes. Although a first job
transfer may be recorded in the TW Start and TW End fields, the Tools-
Restricted Days menu should be used to enter any subsequent period(s) in the
From/Thru Dates with “Job Transfer” as the Restriction.

Suspension Effective Date

The
date the suspension became effective will be exported to the state when
reporting a suspension.

Suspension Reason

The
reason for the suspension.

MMI Date

The maximum medical improvement (MMI) date is required
when using some of the MTC codes in the EDI export file to be transmitted to the state.

The
MMI date is also a statutory requirement in some
states such as Florida. When this date is reached, a popup message will
appear when saving a new payment for the claim. If you click "Yes"
to continue, a $10 copayment should be applied to doctor's visits paid to the
employee on or after the MMI date. If "No" is selected, the
operator will be returned to the check payment form.

P.
I. Percent

The percentage the employee is permanently
disabled.

Some
screens may also allow you to enter the date the employee became permanent
and stationary.

P.
I. Minimum

A
check indicates that payments are made for a minimal amount if a final rating
is not available.

TW Start

The date the employee started transitional
work should be entered if the person was
transferred to another job due to the injury or illness. If the employee has
had multiple job transfers, use the Tools-Restricted Days menu to enter the
subsequent period(s) in the From/Thru Dates with a note such as “Job
Transfer” as the Restriction.

Note
that according to the OSHA 300 guidelines, the number of days doing
transitional work will be added to the restricted work days
for reporting purposes.

TW Review

The
date to review the transitional work.

TW End

The
date that the transitional work ended.

OSHA Days

Since the OSHA 300 was implemented, both OSHA Days
restricted days are based upon calendar days.

The
OSHA Days field will always be empty in medical
only claims or when the employee returned to work before the waiting period
expired. In those cases, the days lost are calculated using the employee’s
Current Disability Began (First Day Off) and Returned to Work dates. (A
technical note on producing the OSHA 300 is available from ATS support.)

The
number of lost OSHA days for an indemnity claim are normally
updated as payments are made against reserve categories 1 and 3 (indemnity
and rehab) for pay codes with “TD” in the Grouper
field.

If
the claim is in a state or federal jurisdiction that tracks loss of earning
power, temporary disability payments will need to be made with a pay code
that contains I08 (wage loss) so the days will be ignored when reporting lost
days to OSHA. For example,
someone working another job or the same job with a restriction that pays less
than their usual salary would get a comp payment to make up the difference. If this feature
is not used, the days would be counted as both restricted and lost time on
the report.

Note:
Auto payments will not update this value until the payments are batched.

OSHA Code

If
the claim is for an occupational illness or disease, enter the appropriate
OSHA code for reporting purposes.

Privacy
Case

A
check in this box indicates that the employee’s name should not be displayed
on the OSHA 300 Log.

Recordable

By
default, all claims must be reported to OSHA.  Remove the check from this box if the
employer has determined that this claim is not recordable and should not
appear on the log.

Injured
at Work

A
check in this box indicates that the accident or illness occurred on the
employer's premises. Although this information is not required, it may be
useful in custom management and/or safety reports.

Wage Continued

A
check in this box indicates that the employee is receiving his/her payroll in
lieu of worker’s compensation benefits.

Serious
& Willful

A
check will indicate that the accident is considered serious and willful.

Hospitalized

A
check will indicate that the employee is/was hospitalized due to the accident
or illness.

Rehabilitation

A
check will indicate that the employee is/was receiving vocational
rehabilitation services.

Broken Waiting Period

A check will indicate that the waiting
period was broken. An option on the Tools menu may be used to track the time
missed. Your screen may have been customized to display this value.

Please
refer to the Using the Tools Menu section for details on how to use this
feature.

NCCI Injury Code

The
type of injury code related to the injury or illness is required for some
state reports. Click the Ellipsis button to list the codes that have been
entered with the Maintain-Carrier Tables-NCCI Type of Loss menu.

