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Need Workers' Comp Help? University Business Services © UC Santa Cruz
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Workers' Compensation Handbook - Chapter 4 Summary: Chapter 4 - Claim Processing
IntroductionThis chapter provides information for supervisors about the processes and expectations for filing claims for injured and ill workers. It includes a description of the claim forms and filing process. The different claim outcome possibilities are also described in detail. Reporting Job-related Injuries and IllnessesA workers supervisor must complete a UCSC Incident Report for any of the following occurrences:
A State of California workers’ compensation claim form (DWC-1) will be provided to the employee by the treating physician or by Risk Services and filed if it is determined by a physician that medical treatment for the injury or illness will extend beyond First Aid Treatment (see Glossary.) The law requires the University to report every such injury or illness to its third party administrator, Sedgwick CMS, so that a determination can be made as to whether or not the injury or illness is compensable under workers' compensation law. The employee's supervisor must report the injury or illness by faxing the completed UCSC Incident Report Form to UCSC Risk Services within 24 hours of the time the employee communicates to their supervisor that he or she has an injury or illness as a result of their University job. Medical treatment must also be offered within the same time period. FormsThree forms are necessary for reporting a workers compensation claim:
A Worker’s Compensation Claim Form will be immediately provided to the employee by the treating physician or Risk Services upon notification by a physician that medical treatment for the injury or illness will extend beyond the definition of First Aid (see Glossary.) Claim ProcessWithin ONE working day of knowledge of injury, FAX the UCSC Incident Report Form to the UCSC Risk Services Office at FAX: 831-459-3268. Sedgwick CMS manages all University workers compensation claims. They will investigate the injury and determine compensability of a claim. Reporting an injury or submission of a claim form does not mean automatic approval. Sedgwick CMS will notify the injured employee of the status of the claim within 14 days after they receive it for processing. Some claims require extended investigation to verify compensability. For example, stress claims and cumulative trauma claims such as carpal tunnel syndrome may or may not meet California legal requirements for compensability. Sedgwick CMS may use any of the following procedures to determine compensability when it investigates claims:
Possible Claim OutcomesThree distinct responses are possible for each claim filed:
Process for Accepted ClaimsOnce a claim is accepted, Sedgwick CMS authorizes medical treatment and issues any temporary or permanent disability payments and/or medical payments related to the claim. The funding for these payments is provided by the Universitys self-insurance program. When an employee is losing time from work for an accepted claim, Sedgwick CMS will begin payment of temporary disability. The check pays two-thirds of the employees weekly salary up to a maximum amount determined by the State of California. A letter confirming that the claim has been approved will be sent to the employee. The temporary disability check will be mailed to the employee's home. Since the employee's weekly salary is likely to be more than the temporary disability wage, the remainder of the employees salary may be paid through the UCSC payroll system using accrued sick leave and, if the employee so chooses, vacation. The Payroll Office will issue a check minus the amount already paid to your employee by Sedgwick CMS. There is a 3-day waiting period before the Workers Compensation maximum temporary disability payments begin. The employee's sick leave and other selected leave balances can be used to cover any lost-time during the first three days after the date of the injury. If the employee does not have sick leave to cover the first three days, the University will pay extended sick leave which equals 80% of the employee's normal wage. Process for Delayed ClaimsIf more time is needed to make a decision regarding acceptance of the claim, Sedgwick CMS will mail a letter to the employees home stating the date a decision will be made. If the employee is losing time from work while the case is on delay, he or she should apply for other Disability Benefits. Employees should call the Benefits Dept. (X92013) to apply for Non-Industrial Disability (paid by Liberty Mutual Insurance Company) during this interim period. Faculty who do not accrue sick leave should request a leave with pay from their department chair, during the delay process. Necessary medical treatment will continue to be provided during the delay period, up to a maximum of $10,000. Once a decision is made on a claim, Sedgwick CMS will inform the employee by mailing a letter to his or her home. The decision on a claim can be delayed for a maximum of 90 days. Process for Denied ClaimsIf a claim is denied, Sedgwick CMS will mail a letter to the employees home explaining why the claim has been denied. A copy of this letter will also be mailed to UCSC Risk Services. The employee's supervisor may call UCSC Risk Services at 831-459-2850 at any time regarding the status of a Workers' Compensation claim. An employee has appeal rights in the event that the claim is denied. Specific information on these rights is provided to the employee at the time the claim is denied. Last revised: November 02, 2007 (am)
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