Chief of Operational Policy, Analytics & Compliance (Signature on File)
Management policies, directives and memos regarding claim reviews that predate
the effective date of this policy.
The purpose of
this policy is to provide guidance for the claim review process to ensure that
field staff are accurately paying compensation and managing claims in
compliance with all applicable statutes, rules and agency directives and making
quality claim determinations.
applies to BWC Field Operations, particularly: Field Staff Supervisors, which
includes Injury Management Supervisors, Medical Claims Specialist Supervisors
and Employer Management Supervisors and to Benefits Payable staff.
program that computes a group of items together and runs it through the system
at one time.
Tool: An Access
database used to maintain claim review records.
by Team Members” report: A report produced daily that indentifies
batch or daywork payments.
Daywork payment: Claims management
system-reference to compensation and benefit payments that cover past periods
but do not extend to future scheduled payments.
Payment Authorized by Team Members” report: A report produced daily that identifies
payments made using Miscellaneous Payment.
management system-reference to future compensation payments that are scheduled
on a two-week basis.
Authorized by Team Members” report: A report produced every two weeks to show new pension
Warrant: Payments made by BWC,
usually in the form of an electronic transfer of funds, or, in rare circumstances,
A. It is the policy of BWC to
conduct random claim reviews to:
1. Ensure appropriateness and
accuracy of payments;
2. Identify user and system
3. Identify trends;
4. Monitor claims management
5. Detect fraudulent activity.
B. Claim Review outcomes are used by Service Office
Managers (SOMs) and Field Staff Supervisors to:
1. Create management reports;
2. Identify performance trends
by office, team and/or member;
3. Identify opportunities for
coaching, mentoring and training, when appropriate.
C. Types of claim reviews
1. Import Reviews
a. Initial determination
b. Additional allowance
c. Newly granted compensation
d. On-going claims and
2. Daily Reviews
a. Compensation payments
b. Claims management practices
D. Claim reviews are used by field operations
1. Evaluate the quality of the initial
2. Review appropriateness of:
a. Determination of requests for
an additional condition(s);
b. Newly initiated pending
compensation payments in a claim;
c. The accuracy of any newly
initiated released compensation payment in a claim.
3. Assess the Claims Service
Specialist’s (CSS) claim management practices;
4. Proactively detect processing
5. Provide opportunities for
claims processing mentoring.
E. The Field Staff Supervisor, by using the claim
1. Determine how proactively and
consistently the CSS is monitoring ongoing compensation and taking steps to
resolve outstanding issues;
2. Work with Benefits Payable to
prevent warrants being released incorrectly;
3. Monitor policy and procedural
4. Identify trends and areas of
improvement to share with the CSS to improve case management skills.
BWC staff may refer to the
corresponding procedure for this policy entitled “Procedures for Claim Reviews”
for further guidance.