Subrogation

A
check in this box indicates that the claim is in subrogation or that the
possibility for recoveries exists.

Litigation

A check in this box indicates that the
claim is or may be in litigation. This box will automatically be checked when
a legal firm has been entered for either the claimant or the defense.

These
claims will be identified as "LEGAL" on some of the standard
reports.

Longshoreman Act

A
check in this box indicates that this is a federal claim covered under the
Longshoreman Act.

Include
on SI-4

A
check indicates that this claim should be included on New York’s SI-4 report.

Became
Lost Time

This
box should be checked if the claim was initially medical only before becoming
a lost time case.

Second
Injury Fund Date

The
last day to apply for reimbursement from the state’s second injury fund if
applicable.

Injury
Description

The
description of the injury.  Note that
the first fifty (50) characters of the description will be exported to the
CMS for Medicare beneficiaries. It should describe the cause
of the incident and the body parts that were injured. The description is
required through December 31, 2010 if no ICD-9 cause and diagnosis codes are provided.

The Reserves section is used to track the amounts reserved,
paid, and outstanding.  In addition, the
fields in the lower portion of the screen may be used to enter the name and
address of the party involved in subrogation.  Later, this information can be retrieved when
making a recovery using Finance features.

The standard screen shows six categories, but the last
two are optional. The number of categories is set with the Application
Parameters menu. The names of the categories and the
default reserve values for new indemnity and/or medical claims are entered on
the Reserve Types maintenance page.

Normally,
reserves may either
be entered manually in the Incurred fields or by selecting the Reserve
Worksheet button to display a special worksheet that
calculates reserves based upon making specific payments.  Depending on how your system has been set up,
you may only be able to use the worksheet. (See the Reserve Worksheet section
later in this chapter for details.)

A worksheet is also available if you use the Stanford Reserve
Estimate which calculates the reserves based upon the Nature and Body Site codes in the claim. (Stanford Reserves are entered using the User Tables maintenance
page.)

When a payment is made, the amount Paid is updated and
subtracted from the Incurred. The Future Reserves and Totals are adjusted accordingly. Credits and voids will be subtracted from the amount
paid, but recoveries won’t be. Any Recoveries are recorded separately.

Figure 5‑5: Claim Page – Reserves Section

When you save a claim, the program will check for any
changes to the reserves.  If any have been made, a dialog will be
displayed so you can indicate the reason for making the change(s).  The sample change codes shown below were
entered with the Reserve Change option on the Reserve/Payment/Recovery maintenance
page.  After the record has been saved,
the amounts on the screen will be updated.  Later, these transactions may be viewed with
the Reserves History button.

Figure 5‑6: Reserves Change
Reason Dialog

Note
that the Claim Type will automatically be changed to “INDEMNITY”
if there are any indemnity reserves.
If any other type of reserves is entered and the Claim Type is “NOTATE ONLY”,
it will be changed to “MEDICAL.

The Medical section displays the following screen. Note
the grayed-out fields below.  You cannot
type in the information. After the claim has been saved, an unlimited number of
medical providers may be added to a claim using the procedure described
below.  The information on the primary
care provider (i.e. the first one on the list) will appear in the Medical section.
Other details may be supplied as needed.

Figure 5‑7: Claim Page – Medical Section

To select a specific medical care provider:

1.
Click the Ellipsis button next to the Medical
Provider’s Code to display the Case Management screen with menu options for Care Providers
and Diagnosis Codes.  Select the Care
Providers menu and click New. When this window appears, click the Ellipsis
button next to the Fed ID Number to display the Vendor Selection dialog. Note
that only vendors with “P” or nothing in the filter field will be displayed.

The ATS Case
Management system is an optional, add-on module that is
described in the Options chapter. The standard system uses two of these features.

2.
The program will display the information found
in the selected vendor’s record. If there is no
contact name in the record, you may enter a name here or directly on the
Medical page. Note that the Physician and Contact’s Phone/Fax will not appear
on the Medical page unless your claim screens have been customized.

