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Claims Services Division

Claims Services Division

 

The Claims Services Division is responsible for a variety of programs.  We provide oversight of the Old Fund for the Offices of the Insurance Commissioner (OIC), which is the state’s claims liability after the privatization of workers’ compensation.  We have three third-party administrators (TPAs) administering the claims on our behalf.  The TPAs under contract are:  Sedgwick CMS, which has the largest portion of the old fund trauma claims; Wells Fargo Disability Management, which has the majority of State Occupational Pneumoconiosis (OP) claims; and American Mining Insurance Group that has the majority of Federal Black Lung (FBL) claims.  We also monitor the Uninsured Employer Fund (UEF) claims.  The Claims Services staff conducts monthly quality assurance reviews, quarterly large loss claims staffing and on-site semi-annual claims best practices reviews to maintain efficiency and compliance amongst the multiple accounts.  There is daily interaction with the accounts. 

 

New Claim Applications

This Division receives new applications with exposure that falls within the Old Fund and new applications that are specifically for the Uninsured Employer Fund (UEF) or Coal Workers’ Pneumoconiosis (CWP) Fund.  The new claims must be researched, entered and assigned to the TPAs for administration.  It is very important to validate the date of last exposure when determining where the application should be filed.  We receive occupational disease claims; such as occupational pneumoconiosis (OP) and Hearing Loss (HL), the applications must have a date of last exposure prior to July 1, 2005.  We also receive new claims filed for Federal Black Lung (FBL), the date of last exposure for these claims must be prior to January 1, 2006; the FBL claims are paid out of the CWP Fund.  Any claims filed after the specified dates, should be filed with the new carriers.  As mentioned previously, we have the Uninsured Employer Fund (UEF) which came into existence on January 1, 2006.  The uninsured claims are initially filed and received in the Employer Coverage Division at the OIC; the date of injury or date of last exposure for an uninsured claim must be on or after January 1, 2006.  All efforts are made to identify the chargeable employer. 

 

Electronic Data Interchange (EDI) Program

The Claims Services Division is responsible for the EDI Program.  We have a WC System Specialist that assists the new carriers and self-insured employers with their EDI issues.  We are in the process of developing a comprehensive EDI program to monitor regulatory compliance of all the workers’ compensation carriers.  We will be monitoring the claims reporting, educating the carriers on the process and applicable policies, trending the data via reports and lastly implementing a penalty and fine system for carriers that are repeatedly non-compliant.

 

WV State Agency Workers’ Compensation Program (SAWC)

The SAWC program has a two-hundred and fifty thousand dollar deductible policy with Zurich; the effective date of the initial policy was October 1, 2011.  The Claims Services Division conducts ongoing quality assurance reviews, coordinates and participates with large loss claims staffing and travels to Pittsburgh, PA to conduct on-site semi-annual claims best practices reviews to ensure compliance and claims handling efficiency.  

OP Board and PTD Review Board

We are responsible for Occupational Pneumoconiosis (OP) Board and the Permanent Total Disability Review Board (PTDRB); including the scheduling of the docket, communication to the pertinent parties and payment approval of the board’s invoices.  It should be noted that we receive applications for the OP Board and PTDRB from the old fund, new carriers and self-insured employers. 

 

Claims Index

The Claims Services Division reviews applications for access to the Workers’ Compensation Claims Index.  Approval may be given to workers’ compensation insurance carriers or third-party administrators (TPAs).  The Claims Index is legislatively mandated uniform system of gathering workers’ compensation claim information in order to make it available to the workers’ compensation industry.  The index contains basic demographic data to assist insurers in obtaining information from other insurers regarding previously filed workers’ compensation claims by a particular claimant.

 Please make safety a priority, every individual is responsible for helping ensure their work environment is safe and free of hazards.  Let us all work to eliminate potential risk and when an unavoidable accident does happen and there is a compensable injury, please assist the injured worker in receiving timely and adequate indemnity and medical care for the compensable injury.  If you do not have a return to work program, consider what options your company has available to assist an injured worker with returning to work.   

CLAIMS SERVICES 

    Phone: 304-558-5838 
    Fax: 304-558-8948 
    Mailing Address:   PO Box 50541 
                                Charleston, WV 25305


TPA’s CONTACT INFORMATION

Sedgwick CMS
P.O. Box 14490
Lexington, KY 40512
Phone: 1-(877)-925-5580
Fax: 1-(866)-828-8550

HealthSmart Disability Management
P.O. Box 3389
Charleston, WV 25333-3389
Phone: (304)-556-1100
Fax: (304)-556-1112


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