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Claims Services Division


~ Claims Services Division ~

The Claims Services Division is team of dedicated employees providing quality oversight and support to various programs. Our oversight includes monitoring the claims administration of the West Virginia State Agency Workers’ Compensation Program (SAWC), Old Fund claims with a date of last exposure prior to July 1, 2005, Coal Workers Pneumoconiosis claims with a date of last exposure prior to January 1, 2006, and established Uninsured Employer Fund (UEF) claims. 

The Claims Services Staff strives to maintain efficiency and compliance via monthly quality assurance reviews, quarterly large loss claims staffing, and on-site semi-annual claims best practice reviews. Our staff is also responsible for reviewing and approving benefits payments set up by the Third Party Administrators’ (TPA), reviewing and approving reserves of $25,000 or greater, and reviewing and approving settlements of $25,000 or greater. We work with the West Virginia State Auditor’s Office to establish Electronic Fund Transfers (EFTS) for injured workers or their dependents who receive benefits. 

In addition to our claims staff, we have a nurse on-site to review pharmacy reports for trends, conduct internal medical reviews of claims with complicated medical conditions or issues, and to assist the claims staff in determining appropriate medical oversight of claims. We also have Insurance Program Specialists, who are responsible for monthly and yearly reporting, trending based on those reports, IT testing and workflow development, Electronic Data Interchange (EDI), and automation of our claims review processes. In addition, we will implement a medical audit project in the near future. 

The Claims Services Division is currently working with, or is responsible for the oversight of the following programs:

      1)  West Virginia State Agency Workers’ Compensation (SAWC)
      2)  Electronic Data Interchange (EDI)
      3)  Uninsured Employer Fund (UEF)
      4)  Old Fund Claims
      5)  New Claims Applications
      6)  Occupational Pneumoconiosis (OP) Board
      7)  Permanent Total Disability Review Board (PTDRB)
      8)  West Virginia Workers’ Compensation Claims Index 



The Claims Services Division contracts with TPAs to administer claims on its behalf. The three TPAs currently under contract are:

  • Sedgwick CMS, which administers the largest portion of the Old Fund Trauma and UEF claims;
  • HealthSmart Disability Management, which administers the majority of State Occupational Pneumoconiosis (OP) and Federal Black Lung (FBL) claims;
  • Zurich, which administers the State Agency Workers’ Compensation (SAWC) program.
To maintain efficiency and compliance within the multiple programs, the Claims Services staff conducts monthly quality assurance reviews, quarterly large loss claims staffing, and on-site semi-annual claims best practices reviews. In addition, there is interaction between the Claims Services staff and the TPAs daily..

CLAIMS SERVICES DIVISION
P.O. Box 50541
Charleston, WV 25305
Phone: (304)-558-5838
Fax: (304)-558-8948

WV State Agency Workers’ Compensation Program (SAWC)

The SAWC program has a $250,000.00 deductible policy with Zurich, which was initially effective on October 1, 2011. The Claims Services Staff conducts ongoing quality assurance reviews, coordinates and participates with large loss claims staffing, and travels to Pittsburgh, PA when conducting on-site semi-annual claims best practices reviews that ensure compliance and claims handling efficiency.

The West Virginia state agencies, boards and commissions have been combined under one workers' compensation policy covering all state employees. Specific policy information is provided below:

Enabling Statute - WV Code §33-2-21a
Member Listing - SAWC Members PDF
Workplace Posting Notice - Posting Notice PDF
SAWC Safety Policy Statement - SAWC Safety Policy Statement PDF

Additional Information:

  Claims Reporting –

Employer Manual

HealthSmart Wallcard

Zurich - Important Information

Employee Manual

HealthSmart Employee ID

TTD Wage Calculator

Employee Brochure

Agency and Location Site Codes

Election of Option Form

Customer Letter

Zurich FAQ

  Forms –

Application for Fatal Dependent Benefits

SAWC 1 - First Report of Injury - Employer

Report of OP - Employer

Attending Physicians Report

SAWC 2 - First Report of Injury - Employee / Physician

Report of OP - Physician

Change of Address Notification

Functional Job Description

Report of OP - Physician Interpretation

Change of Physician

Pharmacy Invoice

Service Invoice

Claimant Travel Voucher

Physician Statement of Physical Capabilities

Transitional Employment Agreement

Claim Reopening Form

Report of Hearing Loss

Wage Report

Diagnosis Update

Report of OP - Employee

Request for Change or Opt-Out

Contact Information:

Zurich
P. O. Box 968044
Schaumburg, IL  60196-8044
Phone: 1-(800)-987-3373
Fax: 1-(973)-394-5262

Tonya Montez (claims questions)
Phone: (304)-558-1966, ext. 3132
Email: tonya.montez@wvinsurance.gov

Rick Fisher (claims questions)
Phone: (304)-558-1966, ext. 3028
Email: rick.fisher@wvinsurance.gov

Email Inquiry – SAWC@wvinsurance.gov
Tom Judy, Program Manager (policy inquiries)
Phone: (304)-558-6279, ext. 1127
Email:
thomas.judy@wvinsuarnce.gov


Electronic Data Interchange (EDI) Program

The Claims Services Division has a Workers’ Compensation System Specialist who assists the new carriers and self-insured employers with their EDI issues. Claims Services is currently developing a comprehensive EDI program to monitor regulatory compliance of all Workers’ Compensation carriers. The program will include the following tasks:

  • Monitoring the claims reporting;
  • Educating the carriers on the process and applicable policies;
  • Trending the data via reports;
  •  Implementing a penalty and fine system for carriers that are repeatedly non-compliant.