3.
Click Save to add the vendor to the list of care providers. Exit the Case
Management window.

4.
If there is more than one vendor on the list, the first one is considered the
primary provider whose information will appear on the Medical page.

To
make another provider primary, highlight the provider and click the Make
Primary button on the toolbar. The next time you view the list, it will appear
at the top.

When
there is more than one provider, we recommend that the vendor who will receive the majority of the medical
payments is made primary so that the Payment module will get the name and
address information from the claim record when a “P” is entered as the Payee.
As the medical treatment changes, the primary vendor may also be changed to
facilitate the payment process.

The Legal Firms section may be used when a claim has gone into
litigation.  Click the Ellipsis button to
search for a vendor.  Only those with a Filter containing an “A” or
nothing will be available.  The program
will fill in the name and contact information from the vendor’s record you
selected.  The date the case was assigned
to the firm and any additional attorneys or legal firms involved may be entered
when relevant.

When a legal firm has been specified, the program will
check the Litigation box in the Details section as it saves the
claim.

Figure 5‑8: Claim Page – Legal Firms Section

Most of the fields on the screen are self-explanatory.
Those that have been added or modified for CMS reporting are:

Field Name

Description

Type
of Representative

The
type of representative, either: Attorney, Guardian/Conservator, Power of
Attorney, or Other.

TIN
/ Vendor code

The
tax ID, either a FEIN or SSN.  If you click the ellipsis button to search
for a legal firm, the program will fill in the vendor’s code and
relevant data from the vendor’s table.

Firm
Name

The
name of the firm, if appropriate. This is required on reports submitted on or
after January 1, 2011 if the representative is associated with or is a member
of a firm.

Address
and Phone

The
representative’s address and phone number.
Representative’s Name     The first and
last name of the representative.

When the claim has gone into litigation, the Litigation screen may be used to add information regarding
the case.

Figure 5‑9: Claim Page – Litigation Section

The Litigation section of the standard screen is shown above.
A description of the fields; including those for CMS reporting, are described as follows:

Field Name

Description

Date
Filed

The
date the case was filed with the state workers’ comp board.

Date
Assigned

The
date the workers’ comp board assigned a number to the case.

Case
Number

The
claim number assigned by the state.

Mediation

The
date set for mediation.

Trial

The
date set for the trial.

Claimant’s
Demand

The
amount the claimant wanted.

Initial
Offer

The
amount and date of the initial offer.

Final
Offer

The
amount and date of the final offer.

Settlement (TPOC)

For structured settlements or annuities,
enter the total amount of the obligation based on life expectancy, not the
amount of the individual payments. Include the amount an insurance carrier
reimburses the self- insured entity for a payment made to the injured individual. When an
entity is self-insured for a deductible but the payment of that deductible is
done through the insurer, then the insurer is responsible for reporting the
deductible, not the self-insurer.

Note: The CMS refers to the settlement as the "Total
Payment to the Claimant" or TPOC.  This field is for the first TPOC.  Use the Actions- Bridge menu to enter up to
four additional amounts.

Since
there are current thresholds for CMS reporting,
we suggest that the system administrator set the Settlement Date and Amount as transactional fields so
you will be able to provide proof as to why the claim was  not reported earlier (i.e. the amount was
less than the threshold on the date in question).

Settlement Amount

The
date is when the obligation was established; the date the obligation is
signed if there is a written agreement unless court approval is required. If
court approval is required, it is the later of the date the obligation is
signed or the date of court approval. If there is no written agreement it is
the date the payment is issued (or the first payment if there
will be multiple payments).

Funding
Delayed

The
actual or estimated date of the settlement (i.e. when the money was or will
be released).

Type
of Settlement

A
code for the type of settlement made.

Court

The
name of the court handling the case.

Judge

The
name of the presiding judge.

Status
Reports

The
status reports that were filed.

