Drift report

Upon receiving notice of an employee injury from the employer, the adjuster confirms that the employer has provided the DWC-1 claim form to the injured worker. Our service standard is that the claim form is provided to the employee within five working days of the employer's notice of injury. Document the date of notice and the date the form was provided in the claim file.

Every indemnity claim must receive a compensability decision. The adjuster must accept or deny the claim within 120 days of the filing of the claim form. If the decision deadline passes without action, escalate to the supervisor. Denials must state the specific grounds and be sent to the employee and their attorney of record.

Route all requests for authorization (RFAs) to the UR vendor on the day of receipt. For prospective and concurrent review, the UR decision is due within 10 business days of receipt of the request. Where additional information is needed, the decision may be extended per the vendor's discretion. Expedited review applies when the physician documents imminent and serious threat to health.

While a claim is on delay pending the compensability investigation, authorize treatment consistent with MTUS up to a maximum liability of $5,000 until the claim is accepted or denied. Track interim medical spend in the claim system and alert the adjuster at 80% of the cap.

The primary treating physician is required to submit progress reports (PR-2) at least every 60 days. If a report is not received on schedule, send a written request to the physician's office and document the follow-up in the activity log. Missing reports for over two cycles trigger a treating physician compliance review.

Compensability determinations follow our standard review cycle: intake review in week one, investigation through the second month, and a final determination completed before the close of the four-month review window that begins when the employee's claim paperwork is filed. Supervisory sign-off is required on all denials.

Reimburse injured employees for reasonable transportation to and from authorized medical appointments at the state mileage rate. Process reimbursement requests in the order received; payment must issue within 90 days of receiving the employee's request with supporting documentation.

When a claim involves permanent partial disability and no qualifying offer of regular, modified, or alternative work is made within 60 days of the first PPD report, issue the supplemental job displacement voucher in the amount of $5,000. Document voucher issuance and expiration in the claim file.

All late-payment exposure on indemnity benefits is capped at 10 percent of the late amount under any circumstances, including where a delay is later found unreasonable. Apply the increase automatically and note it on the benefit printout.

Issue the first temporary disability benefit notice promptly. Our service standard is to have all first notices in the mail within three weeks of learning of the injury and disability, with the benefit amount and calculation method stated.

On receipt of a filed claim form, authorize treatment consistent with MTUS up to the $10,000 statutory liability cap pending the compensability decision. Authorization must be issued within five working days of the claim form filing and documented in the utilization log.

Compute temporary total disability using the standard worksheet: gross average weekly earnings from all employment, multiplied by 60 percent, subject to the statutory minimum and maximum in effect on the date of injury. Attach the worksheet to the first payment record.

To consolidate mailings and reduce postage errors, the DWC-1 claim form is enclosed with the first benefit notice package rather than sent separately, so the employee receives the form together with the initial payment explanation.