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Claims Overview

Workers’ Compensation regulations and rules are established by each U.S. State, thus many requirements and timeframes vary depending on jurisdiction. along with our insurance carrier and TPA partners provide the compliance expertise and strategies to promote safe workplaces and comprehensive claims services for your specific State or States. The following Claims Overview highlights key steps and actions if an employee provides notice of a workplace injury or illness.

Notice and Injury Reporting

If an employee provides notice or reports an injury or illness resulting from the workplace, the first step is to obtain appropriate medical care. Thus, a pre-established medical care protocol to include emergency situations, immediate care, and how to access care after hours provides the medical care your employees need while responding to workplace impacts.

Either concurrent with coordinating initial medical care or as soon as possible conduct an accident investigation to include date/time/location, detailed accident description, documented witness statements, and any third-party involvement, i.e. machinery, sub-contractors, automobiles.

Timely claim reporting directly impacts the ability to manage claims outcomes and increases claims costs. A major insurance company study reported claims costs increased up to 32% when claims were reported after three days from the injury. Additionally, timely reporting is required to meet state compliance requirements.

The best standard for reporting is Immediately or if necessary, as soon as medical care is secured. provides 24/7 website and telephone reporting to capture compliance reporting and promptly initiate claims investigations.


Key to accident investigation is timely reporting. Immediate reporting is essential to preserve the accident site for internal safety review and external experts if necessary, obtaining detailed witness statements and all related time/location facts as well as any third-party involvement.

Claims expertise is essential during the investigation process to establish whether the employee’s alleged injury was work related and occurred in the course and scope of employment or if non-industrial or resulted from third-party involvement.

The primary considerations for determining compensability:

  • Arising Out of Employment (AOE)
  • Course of Employment (COE)

All reported injuries are reviewed by’s insurance carrier and TPA partner experts who will review first report of injury and all related information then contact the employer, employee and medical provider. A detailed submitted first report of injury is key for timely contacts and assigning the appropriate resources early in the investigation process.

The investigation process includes:

  • Accident Description and Witness Statements
  • Review for Fraud Red Flags
  • Employer Coordinated Drug Screening
  • Subrogation — Third Party Involvement
  • Medical Treatment and Relatedness to Alleged Injury
  • Response to Catastrophic occurrences

The accident investigation goal is to be both timely and thorough, ensuring appropriate medical and benefits are paid while actively managing a safe return to work. The timeframe to investigate and issue a determination varies by state. Most states require compensability decision within 21 days.

Medical Treatment

Timely access to appropriate, quality medical care is the most cost effective strategy. Medical costs continue to represent nearly 60% of total losses according to NCCI thus a comprehensive yet practical approach is required to manage claims outcomes as well as meet individual State compliance requirements.

Medical Cost Containment Services

  • Medical Provider Panels (Urgent Care, Physicians, Hospitals, Specialty)
  • Utilization Review (Medical Treatment Guidelines and State Requirements)
  • Diagnostic Procedures Protocols (X-ray, MRI, CT Scan)
  • Durable Medical Equipment
  • Prescription Drug Program
  • Medical Bill Review Services insurance carrier and TPA partners offer Medical Provider Panels to meet initial treatment through full recovery care as well as compliance obligations for Provider Panel quantity and Specialty required to be posted in the workplace. Additionally claims adjusters and nurse case managers work with physician treatment plans and utilize nationally recognized protocols to coordinate a safe return to work.

Claim Types and Severity

While there are many categories of workers’ compensation claims and some claim types are unique to specific States, the following represent the most common claim descriptions:

  • Report Only: Completed first report of injury or accident form with no indication of initial medical treatment nor anticipated medical treatment. Also referred to as Notice Only or Record Only.
  • Medical Only: Reported claim with initial medical treatment or continuing care. Either no lost days from work or total days lost are less than State minimum lost days to qualify as Lost Time. The range of lost days to calculate qualify as lost time vary by State and range from 2-7 or more days.
  • Lost Time: Reported claim with initial medical treatment and continuing care as well as lost work days which exceed State range.
  • Occupational Disease: While the standard and timeline for reporting vary by State, an occupational disease is most commonly defined as a chronic condition which develops over a period of time. Thus, identifying origin and timeframe are critical when determining compensability.
  • Death

How are benefits paid?

Employees with compensable claims are entitled to appropriate medical care consistent with allowed body parts often referred to as the allowed conditions. Medical bills are submitted to the insurance company or TPA specific to the allowed claim identifier (number). If an employee receives medical bills from the provider, the employee must contact their assigned adjuster to avoid past due notices.

Insurance companies and TPA’s will review medical bills for relatedness and appropriateness to allowed conditions and if approved will reimburse providers at the lessor of usual customary reasonable, state fee schedules or negotiated network rates.

Employees with compensable claims and lost work days that exceed State minimums are entitled to wage replacement, commonly referred to as temporary total disability (TTD) for a period up to return to work, maximum medical improvement or State specific schedules. Additionally many States permit temporary partial disability (TPD) also known as “wage loss” if an employee returns to work at a lower wage then pre-injury.

Wage replacement benefits, specifically temporary total disability (TTD) are calculated as a percentage of the injured employees Average Weekly Wage (AWW). While the percentage and calculations vary by State, the most common calculation is 66⅔% of the injured employees AWW subject to State minimums and maximums.

Wage replacement benefit calculations vary by state and may involve many considerations to determine average weekly wage as a basis for other benefits. Thus, the insured’s payroll records are critical to timely and accurately providing wage replacement benefits.

Return to Work

Along with timely, quality appropriate medical care the most powerful tool an insured has to positively impact a workers’ compensation claim is Return-to-Work (RTW). A safe return to work is an important step to complete the recovery process as well as restore an injured employee’s productive lifestyle.’s insurance company and TPA partners work directly with treating medical providers to identify appropriate return-to-work opportunities and coordinate a safe return to work with insureds. Return-to-Work opportunities may include modified or light-duty positions for specific periods of time during the recovery process. The benefits of a safe return-to-work go far beyond cost containment and facilitate a structured recovery, restoring a productive lifestyle.

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