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.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and.
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.
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 Duplicate Claims and Customers CoreSuite job aid provides detailed steps on how to
process duplicate customer issues.
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.
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.
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.
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 Claim Cost 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.
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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