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Policy and Procedure Name:
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Standard Claim File Documentation and Altered Documents
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Policy #:
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CP-19-03
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Code/Rule Reference:
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N/A
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Effective Date:
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2/18/2020
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Approved:
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Ann M. Shannon, Chief of Claims Policy & Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-19-03, effective 03/06/13 and Procedure #
CP-19-03.PR1, effective 07/11/16
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History:
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Previous versions of this policy are available upon
request
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Contents
I. POLICY
PURPOSE. 3
II.
APPLICABILITY. 3
III.
DEFINITIONS. 3
IV. POLICY. 3
V. PROCEDURE. 3
A. Claim File General
Provisions. 4
B. Notes. 4
C. Documents. 5
D. Altered Documents. 5
E. Hard Copy Evidence
(HCE) 6
F. Text
Messages, Faxed Cover Sheets, and Blank Forms. 7
G. BWC Attorney-Client
Privilege, Attorney Work Product, and Fraud Information and Documentation. 8
H. Retrieving Hard
Copy or Physical Files or HCE From MAFIL, and Claim Reconstruction. 8
The purpose of this policy is to ensure that the Bureau of
Workers’ Compensation (BWC) provides direction to BWC and managed care organization
(MCO) staff for entering appropriate, accurate, and complete information into a
claim.
This policy applies to BWC claims staff and MCO staff.
Altering documents: Making a mark or markings that
change the meaning, intent or facts presented in a document.
Attorney work product: Documents, electronically
stored information, and tangible items prepared by an attorney in anticipation
of litigation or for trial.
Claim files: Individual claim information maintained in
BWC’s claims management system or in remaining paper claim files.
Electronic storage media: Any electronic device that
can be used to store data. This includes, but is not limited to, internal and
external hard drives, CDs, DVDs, Floppy Disks, USB drives, ZIP disks, magnetic
tapes, and SD cards.
Evidence: Any document or claim note used to support
or disprove allegations or facts of a claim.
Hard copy evidence: Evidence that cannot be imaged
into a claim or can be imaged but significant detail is lost in the imaging
process (e.g., CDs, DVDs, memory cards, photographs, X-rays).
MAFIL: The main file room for BWC to house hard copy
claim files and hard copy evidence.
Tampering with evidence: Altering, destroying,
concealing, or removing evidence that is relevant to an investigation or
decision in a claim.
A. It is the
policy of BWC to ensure that claim files contain a complete and accurate record
of all claim activity.
B. Claim
files shall not include BWC attorney-client privileged information, fraud
investigation information or other confidential information unless specifically
authorized.
C. BWC claims staff
shall document specific information in claim level notes the same day the
action occurs.
D. Claim
files shall be maintained in compliance with the BWC Record Retention schedule.
A. General
Claims Provision
The contents of a claim file shall include general
information pertaining to the injured worker (IW), MCO, employer and provider
demographics, claim level information, documents and reports related to the
claim, and compensability information. See Standard
Claims File and Altered Documents General Information Checklist for data
elements that should be included in a claim file.
1. General
Procedures Applicable to All Notes
a. BWC claims
staff and MCO staff shall ensure that claim notes are carefully reviewed for
proper content, spelling, and grammar and that notes are located in the proper
claim before saving notes to a claim.
b. Based on
the type of note, BWC claims staff and MCO staff shall add the proper
information for “Category,” “Subject,” “Call Type,” and text that contains the
specific information being documented.
c. BWC
and MCO staff shall identify a note as “Phone Note” if the information being
documented is related to a telephone contact or “Note” for all other
information.
d. BWC claims
staff shall only copy notes between multiple claims, for the same IW, when one
of the following occurs:
i. Compensation
is split between claims;
ii. Processing
the following claim requests:
a)
Occupational Disease;
b)
Lump Sum Settlements;
c)
Additional Conditions;
d)
Claim Determination; and
e)
C-92 Applications.
iii. An
overpayment is recovered from multiple claims; or
iv. Other
appropriate circumstances, as approved by the supervisor.
a. Claim
level notes, which include general notes, linked notes, and case notes, shall
reflect a complete history of a claim throughout its life cycle. BWC and MCO staff
shall enter claim notes that:
i. Contain
only relevant information stated clearly and succinctly;
ii. Are
professional in tone and do not contain any rude or derogatory language;
iii. Relate
events in a logical, sequential order; and
iv. Include authors’
and contacts’ names:
a)
BWC and MCO authors and contacts shall be cited by first name and
last initial.
b)
External contacts shall be cited by first and last name, phone
number, and relationship to the claim.
