We offer Member-focused service, a wide choice of plans and doctors, financial strength and affordable rates.

Workers' Compensation FAQ

Can Pacific Group Agencies Coordinated Plans make a group benefits health claim and a workers' compensation claim?

No, workers' compensation carriers are enjoined by most states not to solicit claims either from the group health benefits to workers' compensation or vise versa.

Who determines the claims status as to coverage compensability?

Physicians 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.

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.

What should an employer do if they don't have all the facts and claims answers?
The 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.
When are the forms, 5020, 5021 and DWC-1 to be completed, mailed or faxed?
Please send them at your convenience when the injury occurs.
How soon would a claim number be available?
Within 24 hours, Pacific Group Agencies will coordinate the claim set up and contact all parties with the claims information.
How does Pacific Group Agencies effect claims reserving for workers' compensation claims?
Pacific 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.
What is the best way to report a claim if the employer is not sure if it is work related?
Always 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.
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.
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' compensation plan.
Will Pacific Group Agencies coordinate all workers' compensation benefits?
How would Pacific Group Agencies handle an employer representative's disagreement on the handling of a claim?
The 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.
What is Pacific Group Agencies policy towards FRAUD investigations?
Pacific 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.