Litigation Plan

The
name of the litigation plan that was used.

Action
Over

Check
this box if the litigation is over.

Outcome

Indicate
the outcome of the case. Press the Ellipsis button for a list of choices
entered with the Maintain-Legal menu.

Defendant(s)

The
name of 1 to 4 defendants with last name first as in Johnson, Randy.

CMS Reporting Notes

1.
When you have a situation where you have assumed
responsibility for medical and there is no dispute, the Settlement Amount should be blank. For example, six
months after the claimant tripped and broke his leg, everyone agrees there will
be no future medical and the claim is closed. No settlement is involved.

2.
For settlements (TPOCs) involving a deductible,
be sure to include it if you are responsible for reporting both the deductible
and any amount above the deductible.

3.
The CMS recognizes four additional TPOCs so an option
was added to the Bridge menu which is covered later in this chapter.

The Rehab section may be used if the claimant is or was
receiving any vocational rehabilitation services.

Figure 5‑10: Claim Page – Rehab Section

The following fields appear on the standard screen in
addition to the vendor information.

Field Name

Description

Patient
Number

The
patient number assigned to the claimant.

Rehab
Number

The
vocational rehabilitation number.

Date
Assigned

The
date the claimant was assigned to a rehabilitation program.

Plan

The
plan used by the vendor providing the rehabilitation services.

Date
Rehab Started

The
date the claimant started rehabilitation.

Date
Rehab Ended

The
date the claimant ended rehabilitation.

Printing a Claim

The File-Print menu may be used to print all the fields
on the selected pages even those that have been created only for your use.
Depending on the particular screen, you may have to set the Preference for the
printer to landscape when the Print dialog appears so the fields on the right will
be displayed on the printout.

Saving a Claim

When the claim is saved, the program will:

1.    Check for
required fields. If any are blank, the message “Required Fields Missing” will
appear in the title bar and position you on that page so you can enter the
missing information.

Note that the Claim Type will automatically be changed to “INDEMNITY”
if there are any indemnity reserves.

2.    Assign a
claim number where the
first 2-digits are based on the Fiscal Year in the client’s record and the
Injury or Open Date. For example, if the Injury Date is “09/01/2010” and the Fiscal Year is “0701”,
the claim number will start with “11”.
To base the number on the Open Date, enter “OPEN” as the Next Claim
Number with the
Administer-Configuration-Application Parameters menu.

If policies are used, these 2-digits may be overwritten
by the Claim Number Prefix in
the policy.

Opening another Claim

The Open Claim button may be used to
select another claim. The Claim Selection screen shown below will appear to assist you
in finding the claim you wish to view and/or edit. The original claim screen
will stay open.

If you want to view another claim that the employee has
filed, click the Open Other Employee Claims button to display a list of all the other
claims. The original claim screen will still be open after you select another
one so you may refer back to it if necessary.

Editing a Claim

Users with the proper authority may edit a claim using
the Select Claim menu item. A variety of options are provided to assist you in
finding a claim. If you know the claim number, enter it on the Claim
Selection screen. For example, you could search for all
claims with injury dates between 1/1/2019 and 6/30/2019 where the adjuster is
DEMO.

Figure 5‑11: Claim Selection Screen

Click Search or press <Enter>
and a list of possible matches will appear. Select the one you want to view
and/or modify.

Figure 5‑12: Selected Claims List

Closing a Claim

Clicking the Exit button
will ask if it is OK to close the claim (with the current date), file the
record, and exit. If Auto Close has been set on the Application Parameters menu, the incurred reserves will be set to equal the paid-to-date so the futures
will be zero.

If a closed date is entered manually (and the value of
Auto Close is set to “Y”), you will be asked what to do
about the future reserves when saving the record.

However you close the claim, the program will search
for future diaries. If any are found, you will be asked if they should be
deleted.

The claim cannot be closed if the user’s reserve limit
is not high enough to zero out the future reserves.

