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Group Agencies, Inc. CA Insurance License #0078489
Workers' Compensation FAQ
1. Can Pacific Group Agencies Coordinated Plans make a group
benefits health claim and a workers' compensation claim?
workers' compensation carriers are enjoined by most states not to solicit
claims either from the group health benefits to workers' compensation or vise versa.
2. Who determines the claims status as to coverage
are the sole determinate of whether a claim is a workers' compensation claim
or a group benefits claim. The attending physician examines the claimant. If
it is industrial, that is the way it is filed. The status of the physician in
the file is pertinent for the interpretation of their evidentiary opinion but
note not all physicians can make the decision for the file.
3. How soon after a suspected industrial illness or injury
occurs, should Pacific Group Agencies receive the notice of claim? On the job illness and / or
injuries should be reported the moment they are know, by calling a Special
Pacific Group Agencies, Inc. Claims 800-line.
4. What should an employer do if they don't have all the facts
and claims answers?
employer should still notify Pacific Group Agencies by the Special Pacific
Group Agencies Claims 800-line, which is available 24 hours a day, 7 days a
week, in order to activate the claim's Medical Case Manager. If this
notification is not immediate, experience has shown, that the final claims
cost is higher. The initial treatment's triage and medical direction is
critical to an employer's realized claims savings.
5. When are the forms, 5020, 5021 and DWC-1 to be completed, mailed or faxed?
send them at your convenience when the injury occurs.
6. How soon would a claim number be available?
hours, Pacific Group Agencies will coordinate the claim set up and contact
all parties with the claims information.
7. How does Pacific Group Agencies
effect claims reserving for workers' compensation claims?
Group Agencies coordinates claims reserving which is usually lower, because
our medical management is more effective in keeping the treatment within our
contracted physicians network. By accomplishing
this, the medical treatment outcomes are improved at lower costs.
8. What is the best way to report a claim if the employer is
not sure if it is work related?
report a claim exactly as you perceive it. When reporting the claim on the
Pacific Group Agencies Claims 800-line, explain your concerns. Pacific Group
Agencies assist aggressive adjudication of "Gray" claims, i.e.;
those claims about which we have questions.
9. Can Pacific Group Agencies delay and fully investigate a
claim while simultaneously continuing to coordinate the medical administration
under that status? Yes, and Pacific Group Agencies can coordinate the
group's health plan medical data to match treatments, care plans and
physicians to coordinate efficient medical care, regardless of cause.
10. Do the legal requirements of workers' compensation claims
apply to the Pacific Group Agencies, Inc. coordinated plans? Yes, the laws governing
claims payments do apply the same as they would to any other workers'
11. Will Pacific Group Agencies coordinate all workers'
compensation benefits? Yes.
12. How would Pacific Group Agencies handle an employer
representative's disagreement on the handling of a claim?
employer's proper notice entitles such a claims inspection, at the employer's
convenience. Pacific Group Agencies coordinates claims on behalf of the
employer, within the constraints of the law. In this capacity, the
"Employer's Bill of Rights" is applied and a claims objection can
hold up a claims settlement by writing to the court, who would then address
it with the employer.
13. What is Pacific Group Agencies
policy towards FRAUD investigations?
Group Agencies is very aggressive in protecting the employer's policy from
criminal and careless access to workers' compensation benefits to the
greatest extent possible. Methods center on the refer
of all suspicious claims to Special Investigations and if they are found to
be criminal, the District Attorney's office is notified.