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Claims Services Division

            

The Claims Services Division is a team of dedicated employees providing quality oversight and support of multiple workers’ compensation programs. The Old Fund is the legacy claims liability that existed upon the privatization of workers’ compensation, which is administered by the Third Party Administrators (TPAs); Sedgwick CMS and HealthSmart. In addition, this Division provides claims oversight of the Uninsured Employer Fund (UEF), the Federal Black Lung program with dates of last exposure prior to January 1, 2006, and the State Agency Workers’ Compensation (SAWC) program. A primary focus is to ensure the claims are properly reserved and administered to the Best Claims Practice standards, and that the claims are in compliance with statutory and regulatory provisions. 

There are additional internal controls for which this Division is responsible for to ensure proper management of these claims. For example, the Claims Services Division performs on-site Best Claims Practice Reviews, on-going quality assurance reviews, large loss review staffing with each TPA, indemnity payment approval threshold of $25,000.00 or greater, and the settlement initiative. This Division also performs multiple regulatory duties; such as, maintaining the Occupational Pneumoconiosis (OP) Board and the Permanent Total Disability Review Board (PTDRB) dockets, the Claims Index, and the Electronic Data Interchange (EDI) program. In addition, the Claims Services Division coordinates with the West Virginia State Auditor’s Office and the TPAs to establish Electronic Fund Transfers (EFTS) for injured workers or their dependents who receive benefits. 

The Claims Services Division maintains 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. This Division also has 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, this Division 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. Click on the applicable links below for additional information regarding each program.

  West Virginia State Agency Workers’ Compensation (SAWC) 
  Electronic Data Interchange (EDI)
  Uninsured Employer Fund (UEF) 
  Old Fund Claims
  New Claims Applications
  Occupational Pneumoconiosis (OP) Board
  Permanent Total Disability Review Board (PTDRB)
  West Virginia Workers’ Compensation Claims Index
  Independent Medical Examiner (IME) Listing

The West Virginia Offices of the Insurance Commissioner (WVOIC) contracts with two TPAs and a carrier to administer claims on its behalf. The two TPAs and carrier 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, Security, and Guaranteed funds
  • Zurich, the carrier which administers the State Agency Workers’ Compensation (SAWC) program

To maintain efficiency and compliance within the multiple programs, the Claims Services staff has interaction with Zurich, Sedgwick CMS, and HealthSmart daily.
 

CLAIMS SERVICES DIVISION
P.O. Box 50540
Charleston, WV 25305
Phone: (304)-558-5838
Fax: (304)-558-8948
           

                       

Notices to Dependents

WV Code §23-4-10 – Classification of Death Benefits; “Dependent” defined:

There are two types of dependent benefit applications; the 104 Weeks, and Dependents Benefits. Please review each application carefully to determine which is applicable.

The following Notices to Dependents under WV Code §23-4-10(f) are to be used by the WVOIC, self-insured employers, private carriers, and TPAs to inform dependents receiving 104-week awards that they may be eligible for benefits under WV 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]
  Application for Fatal Dependents’ Benefits {OIC-WC-201]

 

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 
  Application for PTD Benefits 
  Controlled Substances Form
  Attending Physician Benefits Form
  Diagnosis Update
  Direct Deposit Form 1-04-11
  Low Back Examination
  Old Fund Claim Re-Opening Application for Permanent Partial Disability
                           

  

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 the Claims Services Division webpages, 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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