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Policy and Procedure Name:
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Duplicate Claims and Customers
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Policy #:
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CP-04-05
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Code/Rule Reference:
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None
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Effective Date:
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11/05/2021
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Approved:
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Ann M. Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-04-05, effective 11/14/16
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History:
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Previous versions of this policy are available upon
request
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Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
IV. POLICY
V. PROCEDURE
A.
General Claim Note and Documentation Requirements
B.
Identifying Duplicate Claims
C.
Investigating/Processing Duplicate Customers
D.
Investigating/Processing Duplicate Claims
E.
Duplicate claims that have different accident types (injury,
occupational disease or death)
F.
Combining and Decombining Claims
G.
Overpaid Compensation and Medical Bills
VI. Appendix A: Combining Duplicate
Claims
The purpose of this policy is to
ensure that duplicate claims are properly identified and combined in an
efficient manner to prevent duplicate actions.
This policy applies to all BWC staff and managed care
organizations.
Alias Claim: The claim
that is combined into the surviving claim.
Duplicate Claim: When more
than one claim has the same injured worker name, social security number,
risk/policy number, and date of injury.
Surviving Claim: The claim
that remains once the alias claims are combined.
It is the policy of BWC to
identify and combine duplicate claims in a manner that avoids or corrects
overpayments and creates one complete and accurate claim.
V.
PROCEDURE
A.
General Claim Note and Documentation Requirements
1.
BWC staff shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and.
B.
Identifying Duplicate Claims
1.
Claims may be considered duplicate when they contain the following
identical elements:
a.
Injured Worker’s name;
b.
Social security number;
c.
Risk/policy number;
d.
Date of occurence.
2.
Duplicate claims may be identified as follows:
a.
The claims management system provides an alert of a duplicate or
potential duplicate claim;
b.
An Industrial Commission (IC) order identifies one or more claims as
duplicate;
c.
BWC staff identifies a potential duplicate while conducting a name and
social security review;
d.
Notification from the MCO;
e.
The Automatic Claims Processing (ACP)
Potential Dupe Same Policy flag;
f.
A
duplicate claims report that has been posted to the IMS/EMS SharePoint Cognos
Reports folder; or
g.
Parties to the claim.
C.
Investigating/Processing Duplicate Customers
1. Prior
to resolving duplicate claims issues, claims service staff shall determine if a
duplicate customer record exists.
2. If
a duplicate customer is discovered, claims service staff shall determine which
customer’s information is correct and address the discrepancy.
3. If
the customer record for the IW in which the error(s) occurred contains more
than one claim for the IW, claims service staff must review all claims attached
to that customer record and move all of the claims to the remaining viable
customer record before flagging the incorrect customer records as “DO NOT USE”.
4. Once
the discrepancies are reconciled, one customer record will be the surviving
customer and one shall be updated to reflect “Do Not Use” and have a Block set
for “invalid customer.”
5. The BWC Duplicate Claims/Duplicate Customer CoreSuite job aid provides detailed steps on how to
process duplicate customer issues.
D.
Investigating/Processing Duplicate Claims
1.
After resolving duplicate customer issues, claims service staff shall
investigate indicators of potential duplicate claims as referenced
in Section C above.
2.
When duplicate claims have different employers, claims service staff
shall investigate to determine the correct employer for each claim.
3.
If the investigation reveals that two employers employed the IW and the
accident descriptions are different, then claims service staff shall process
the claims separately.
4.
If the investigation reveals that both claims should have the same
employer, and the claims are duplicates in all other
respects, claims service staff shall:
a.
Make the employer correction following the procedures outlined in
the Initial Claim Determination procedures
if the claim with the incorrect employer has not yet been determined; or
b.
Make the employer correction following the procedures outlined in
the Changing the Employer and or
Policy Number after Initial Determination procedures if the
claim with the incorrect employer has been determined; then,
c.
Refer to Appendix A below to determine the appropriate action.
d.
Notify the identified employers of the findings.
E.
Duplicate claims that have different accident types (injury, occupational
disease or death)
1.
If potentially duplicate claims with different accident types have been
allowed, BWC staff shall discuss potential continuing jurisdiction with the BWC
attorney.
2.
If the potentially duplicate claims with different accident types have
not been determined, BWC staff shall investigate to determine the appropriate
accident type, make a determination and then refer to Appendix A for further
action
3.
If the investigation does not clearly reveal the correct employer and
the claims appear to be duplicates in other respects, BWC staff shall staff the
claim with the BWC attorney for further direction.
F.
Combining and Decombining Claims
1.
BWC staff shall combine verified duplicate claims or decombine claims in
the claims management system pursuant to the instructions in the CoreSuite
Training manual and/or the “Duplicate claims/duplicate customer” CoreSuite job
aid available on the Duplicate Claims policy page on COR.
2.
