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Module 5

adjudication

judicial dispute resolution process in which an appeal board makes a final determination

arbitration

dispute-resolution process in which a final determination is made by an impartial person who may
not have judicial powers.

Federal Black Lung Program

enacted in 1969 as part of Black Lung Benefits Act; provides medical treatment and other benefits for respiratory conditions related to former employment in the nations coal mines.

First Report Of Injury

workers' compensation form completed when the patient first seeks treatment for a work-related illness
or injury.

Material Safety Data Sheet ( MSDS )

contains information about chemical and hazardous substances used on site.

Merchant Marine Act ( Jones Act )

not a workers' compensation statue, but provides seaman with the same protection from employer
negligence, as FELA provides railroad workers.

permanent disability

refers to an illness or injured employee's diminished capacity to return to work

survivor benefits

claim that provides death benefits to eligible dependents, which are calculated according to the
employee's earning capacity at the time of illness or injury.

temporary disability

claim that covers healthcare treatment for illness and injuries, as well as payment for lost wages.

vocational rehabilitation

claim that covers expenses for vocational retraining for both temporary and permanent disability cases

The Office of Workers' Compensation Programs ( OWCP)

administers programs that provide medical treatment, vocational rehabilitation, and wage replacement benefits

The Energy Employees Occupational Illness Compensation Program

began providing benefits to eligible employees and former employees of the Department of Energy in 2001

The Federal Black Lung Program

was enacted in 1969 to provide medical treatment and other benefits for respiratory conditions related to
persons formerly employed in the nation's coal mines.

The Federal Employee's Compensation Act ( FECA )

program provides workers' compensation to all federal and postal workers throughout the world for employment-related injuries and occupational diseases, and includes medical and vocational rehabilitation, payment for medical care and wage replacement.

The Longshore and Harbor Workers' Compensation Program

covers private-industry workers who are engaged in extracting natural resources from the outer continental
shelf

Material Safety Data Sheets contain information about

chemical and hazardous substances used on site

Workers Compensation Board

responsible for administering workers' compensation laws

adjudication

the judicial dispute resolution process in which an appeals board makes a final determination

First Report of Injury

is completed when the patient initially seeks treatment for a work- related illness or injury

The Division of Coal Mine Workers' Compensation administers and processes
claims for the

Federal Black Lung Program

Federal and state laws require employers to maintain workers' compensation coverage to
meet minimum standards, covering a majority of employees for work-related illnesses and injuries

if the employee was not negligent in performing assigned duties

The medical term for black lung is

pneumoconiosis

The Mine Safety and Health Administration (MSHA) is similar in purpose and intent to the

Occupational Safety and Health Administration (OSHA)

Material Safety Data Sheets (MSDS) contain data regarding

chemical and hazardous substances used at a worksite

How long must records of employee vaccinations and accidental exposure
incidents be retained?

20 years

The Federal Employment Liability Act (FELA) and the Merchant Marine Act were designed
to

provide employees with protection from employer negligence

Which agency is responsible for handling appeals for denied workers' compensation claims

State Workers' Compensation Commission

Workers compensation survivor benefits are calculated according to the

employee's earning capacity at the time of illness or injury

A patient was treated by his primary care physician on 01/25/YYYY for a wrist fracture that
occurred on the job. On 02/02/YYYY, the patient was evaluated for symptoms of severe high blood pressure and a recheck of the wrist fracture. Where should the provider document treatment from the visit on 02/02/YYYY?

Only the fracture recheck is to be recorded in the workers' compensation record

The First Report of Injury form is completed by the

provider

The treating physicians personal signature is required

on all original reports and photocopies

After the claim has been acknowledged, the information that must be included on all correspondence to the employer, payer, and the Commission Board is the

file/case number assigned to the claim

When an appeals board renders a final determination on a claim, this is known as

adjudication

Which of the following can be a designated state workers' compensation fiscal agent?

a private, commercial insurance company

Workers compensation plans allow an employer to set aside a state-mandated
percentage of capital funds to cover employee compensation and benefits are

self-insurance plans

If a patient fails to alert the provider that an injury was work-related, then changes his mind later and tries to receive workers' compensation benefits, the claim will most likely be

denied by the workers' compensation payer, and the patient will have to appeal

Which box is marked in Block 6 workers' compensation CMS-1500 claims?

OTHER

What is entered in Block 17a of the workers compensation CMS-1500 claim?

nothing ; the block is left blank

How do workers compensation laws protect the employer?

by limiting the award an injured employee can recover from an employer and by limiting the liability of
coworkers in most incidents.

5 classifications of workers' compensation cases?

medical treatment, temporary disability, permanent disability, vocational rehabilitation, and survivor
benefits.