Using the Claim Tools

The Menu Bar provides you with a number of features
that make it easy to perform the typical operations that need to be completed
when processing a claim. Each of the items is covered in alphabetical order in
this section.

It is important to note that many of the tools are
available on the selection screen.
Simply highlight the desired claim and click the button on the toolbar.  You don’t have to actually open the claim.

AutoPay

This option displays the Auto Pay List so that you
can schedule recurring payments or edit an existing schedule. This feature is
covered in detail in the Financial chapter.

Figure 5‑13: Auto Pay Screen

Clicking the Auto Setup of Compensation button displays
the setup screen.

Figure 5‑14: Auto Pay Setup Screen

Set the Add Weeks field to the number of weeks to pay and
then click the OK button.

Dependents

This feature is provided to associate dependents with
a specific claim when:

1.    The state
of jurisdiction for the claim considers dependents when
calculating the employee’s benefit rate.

2.    The
employee has died. In this case, the individual who will receive the death
benefits may be entered as a dependent on the claim to facilitate the payment process.

3.    The
employee’s wages have been garnished and a lien has been entered in the employee’s
record.

Diary

The ATS Diary is a powerful tool that may be used to remind
you of things that need to be done. Depending on how the system has been set
up, claim specific diaries may also be generated automatically.

In this section, we will provide you with an overview
of the ATS Diary. All of the features are covered in detail in a
separate chapter of this manual.

Existing diaries may be viewed or new ones created
depending on the user’s access rights. When enabled, this feature may be used via
the Diary menu item. (The Diary module is also available
from the ATS Console.)

In the following example, the window is empty because
there are no diaries for the claim.

Figure 5‑15: Claim Diaries List

To create a new Diary, click the New
button. The Diary will automatically be related to the claim you are currently
working on.

A sample diary is shown below.

Figure 5‑16: Claim Diary

The Subject is the text to be displayed on the Diary List. Entering a Message is optional. After
you finish entering the message, click the Save button to
save the entry and then exit. The new diary will appear on the list.

Editing Diary Entries

Diaries may be edited by selecting the item and
clicking the Open button. The fields in the diary are edited in the
same dialog that is used to create a new entry.

Marking Diary Entries as Reviewed

A diary must be marked as reviewed before it can be
removed from the Active Diary List. To do this, edit the entry and check the
Reviewed box. After you exit, the item will no longer appear on the list.

We have just touched upon the features in the ATS
Diary. For complete information, please refer to the
Diary chapter in this manual.

Forms/Letters

This feature may be used any time you wish to create
a document using the currently displayed claim. Standard forms for the state of
jurisdiction specified in the claim will be listed along
with any custom or user documents that have been designed for your organization.

The ATS system allows you to save the documents that
have been sent for a claim so they may be viewed later with the History module. For information on how to set up this
feature, refer to the Forms/Letters section of this manual.

General Payments

Click the General Payment menu option to make a
payment on the
claim. See the Finance chapter for information on how to use this program.

ISO Claim
Search Export
Utility

The Insurance Services Offices (ISO) acquired the Central Index
Bureau (CIB), a national clearinghouse
for data on bodily injury claims that can be used to identify possibly
fraudulent claims.

ATS provides the ISO Export utility as an optional, add-on
interface with the ClaimSearch software from this
third-party vendor. Once the utility has been
installed, you may use this feature to write selected fields to a text file for
export purposes. This dialog will appear so you can select the type of report
you wish to send.

Figure 5‑17: ISO Export
Utility

If you are planning on using this feature, it is
important to note that the items below are required in order for the utility to
operate successfully.

·
Social Security Number

·
Name (including any middle initial)

·
Street Address

·
City

·
State

·
Zip Code

·
Date of Birth

·
Date of Injury

·
Location State (where the injury occurred)

·
Cause

·
Body Site

·
Nature

If any of this information is missing, an error will
be detected when you attempt to use the Prepare to Export menu in the Process
module.