Claims shall be combined into the earlier filing date, unless:
a.
Compensation has been, or is being paid in one claim and not the other,
then the claims shall be combined into the claim in which compensation has or
is being paid;
b.
The IC has issued an order outlining how BWC shall combine the claims;
c.
Both claims were filed within the statute of limitations and
circumstances make it more efficient to combine the claim into the later filed
claim. E.g., one claim has more information than its duplicate; the claim may
be combined into the claim with the most complete information.
d.
Compensation is paid in more than one claim.
i.
If duplicate records exist, claims services staff shall select the claim
that has the most compensation paid as the surviving claim.
ii.
Claims services staff shall stop compensation in the alias claim(s),
send a subsequent order and adjust compensation in accordance with the Adjustment
of Overpaid Compensation policy and
procedure.
3.
When combining duplicate claims, claims
services staff shall confirm that the alias claim(s) is properly associated
with the surviving claim.
4.
Claims services staff shall decombine claims when either of the
following occurs:
a.
The IC orders it; or
b.
Claims services staff combines claims in error. In this case, a BWC
order is not required.
G.
Overpaid Compensation and Medical Bills
1.
If claims services staff identifies an overpayment of compensation
because of claim duplication, claims services staff shall follow the procedures
set forth in the Adjustment
of Overpaid Compensation policy and
procedure. Claims services staff shall not combine duplicate claims until the
subsequent order is issued and the appeal period expires.
2.
If claims services staff identifies an overpayment of medical bills
because of claim duplication, claims services staff shall follow the procedure
set forth in the Medical
Recovery-Medical Bill Adjustments policy and procedure.
· Claims
may be considered duplicate when they have the same claimant name and/or
risk/policy number.
· Date
of occurrence and accident description: Claims containing no social
security number (SSN) or the same SSN are only considered to be duplicate when
they also contain the same claimant name and/or risk/policy number.
· Claims
service staff must also review the customer records of the possible duplicate
claims prior to addressing the combining of claims.
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Claim Status and Claim Status Reason
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Combine?
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Note
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Both Claims in Pending Status
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Yes
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If the accident and time of injury are the same, claims
services staff will combine the claims.
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One Claim in Accepted Status and one in Pending Status
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Yes
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An investigation must be conducted to determine if the
accident and the time of injury are the same. If the accident and time of
injury are the same, claims services staff will combine the new claim into
the allowed claim.
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One Claim in Denied Status and one in Pending or
Accept/Appeal Status
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No
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If the BWC denied the claim due to lack of medical
evidence (as opposed to insufficient medical evidence) and there is now
medical evidence for the BWC/IC to consider, an IW’s representative can file
the additional evidence and ask the BWC/IC to reconsider the allowance based
on the new evidence. Reconsideration does not apply if BWC denied the claim
on the merits (medical review/ not in course and scope, etc). In that case,
the IW must file a motion requesting continuing jurisdiction.
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One Claim in Accepted Status and one in Denied Status
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No
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Staff with a BWC attorney for continuing jurisdiction.
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Two Accepted Claims
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Yes
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Claims services staff may combine the claims only if the
parties agree to it and if the accident and time of injury are the same. If
the parties do not agree to have the claims combined, the claim shall be
staffed with a BWC attorney for continuing jurisdiction.
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One Claim in Accept/Appeal Status and one in Deny/Appeal
Status
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Yes
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If no appeals are filed and if the accident and time of
injury are the same, claims services staff will vacate the order in the alias
claim only. The order must vacate the previous order and explain the claims
will be combined. Upon the expiration of the appeal period, the claims will
be combined.
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One Claim in Accepted Status and one in either
Accept/Appeal or Deny/Appeal Status
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Yes
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If no appeals are filed and if the accident and time of
injury are the same, claims services staff will vacate the order of the claim
in the appeal period and issue a modified order. The modified order must
explain the claims will be combined. Upon the expiration of the appeal
period, the claims will be combined.
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One Claim in Dismissed Status and one in Pending Status
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Yes
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Contact the IW to determine if they want to dismiss the
new claim or move forward. If they want to move forward, combine into the
dismissed claim and issue a decision.
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One Claim in Dismissed Status and one in Accepted or
Denied Status
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Yes
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Combine the dismissed claim into the claim that has been
determined.
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One Claim in Dismissed Status and one in either
Accept/Appeal or Deny/Appeal Status
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Yes
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If no appeals are filed and if the accident and time of
injury are the same, claims services staff will vacate the order of the claim
in the appeal period and issue a modified order. The modified order must
explain the claims will be combined. Upon expiration of the appeal period,
the dismissed claim will be combined into the determined claim provided there
are no appeals.
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One Claim in Hearing Status and one in one of the other
statuses
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No
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Staff with BWC attorney for continuing jurisdiction. Do
not combine the claims until after the IC decision is issued.
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