b. Claim
level notes shall document the following:
i. Facts
gathered during the investigation of the claim;
ii. Issues
identified throughout the life of the claim;
iii. Action
steps to resolve claim issues (e.g., attempt at phone contacts, phone
conversations or voicemail messages, etc.);
iv. Outcomes of
claim issue resolution;
v. Compensation
payments and adjustments;
vi. Claim decisions
and the reason(s) for decisions.
c. In
accordance with Chapter 2 of the MCO’s Policy Reference Guide, MCO staff
shall ensure the following when documenting claim notes:
i. In
new claims, notes shall be submitted within one business day of claim number
receipt.
ii. Notes
are submitted within one business day of creation.
iii. MCOs shall
continue to enter notes in compliance with the MCOs’ medical management
policies and procedures as required by URAC accreditation, with the following
exceptions:
a)
MCOs shall not include BWC servicing provider numbers.
b)
MCOs cannot append an existing note. The MCO shall create a new
note.
iv. Notes submitted
with a creation date more than ten (10) calendar days prior to the submission
date will be rejected.
3.
Customer Level Notes
a. BWC claims
staff shall ensure that notes entered at the customer level contain only
general information about the customer and do not contain claim-specific
information.
b. If
customer information is not already in the claims management system, BWC claims
staff shall enter the information, if appropriate to do so, or notify the appropriate
department responsible for entering the information about the customer.
1. BWC shall immediately
scan all claim-related mail and documents received through email or fax into
the claim upon receipt.
2. BWC claims
staff shall rename and delete an imaged document when it is an exact duplicate
of a previously imaged document. The deleted document will be stored in a
holding file for future reference, as needed.
3. BWC claims
staff shall comply with indexing and renaming guidelines available on the Claims
On-Line Resources (COR) site.
1. BWC and
MCO staff shall not withhold, destroy, or alter any document in a manner that
may cause harm or damage to an IW, provider, representative, employer, or the
originator of the document.
2.
BWC claims staff and MCO staff may correct information on a hard copy
document if the change is a non-substantive error (e.g., an employer’s policy
number, manual classification, telephone number, or contact name).
a. Corrections
shall be made by striking through the error, so it is still readable, making
the proper correction above the error, and initialing and dating the
correction.
b. Correction
products (e.g., fluid, tape, erasers) or any other means that obscure the text
to correct information on a document shall not be used.
c. BWC claims
staff or MCO staff shall document the description of the alteration in claim notes,
which includes:
i. The
date;
ii. The
name and title of the person contacted for clarification, if applicable;
iii. Whether
the alteration was made by BWC or the MCO;
iv. The name of the
BWC or MCO staff member who made the alteration; and
v. An
explanation for the alteration.
3.
BWC claims staff and MCO staff shall assess all alterations made to documents
to determine if an alteration is appropriate or inappropriate.
a. Examples
of appropriate alterations may include, but are not limited to, the following:
i. An
incorrect date was entered on a document and the originator of the document
corrects the error by drawing a line through the incorrect date ensuring
legibility of the original entry and dating and initialing the correction.
ii. A
provider, who is the originator of a document, submits an addendum that is used
to provide additional information about an injured worker’s condition.
iii. BWC claims
staff receives a document from the Industrial Commission (IC) that is
mislabeled and has a misspelling. BWC claims staff appropriately labels the
document (rename) and corrects the spelling error.
b.
Examples of inappropriate alterations may include, but are not limited
to, the following:
i. An
IW collecting non-working wage loss (NWWL) submits a previously submitted job
search form with a current date that appears to be modified.
ii. An
IW submits proof of earnings with dates and wages that appear to be modified.
4.
If BWC receives an altered document where the alteration has changed the
meaning, intent, or facts presented in the document, BWC claims staff shall
determine, based on the extent of the alteration and the information altered,
what action to take.
a. If BWC claims
staff determines that the alteration is significant, and clarity is needed
(e.g., cross-outs and write-ins on the document without initials indicating who
altered the document), BWC claims staff shall request that the originator of
the document:
i. Submit
a written statement indicating the nature of the alteration, the reason for the
alteration, and that the alteration accurate; or
ii. Verbally
verify the nature of the alteration, the reason for the alteration, and that
the alteration is accurate. BWC claims staff shall document this verbal
verification in a claim note and send an email or letter to the originator,
requiring that the originator respond in writing and indicate agreement; or
iii. Provide a
copy of the original unaltered document or a copy of the initially sent
document with the originator’s initials by each alteration and the date
initialed.
b.