3 circumstances qualify an employee for workers compensation benefits?

1) injured while working within the scope of the job description, 2) injured while performing a service
required by the employer, 3) succumbs to a disorder that can be directly linked to employment ( asbestosis or mercury poisoning ) * some states have protection for jobs considered extremely stressful; stress would be the qualifying reason.

Time limit for filing First Report of Injury form?

Varies from 24 hours to 14 calendar days; depending on state requirements. It is best to complete immediately as not to forget and miss the qualifying time limits.

Why not obtain a signature from First Report of Injury or CMS-1500 claim form?

There is no patient signature line on this form and the law states when a patient requests treatment for a
work related injury or disorder, the patient has given consent for the filing of compensation claims and reports.

Claims for treatment provided to injured employees on worker's compensation cases
should be sent to the

employer-designated compensation payer

Employers with sufficient capital can

self-insure

Which is the special report that is completed and submitted to the workers' compensation
payer when the patient first seeks treatment for a work-related injury?

First Report of Injury form

The death benefits paid to eligible dependents are called _______ benefits.

survivor

Workers' compensation law states that when a patient requests treatment for a work-related
injury, the patient has given consent for

the filing of compensation claims and reports.

Protection from railroad employer negligence is covered under the

FELA - Federal Employment Liability Act

Workers' compensation insurance also provides payments to qualified

dependents of workers who die from a compensable illness or injury.

The State Insurance Fund must offer

offer workers' compensation insurance to any employer requesting it.

The Federal Black Lung Program covers

coal miners who are totally disabled due to pneumoconiosis.

The Date of Current ______ must be completed in block 14 of the CMS-1500 claim.

Injury

What requires employers to maintain workers' compensation coverage?

Federal and state laws

What are the four programs of the Office of Workers' Compensation Programs

1) Energy Employee's Occupational Illness Compensation Program

2) Federal Black Lung Program

3) Federal Employee's Compensation Act ( FECA) Program

4) Longshore and Harbor Workers' Compensation Program

The Department of Labor also manages programs designed to prevent work-related
injuries and illnesses, they include?

Mine and Safety Health Administration ( MSHA )
Occupational Safety and Health Administration
(OSHA)

Other federal programs include:

Federal Employment Liability Act (FELA)
Merchant Marine Act ( Jones Act )

Workers Compensation Board or Commission is:

a state agency responsible for administering workers' compensation laws and handling appeals for
denied claims or cases in which a worker feels compensation was too low

First Report of Injury ( 4 copies go to )

1) State Workers' Compensation Board/Commission

2) Employer - designated compensation payer

3) Ill or injured party's employer

4) Patients' work related injury chart

black lung disease

pneumoconiosis

When patient tells you this was a work related injury, you must obtain the following info:

Name / address of present employer,
Name of immediate supervisor,
Date & time of the accident or onset of disease
Site where injury occurred
Patients' description of the onset of the disorder; if patient is claiming injury due to hazardous chemicals
or compounds, these should be included in the patient's description of the problem
-In addition the patients' employer must be contacted to obtain the name and mailing address of the compensation payer
-ask for a faxed confirmation from the employer of the worker with the on the job injury. If the employer disputes the legitimacy of the claim, you should still file the First Report of Injury. The employer must also file an injury report with the compensation commission/board.

purposeful intent

fraud

taking advantage of a situation

abuse

example of employer fraud

committed by an employer who misrepresents payroll amounts or employed classifications

example of employee fraud

committed when an employee lies or provides false information or a false statement, intentionally fails to
report income from work, or willfully misrepresents a physical condition to obtain benefits from the state compensation fund

provider fraud

committed by healthcare providers and attorneys who inflate their bills for services or bill for treatment of
non-work related illnesses and injuries

Progress reports include:

patients name & compensation file/case number
treatment and progress report
work status at the present time
statement of further treatment needed
estimate of the future status with regard to work or permanent loss or disability
copies of substantiating x-ray, laboratory, or consultation reports

Progress reports copies go to

one copy to compensation payer
one copy to the patient file

What do you do if an injured worker presents for the first visit without a written or personal
referral from the employer

contact the employer immediately

what if treatment is sought in another state than where the injury occurred

contact the workers' compensation board/commission of the state where the work related injury occurred

The Office of Workers' Compensation Programs administers provide

medical treatment, vocational rehabilitation, wage replacement benefits

The Energy Employees Occupational Illness and Compensation Program began providing
benefits to eligible employees and former employees of the Department of Energy in

2001

Which is responsible for administering workers' compensation laws?

Workers' Compensation Board

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