We Are Ready To Answer Your Questions
Workers’ Compensation insurance claims can be an overwhelming process. New state regulations and restrictions can affect the injured employee’s ability to receive timely benefits. We have a proven record of simplifying the claims process, while providing your employees with proper medical treatment to help them return to work.
Forms
State of California
Workers’ Compensation Claim Form (DWC-1)
If you are injured or become ill, either physically or mentally, because of your job, including injuries resulting from a workplace crime, you may be entitled to workers’ compensation benefits.
PLEASE READ ALL INSTRUCTIONS LISTED ON THE FORM
State of California
Employer’s Report of Occupational Injury or Illness (DLSR-5020)
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the
date of the incident OR requires medical treatment beyond first aid.
PLEASE READ ALL INSTRUCTIONS LISTED ON THE FORM
Elite Claims Management™
Supervisor’s Incident Investigation Report
Please use this form provided by Elite Claims Management™ to document the investigation into the injured employee’s incident. Please complete the form fully and return to Elite Claims Management™ as soon as possible.
Elite Claims Management, Inc.
Employee’s Incident Report
If you have been injured in a work-related incident, please use this form to provide a detailed account of the incident. Please be accurate, specific, and as thorough as possible when completing the form.
Frequently Asked Questions (FAQs)
- Claims Management
- Bill Review
- Medical Provider Network
- Managed Care
- Litigation Management
- Disability Management
Disability Management is a program we use to help employers assist their employees who are unable to work due to injury or illness. The goal is to benefit the employer by returning experienced, trained employees to work quickly.
To learn more, see: Disability Management
Litigation Management is a process of planning, controlling, organizing, implementing, and monitoring the cost of legal services. It may only be needed in rare cases, but our team has decades of experience working with and overseeing attorneys during a workers’ compensation claim.
To learn more, see: Litigation Management
A Medical Provider Network (MPN) is a network of providers, including physicians, created to provide medical treatment for work injuries of employees in California. An MPN must be approved by the DWC, and the MPN provides all medical care for employees with work-related injuries or illnesses. Under state regulations, MPN’s are required to have doctors specializing in work-related injuries and doctors with expertise in general areas of medicine.
To learn more, see: Medical Provider Network
Bill Review is the rigorous audit process to recover medical costs due to coding errors, up-coding, duplicate charges, and performing unrelated treatments to the employee’s injury.
To learn more, see: Bill Review
Managed Care is a group of services intended to reduce the cost of providing health care while improving the quality of that care. Elite Claims Management promotes quality patient care through the following services:
- Medical Care Management
- Nurse Case Management by Healthcare Professionals
- Utilization Review (UR) for Treatment Approval
- Pharmacy Care Management
To learn more, see: Managed Care
The medical treatments are subject to the guidelines set forth by the Medical Treatment Utilization Schedule (MTUS) and approval through a Utilization Review (UR) process, which was established in a 2008 State of California Law.
Utilization Review (UR) is the process used by employers or claims administrators to determine if a proposed treatment requested for an injured worker is medically necessary. All employers or their workers’ compensation claims administrators are required by law to have a UR program.
To learn more, see: How Does Utilization Review Affect A Claim?
If you disagree with the Utilization Review determination, the injured employee can ask for a review through Independent Medical Review (IMR).
See the following article: What Is A Claims Administrator?
Please see the following chart: Claims Process
If a claim is delayed, a decision must be made within 90 days of receipt of the DWC-1 claim form. If your was delayed, but is later accepted, lost time benefits due must be mailed within 14 days of the claim being accepted.
Within 14 days of knowledge of the claim by your employer, you will be mailed a notice of either Acceptance, Delay, or Denial.
Helpful Links
State of California: Workers’ Comp Resources
Divisions within the Department of Industrial Relations
Labor Commissioner’s Office
http://www.dir.ca.gov/DLSE/dlse.html
The Labor Commissioner’s Office, also known as the Division of Labor Standards Enforcement (DLSE), was established to adjudicate wage claims, investigate discrimination and public works complaints, and enforce Labor Code statutes and Industrial Welfare Commission orders.
Cal/OSHA
http://www.dir.ca.gov/dosh/dosh1.html
The Division of Occupational Safety and Health (DOSH), better known as Cal/OSHA, protects workers from health and safety hazards on the job in almost every workplace in California through its research and standards, enforcement, and consultation programs. Cal/OSHA also oversees programs promoting public safety on elevators, amusement rides, and ski lifts. In addition, the division oversees programs promoting the safe use of pressure vessels (e.g., boilers and tanks).
CHSWC – Commission on Health and Safety and Workers’ Compensation
http://www.dir.ca.gov/CHSWC/chswc.html
CHSWC is charged with examining the health and safety and workers’ compensation systems in California and recommending administrative or legislative modifications to improve their operation. The Commission was established to conduct a continuing examination of the workers’ compensation system and of the state’s activities to prevent industrial injuries and occupational illnesses and to examine those programs in other states. CHSWC also administers the Worker Occupational Safety and Health Training and Education Program (WOSHTEP), which sponsors workplace health and safety training programs and distributes educational materials on job safety.
DWC – Division of Workers’ Compensation
http://www.dir.ca.gov/dwc
The Division of Workers’ Compensation (DWC) monitors the administration of workers’ compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers’ compensation benefits. DWC’s mission is to minimize the adverse impact of work-related injuries on California employees and employers.
OSIP – Office of Self-Insurance Plans
http://www.dir.ca.gov/sip
The Office of Self Insurance Plans (OSIP) is a program within the director’s office of the Department of Industrial Relations (DIR) responsible for the oversight and regulation of workers compensation self-insurance within California. OSIP is also responsible for establishing and insuring that required security deposits are posted by self-insurers in amounts sufficient to collateralize against potential defaults by self-insured employers and groups.
Office of the Director
http://www.dir.ca.gov/directors_office.html
Coordinate and oversee the activities of the department’s divisions, boards, and commissions; collaborate with policymakers and community leaders to improve working conditions and employment relations throughout California; and communicate with interested parties, the media, and the public.
Industry Organizations
CAJPA – California Association of Joint Powers Authorities
http://www.cajpa.org
Cal PRIMA – Professional Risk Insurance Management Association
http://www.calprima.org
COSIPA – California Council of Self-Insured Public Agencies
http://www.cosipa.org
CSIA – California Self Insurance Association
http://www.caself-insurers.com
PARMA – Public Agency Risk Managers Association
http://www.parma.com
RIMS – Risk and Insurance Management Society, Inc.
http://www.rims.org
SCAHRM – Southern California Association for Healthcare Risk Managers
http://www.scahrm.org