Medical Fee Payments

The Medical Fee or Bill Review module is an optional, add-on product designed
to lower your medical costs by paying the maximum reimbursable for each line
item on the bill. The Medical Fee Payments menu or the corresponding toolbar
button may be used to launch the program. See the Finance chapter for complete
information on how to use this product.

Notes

Existing notes may be viewed or new ones created
depending on the user’s access rights. When enabled, this feature is available via
a toolbar button. By default, the notes will come up in a grid.

Figure 5‑18: Claim Notes List

Click the Report View menu item to display each
note and the contents in a report format that can be printed.

Figure 5‑19: Claim Notes Report
Format

Editing Notes

Notes may be edited only on the day they were
created. Since claim notes have the potential of becoming legal documents, they
may not be changed afterwards.

Creating New Notes

To create a new note, use the New button.
You will be asked to pick the type of note you wish to create. By default, the
program assumes   that you want to create
a note for the current claim. To write a note for another one, click the Selected
Claim button. The LOB (and DataSource) box
will become active so it can be changed if necessary. For example, you may have
a case where a bus driver (an employee) has both a comp and a liability claim.
Being able to write a note for both claims from the same place is a very handy
feature.

The dialog shown below is used to create notes.

Figure 5‑20: Note Entry Dialog

Inserting Attachments

Click the Attach Documents
button to display the dialog shown below.
Click the Browse button to find the file you
want. By default, the program will look in the user's My Pictures folder. After
selecting a file, click the Save button.

Figure 5‑21: Note Attachment Dialog

After selecting a file, an icon will appear in the
note. When the note is saved, a paper clip will appear in the first column for
the entry in the Notes window to indicate that there is an
attachment.

Changing the Filter

The Filter Results menu displays the following dialog
so you may control which notes will appear.
Before using any of the features covered in this section, it is very
important to note that the filters will be used regardless of what claim is
involved until they are turned off or you log out of the ATS system.

The default is to display all notes regardless of
category. In this example, only general notes will appear after clicking OK.
By default, the program does not check the date when selecting notes, but you
enter a specific range of dates or within a specific number of months as in the
example. You may also use the search feature to display only notes that contain
specific characters in the subject line.

History

Selecting History on the Menu bar of the Claim screen will open
the History dialog. This dialog provides access to information about actions
that have occurred during the life of the claim, including; payments,
recoveries, reserves, letters, transactions. It also
includes an Audit feature
that provides a chronological list of every action associated with the claim.  See the History chapter for complete
information on how to use this module.

Payment History

Payments may be used to view the payment, credit and void transactions for the claim.

Figure
5‑22: Claim Payment History

Recovery History

Recoveries may be used to view the recoveries that have
been received for the claim.

Figure
5‑23: Claim Recovery History

Reserve History

The Reserve History button may be used to view the reserves changes that have been made on the claim.   See the History chapter for complete
information on how to use this module.

Figure 5‑24: Claim Reserve History

Letter History

The Letter History menu option shows the forms and letters that have been produced for the claim.

Figure
5‑25: Claim Letter History

Audit

The Audit menu item provides access to a chronological
list of all actions that have taken place for the selected claim.

Figure
5‑26: Claim Audit

Reserve Worksheet

The reserve worksheet is designed to assist adjusters in calculating
the reserves for a claim. Depending on a system setting, it
may be the only way you can enter reserves.

The worksheet is not intended to be a financial tool
since there will never be a program that balances the amounts in the worksheet
against the reserves in the claim. Regardless, the information
should prove to be a valuable reference when the worksheet is used to track the
changes throughout the life of the claim.

Third-party administrators or companies providing similar services should
find the worksheet especially useful when reporting reserve changes to their
clients or members.

Figure 5‑27: Reserve Worksheet

Click the Calc button to
bring up a special payment calculator. Since indemnity reserves are being calculated, the Benefit Type and Rate from the claim are displayed in the
dialog. The total is calculated by multiplying the benefit by the estimated
number of weeks.