If the originator submits a new document, BWC claims staff shall
identify both the originally received document and the new document in the
claim file. BWC claims staff shall entitle the new document “Revised” followed
by the description of the new document type. For example, if BWC claims staff
receives a new medical report, BWC claims staff shall entitle the document,
“Revised Medical Report.”
1. When claims
service staff receives hard copy evidence (HCE), such as a CD, DVD, flash drive,
or photograph, claims service staff shall ensure the evidence is retained and
identified with the claim.
a. If the HCE
is a form of electronic storage media and claims service staff have the
equipment necessary, claims service staff shall
i. Print
any printable images or documents stored on the electronic storage media.
ii. Insert
(scan)/image the printed images or documents into the claim file. If the HCE is
a photograph, claims service staff shall image the photograph into the claim
file.
b. Claims
service staff shall then:
i. Securely
label each piece of HCE with the IW’s name and claim number;
ii. Package
the HCE appropriately to ensure it is not damaged; and
iii. Send the
HCE to MAFIL.
2. MAFIL
staff will create an HCE folder and enter a claim note, if one does not already
exist, describing the HCE in MAFIL storage.
3. If claims
service staff receive documents on a CD or flash drive and do not have the
equipment to image the documents into the claim file, claims service staff may
contact MAFIL directly to make arrangements to have MAFIL image the documents
and store the CD or flash drive as HCE.
1. Text
Messages: Claims Service staff may, when approved by Claims Service management
and with the written agreement of the claimant, text a short message to a
claimant via the claims service staff’s BWC email (or other approved BWC
system).
a. A text
message shall be used primarily to convey a reminder to the claimant to take action
important to the claim, or to alert the claimant of important communications
sent by email or letter to the claimant (e.g., “This is a message to remind you
to submit your class registration for fall semester”).
b. A text
message shall not contain any unnecessary confidential personal information
(e.g., claim numbers, medical information).
c. Claims
service staff shall retain a text message and the response in the claim file in
the same manner as any other communication to the claimant.
2. Outgoing
Fax Cover Sheets:
a. In
addition to entering an appropriate claim note and documenting the action and
relevant information or request in the claim, claims service staff shall image into
the claim the outgoing fax cover sheet and any information sent that is not
already in the claim file.
b. Claims
service staff shall ensure that the following data elements are on the fax
cover sheet:
i. First
name;
ii. Last
initial (do not include the entire last name); and
iii. Direct
telephone number; and
iv. Description of
content within the fax.
3. Blank
Forms: Claims service staff shall enter a claim note reflecting that blank
forms were sent but are not required to image the blank forms or accompanying
cover sheets into the claim file.
1. Claims
service staff shall ensure that attorney-client privileged communications or
attorney work products between BWC claims staff and BWC attorneys are not
contained in a claim file.
a. Claim
files and claim notes shall not include copies, descriptions or summaries of
legal opinions provided by BWC attorneys.
b. BWC claims
staff shall not image, copy, or paste an email from BWC attorneys into claim
files and claim notes.
c. BWC claims
staff shall document in a claim note only the outcome of a staffing with a BWC
attorney (e.g., “Staffed with BWC attorney who recommended paying the
compensation and allowing the claim.”)
d. BWC claims
staff shall direct questions regarding attorney-client privilege and attorney
work product as it relates to claim file documentation and notes to a BWC
attorney.
2. Fraud
Information and Documentation
a. Claim
files shall not include any documents or references to fraud referrals,
meetings, correspondence, or other communications, or any information
pertaining to fraud allegations or pending investigations.
b. Upon
completion of a fraud investigation, the SIU shall determine and be responsible
for updating the claim file with necessary and appropriate investigation
documents.
1. When claims
service staff are trying to determine if a hard copy or physical file exists or
a claim has hard copy evidence stored at MAFIL, claims staff shall review the
Folder Details and Folder Location information in the claims management system,
which will indicate if there is a physical file at MAFIL (if there is HCE it
will also be reflected as a physical file).
a. Select
“ODI SO” (On Demand Imaging) in “Request Type” if claims service staff are
requesting that hard copy documents be imaged into the claim for viewing; and
b. Select
“Service Office” in “Request Type” if claims service staff is requesting that
the hard copy file or HCE be sent to the office location field.
a. Returned
to MAFIL in its folder or otherwise intact; and
b. That the
claim folder location is updated to reflect “In Transit”.
5. Upon
receipt of the needed documentation, claims service staff shall:
a. Ensure all
retrieved documentation is imaged into the claim;
b. Enter a claim
note indicating the claim has been electronically reconstructed and the date.