Additional Information: 

WV OIC EDI

Match Data Table

Dependent Screen Manual for IComp

WVOIC EDI Implementation Guide

Occupation Codes for Manual Classification Code

Track Changes Document

DN Error Table

Population Restrictions Table

Rule 2

Element Requirements Table

Sequencing Table

Event Tables for FROI, SROI, and SROI Periodic

Valid Values Table

 

 
If you have questions concerning the EDI program, you may contact:

Ralph Farmer, Claims Specialist
Phone: (304)-558-1966, ext. 3046
Email: ralph.farmer@wvinsurance.gov


Uninsured Employer Fund (UEF)


UEF claims are filed initially with the Employer Coverage Division. The Claims Services Division monitors the UEF claims that are administered by Sedgwick CMS. The UEF pays awards for injured workers when non-insured employers default in payments. In addition, the UEF maintains a solvent fund balance from which to pay claims via the collection of fines, assessments, and any applicable benefit recoveries. All efforts are made to identify the chargeable employer(s). All UEF claims must be completed and sent to the address provided on the application below:

  Uninsured Employer Fund Application


Old Fund Claims

The claims Services Division provides oversight of the Old Fund for the Offices of the Insurance commissioner (OIC), which is the state’s claims liability following the privatization of Workers’ Compensation. The Old Fund consists of injury claims, occupational disease claims, occupational pneumoconiosis claims, and dependent claims with a date of injury or date of last exposure prior to July 1, 2005. We are also responsible for the oversight of Coal Workers’ Pneumoconiosis Fund claims with a date of last exposure prior to January 1, 2006.

The primary responsibility of the Claims Services Division regarding the Old Fund claims is to conduct reviews relative to quality claims processing and compliance with statutory and regulatory provisions. Claims Services ensures proper management of these claims via on-site bi-annual claims best practices reviews, monthly quality assurance reviews, quarterly large loss reviews, reserve payment approval with a threshold of $25,000 or greater, settlement approval with a threshold of $25,000 or greater, and review and approval of benefit payments.

Claimants' Information Brochure - Sedgwick

Claimants' Information Brochure - HealthSmart

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


New Claims Applications

New claim applications are received by the Claims Services Division that is specifically determined to fall under the Old Fund and the Coal Workers Pneumoconiosis Fund (CWPF).

Claims that fall under the Old Fund include applications for occupational disease claims such as hearing loss or toxic exposure, with dates of last exposure prior to July 1, 2005; applications for occupational pneumoconiosis claims with dates of last exposure prior to July 1, 2005; applications for Fatal Dependents Benefits for claims with dates of last exposure prior to July 1, 2005. Claims that fall under the CWPF include Federal Black Lung Notice of Claim with dates of last exposure prior to January 1, 2006, and Federal Black Lung Survivor claims with dates of last exposure prior to January 1, 2006.

All claims are reviewed for applicable dates of last exposure and the responsible employer. Upon determination that a claim belongs to the Old Fund or CWPF, it is processed to obtain a Jurisdictional Claim Number (JCN), and assigned to a TPA for administration. Claims filed after the specified dates must be filed with new carriers. 

  Employee’s and Physicians Report of Occupational Injury or Disease [OIC-WC-1]

  Employer’s Report of Occupational Injury or Disease [OIC –WC-2]

  Employee’s and Physicians’ Report of Occupational Hearing Loss [OIC-WC-1HL]

  Application for Fatal Dependents’ Benefits {OIC-WC-201]

  Employees’ Report of Occupational Pneumoconiosis [OIC-WC-1OP]

  Employers’ Report of Occupational Pneumoconiosis [OIC-WC-2OP]

Claim applications for Old Fund CWPF must be submitted to:

West Virginia Offices of the insurance Commissioner
Claims Services Division

PO Box 50541
Charleston, WV  25305
Phone: (304)-558-5838
Fax: (304)-558-8948


Occupational Pneumoconiosis (OP) Board

Occupational Pneumoconiosis claims may be referred to the Occupational Pneumoconiosis Board by the Carrier/Self-Insured Employer/TPA for matters concerning exposure and the degree of pulmonary function. Claims Services is responsible for providing support to the Occupational Pneumoconiosis (OP) Board who conducts these examinations. Support includes the receipt and tracking of requests for OP Board examinations, ensuring that all required information is included with the request, scheduling the examinations, issuing related correspondence, communication with pertinent parties, and reviewing OP Board invoices for payment approval.  W. Va. Code § 23-4-8a.