To calculate the claimant’s life expectancy based on
the person’s age, sex, and race, click the Ellipsis
button after the Number of Weeks box. The program will fill in the weeks and
the total amount of PD benefits.

Clicking Save will
close the calculator and enter the value and the equation in the Amount and
Note boxes on the worksheet. Click Add to move
the item to the Worksheet List box and add the amount.

Click the Apply button to
update the claim with the proposed amount. The next time you use the worksheet
the value will appear as the future reserves and the Worksheet Items box will be empty.
Click the Historical option to redisplay the previous
transaction(s).

A Close button is displayed if your
system has been set up to use the reserve worksheet as an optional feature. When Close
is clicked instead of Apply, the window will close.  The reserves in the claim will not be updated.

A Cancel button will appear instead of Close
when using the worksheet is mandatory (i.e. you can not
edit the value on the Reserves page). In this case, the record for the
current change will be deleted from the worksheet items.

If either button is selected before clicking Add
to move a new entry into the Worksheets Item box, the program will exit and
leave everything the way it was before you started adding the new item.

Decreasing the Reserves

There will be times when you need to decrease the
reserves. To do this select the desired reserve category,
enter a negative value in the Selected Items-Amount box, add an optional Note,
and click Add to move it to the worksheet items. Then select Apply to update
the reserves.

Replacing the Reserves

The Replace feature may also be used to change the
value of the future reserves if there is only one transaction for the
category. For example, suppose that the estimated number of TD weeks was incorrect. A new item for the
correct amount may be entered using Replace instead of the Add button. The
future reserves will be set to that value.

Special Considerations

1.    The menu
item will be disabled if the operator does not have permission to change
reserves. (The program will check the operator’s reserve
change limit when the claim is saved, and conditionally allow the changes to be
made.)

2.    Contact
ATS support if you would like to use the reserve worksheet exclusively.

Close Claim

Selecting Close Claim will ask if it is OK to close the claim (with
the current date), file the record, and exit. If Auto Close has been set using the Application Parameters screen, the incurred reserves will be set to equal the paid-to-date so the
futures will be zero. If a closed date is entered manually (and the value of
Auto Close is set to “Y”), you will be asked what to do about the future
reserves when saving the record.

However you close the claim, the program will search
for future diaries. If any are found, you will be asked if they should be
deleted.

The claim cannot be closed if the user’s reserve
limit is not high enough to zero out the future reserves.

EDI Export Utility

This utility may be used to write selected fields
into an ASCII text file for export purposes. The EDI Batch dialog lists the reports that have been
batched/sent Since the EDI Export process varies by state, it is documented
separately.

Figure 5‑28: EDI Batch Screen

Jurisdiction State

When a new claim is saved, the program automatically
assumes that the employer’s state is the state of jurisdiction to be used to calculate the claimant's benefit
rate. The State of Jurisdiction field must be changed in the Detail section,
when necessary.

Policy

If the Policy module is in use, the program will read the
injury date and search for a policy for that year and level (the default) or
for one using the special policy format entered in the Option/Module screen. If
a policy is not found, a warning will be displayed and the claim cannot be
saved.

Unless a special format has been specified, this
option may be used to display a list of policies that have been entered with
the Policy menu. Making a selection will enable the Save
button.  After a policy has been attached
to the claim, the program will display the Policy Number in the window title
bar and write the Deductible amount in the claim record.

Restricted Days

This menu option or toolbar button displays the form
for tracking the details about any restricted work days. Each time you save
specific from/thru dates and a restriction, the information will be displayed
in the box at the top of the dialog. The program will update the Restricted
Work Days field on the Detail page when you exit the
dialog.

Restrictions may be entered manually or by selecting
the Restricted Days menu and selecting a code entered with the Restricted Duty
menu.

