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| Q:
What is Claims Adjudication Services (CAS)?
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| The
Claims Adjudication Services is a centralized adjudication unit,
established in 1996. All New Brunswick claims are adjudicated
by this department. Its mandate is to reduce time to first cheque,
to have a standardized approach and to have consistent decision-making.
Among the services it provides is the inquiry line, imaging,
indexing, payment of medical aid bills, claim preparation and
the adjudication of claims. |
| Q:
How is a claim created? [Top] |
A
claim may be created upon receipt of :
- WHSCC First
Physician's Report of Accident or Occupational Disease Form
8, Outpatient Department report, or a WHSCC Report of Accident
or Occupational Disease Form 67.
A claim number
is assigned immediately upon receipt of one of the above
by WHSCC. The creation of a claim does not constitute its
acceptance. The claim must be adjudicated before acceptance.
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| Q:
What is adjudication? [Top] |
- Adjudication
is a systematic method for the evaluation of information
in the file to determine entitlement to benefits.
- The adjudicator
must determine if the accident is attributable to the worker's
employment and, therefore, compensable. The questions that
the adjudicator must answer are: "did the accident
arise in the course of employment?"; and "did
the accident arise out of employment?".
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| Q:
How is adjudication done? [Top] |
- An adjudicator
within the Claims Adjudication Services (CAS) unit will
make the determination to accept or reject a claim.
- The following
documentation, as a minimum, is required to make this determination:
An
application from the injured worker (Form 67) must be
signed by both the worker and the employer; and
A
medical report from the attending/treating physician (Form
8), or a chiropractic report from the attending chiropractor
(Form 8c).
- In the majority
of cases, a Commission physician will be consulted.
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| Q:
When is medical
assistance sought in adjudication? [Top] |
- Medical relationship
between the accident and injury is not obvious
- Seizures,
food, or blood poisoning
- Hearing loss
- Heart claims,
serious injuries, fatalities
- Pre-existing
conditions
- Psychological
disorders
- Occupational
diseases, infectious diseases
- Repetitive
strains, cumulative trauma
- Complications
of injury, treatment
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| Q:
What is a 'claim adjudicator'?
[Top] |
| The
claim adjudicator accepts/rejects a claim, and then manages
the claim so long as it is expected to remain open less than
6 weeks. |
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| Q:
What is the physician's obligation to file initial
and ongoing reports? [Top] |
| The physician's
obligation, under the Worker's Compensation ACT, to provide
the WHSCC with timely reports regarding the injury and resulting
condition of the worker. |
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| Q:
What if my patient does not
file a claim? [Top] |
| If a physician
has treated a patient who indicated his injury was work related
however he/she does not file an application (Form 67) with the
Commission, this becomes a "No claim" for which the
first treating physician will receive a fee of $10.00. This
is a one- time fee and only applies to the first medical report
received by the Commission. |
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