   
Carrier Request for Occupational Lung Center Examination

All requests must be submitted to the following address:

West Virginia Offices of the Insurance Commissioner
Claims Services Division
PO Box 50541
Charleston, WV 25305
Phone: (304)-558-5838
Fax: (304)-558-8948


Permanent Total Disability Review Board (PTDRB)

When a claim is reopened for permanent total disability consideration or a permanent total disability issue in litigation is remanded to the PTDRB for further evaluation, it is the carrier/self-insured Employer/TPA’s responsibility to obtain current medical information, and prepare the claim for review by the Permanent Total Disability Review Board (PTDRB). W. Va. Code § 23-4-6(j)(1) and  CSR §85-5-3.7.

Claims Services is responsible for providing support to the PTDRB in its consideration of claims for permanent total disability. Support includes the receipt and tracking of requests for review, insuring that all required information is included with the request, scheduling the claims for review, issuing related correspondence, communication with pertinent parties, and reviewing PTDRB invoices for payment approval.

   
Carrier/Self-Insured/TPA Request for Permanent Total Disability Review

All requests for PTDRB review must be sent to the following address:

West Virginia Offices of the Insurance Commissioner
Claims Services Division
PO Box 50541
Charleston, WV 25305
Phone: (304)-558-5838
Fax: (304)-558-8948

If you have questions, you may contact:

Deborah Bryant, Claims Services Supervisor
Phone: (304)-558-1966, ext. 3120
Email:
deborah.bryant@wvinsurance.gov


West Virginia Workers’ Compensation Claims Index

The West Virginia Workers’ Compensation Claims Index was statutorily created to be established by the West Virginia Industrial Counsel.  W. Va. Code § 23-2C-5(c)

The Claims Services Division is responsible for reviewing and approving applications for access to the Claims Index. Approval may be given to Workers’ Compensation insurance carriers or TPAs. The Claims Index contains basic demographic data to assist insurers in obtaining information from other insurers regarding previously filed Workers’ Compensation claims filed by a specific claimant. Completed and signed applications must be sent to the Offices of the Insurance Commissioner Claims Services Division. A release signed by the claimant must be included with the application.

 
  West Virginia Workers’ Compensation Claims Index Application for Access

All applications must be mailed to the following address:

West Virginia Offices of the Insurance Commissioner
Claims Services Division
PO Box 50541
Charleston, WV 25305
Phone: (304)-558-5838
Fax: (304)-558-8948

If you have questions, you may contact:

Tonya Montez
Phone: (304)-558-1966, ext. 3132
Email:
tonya.montez@wvinsurance.gov


Notices to Dependents

The following Notices to Dependents under W. Va. Code §23-4-10(f) are to be used by the WV Offices of the Insurance Commissioner, self-insured employers, private carriers, and TPAs to inform dependents receiving 104-week awards that they may be eligible for benefits under W. Va. Code §23-4-15, and to explain how to apply for such benefits. Please refer to Informational Letter No. 176 found on the Insurance Commissioner’s website at http://www.wvinsurance.gov for additional information regarding these notices.

  Notices to Dependents Links:

  Initial Notice Under WV Code §23-4-10(f) To Recipients Of 104-Week Award Paid In Monthly Payments

  Notice Under WV Code §23-4-10(f) To Recipients Of 104-Week Award Paid In A Lump Sum

  Second Notice Under WV Code §23-4-10(f) To Recipients Of 104-Week Award Paid In Monthly Payments

  Application for 104-Week Dependent’s Benefits – [OIC-WC-202]

Workers’ Compensation Forms

The following forms are approved for use with West Virginia Workers’ Compensation Claims. Private carriers may modify these forms with regard to trade dress and carrier-specific Information (e.g., the name and mailing address of the private carrier or third party administrator), and may alter the forms to provide space for the entry of information on the form by the private carrier. HOWEVER, private carriers may NOT modify, add, or subtract fields requesting information to be provided by injured workers without prior OIC approval.

The forms below have been prepared recently by the OIC as examples of approved forms for general use:

  Request for Settlement Review

  Settlement Application

  Application for PTD Benefits

  Controlled Substances Form

  Attending Physician Benefits Form

  Diagnosis Update

  Direct Deposit Form 1-04-11

  Low Back Examination

  Physician’s Report of OP

Safety Message



Please make safety a priority. Every individual is responsible for helping ensure his or her work environment is safe and free of hazards. Let us all work to eliminate potential risk. 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 the options your company has available to assist an injured worker with returning to work.

*If you have an issue accessing any of the information or forms via the links on this webpage, please contact:

Paul D. Dixon II, MBA
Insurance Program Specialist & Webpage Developer
Phone: (304)-558-1966, ext. 3114
Email:
paul.dixon@wvinsurance.gov

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