According to the OSHA 300 guidelines, all restricted work days are
recordable. Transfers to another job due to the injury or illness must be added
to the restricted days for reporting purposes. Although a first job transfer
may be recorded in the TW Start and TW End fields, use the Restricted
Days menu to enter any subsequent period(s) in the From/Thru  Dates with “Job Transfer” as the Restriction.

In cases where the employee receives indemnity
payments to compensate for the loss of earning power due to a restriction,
enter “I08” (wage loss) in the Report Category field for the pay code so the
days are not counted as both time lost and restricted days on the OSHA log.

Multiple Body Parts

You may report up to 19 different body parts that were injured and their corresponding
IDC-9 diagnosis codes. Use this menu or the Ellipsis button next to the Body
Site field to enter this information. Note that
entering the nature and impairment percentage is optional.

To modify an entry, highlight it, update the data,
and click Save to move the item back to the grid. If you need to remove an
entry, highlight it, and click the red X.

TPOC

The CMS recognizes up to a total of five settlements
or TPOC (Total
Payment to the Claimant) amounts so an option was added to the Bridge menu to
display this window.

Please note that the grid will be blank until you
enter an amount and date(s). All the amounts will be totaled including the
Settlement (TPOC) Amount on the Litigation page to make it easy to determine whether or
not the amount is over the threshold and must be reported.

CMS Batch

A CMS Batch option has been added to the Bridge menu.
Selecting the option will display this window so you can batch different types
of records or transactions. The CMS refers to these as Action Types. For your
convenience, a history of what was batched and sent (by whom) will appear in
the window.

The Action Types

Add

An "add" record or transaction should be
submitted for a new claim that was never submitted, was submitted but not
accepted due to errors, or a claim where the RRE assumed ongoing responsibility for medicals
previously, but the injured party has just become entitled to Medicare. The CMS stores claims by the following key
information:

·     Injured
Party SSN, HICN, Last Name, First Name, Date
of Birth and Gender

·    CMS Date of Injury/Loss

·    ORM Indicator

Delete

A "delete" record or transaction should be
sent to remove information from the CMS database if the original record should never
have sent in the first place or when you need to change key data submitted
previously. In the latter case, the RRE must send a delete record with the key
information that matches the previously accepted (add) record followed by
another add record with the changed information.

Because Medicare stores claims submitted previously by the key
information listed above, it is important that the data not be changed in the
claim. We strongly recommend that someone with system administration rights set
these fields as transactional so the program will track what changes were made
to the data, when the changes were made and by whom. This way you can confirm
that the data is the same.

Update

An "Update" should be sent when you need to
change information previously submitted and accepted. The key information
(listed above) in an update record must also match that in the add record in
order for the transaction to be accepted.

Update records should be submitted under these three
circumstances:

1.    An RRE needs to send the ORM Termination Date to indicate that the
responsibility for ongoing medicals has ended. This may be a simple termination
or it might be associated with the reporting of a settlement, judgment, award,
or other payment TPOC amount/date.

2.  A report of
ongoing responsibility for medicals has already been submitted and accepted and
there is a separate settlement, judgment, award, or other payment TPOC amount/date. The RRE continues to retain ongoing responsibility for
medicals.

3.
Information critical for use by Medicare in its claim payment and recovery processes has changed.

If you need to update one of the key fields listed
above, follow the process described in the previous section where a delete and
add record are required.

If you need to update one of these other fields, send
an update transaction:

·     ICD-9 Diagnosis Codes

·
Description of Illness/Injury

·    Carrier’s TIN (FEIN)

·    TPOC (Settlement) Date

·    TPOC (Settlement) Amount

·    Claimant’s
Representative Information

EFC

The Electronic Filing Cabinet (EFC) module is also called the
Document Manager.  This is the ATS solution to the paperless
document flow many entities require.  For
instructions on using the EFC and help videos, please go to the following
website and create a login:
www.grocefc.com.

Figure 5‑29: EFC –
Document Manager