STANDARD OPERATING PROCEDURES
COST CONTROL PROGRAM
STANDARD OPERATING PROCEDURE FOR
CLAIMS MANAGEMENT BY
NATIONAL RISK SERVICES, INC.
CRITICALPATH Claims Administrators, LLC
National Risk Services, Inc. and their affiliate company, CriticalPath Claims
Administrators, LLC have been formed to administer and monitor worker’s
compensation claims on an on going basis. Subsequent to contract with the Client, the
following changes and procedures are instituted:
1. A Worker’s Compensation HealthCare Network is identified. Local physicians
in clinics are contracted and information is compiled in regard to fees and services
either directly or by the insurance carrier. The objective is to obtain the lowest
possible cost at the practical quality level of health care.
2. An Accident Report (First Report of Injury) is required for every accident and is
to be completed and signed by Client’s representative. This notice of accident is
required by the state.
3. A Supervisor’s Accident Report is to be completed and signed by the claimant or
the claimant’s supervisor.
(FOR NEW YORK, PENNSYLVANIA, AND CONNECTICUT ONLY)
4. Consent for the release of confidential information is to be signed by the
claimant. This release is to be maintained by the personnel department of the
Client and submitted to NRS/CriticalPath, along with the Notice of Incident
Report and the physician’s diagnosis/prognosis statement and billing. Medical
provider invoices will be paid by Client upon receipt of report or submitted to the
insurance carrier for payment if there is any lost time to the claimant. Each
invoice will be reviewed approved by NRS with Client’s approval..
5. A Client information letter explaining the client’s relationship with National
Risk Services will be sent out to the claimant by the Client after the physician’s
statement has been received.
National Risk Services will receive the following summary of information from the
First Injury Report.
Supervisor’s Accident Report.
Consent for the release of confidential information (NY, PA, CT ONLY).
Information letter to claimant.
The employee’s description of the incident.
The employee’s authorization to release medical and payroll information to the employer
and the employer’s insurer.
The employee’s identification number, Social Security number, or other verification of
The supervisor’s description of the incident.
The names of any witnesses.
Witness statements A notation of any treatment rendered at the scene.
A notation of treatment rendered elsewhere prior to the report, including the method of
A relevant medical history (from employee’s personnel record).
Employee’s payroll information (needed for determining level of benefits).
Employee wage and compensation rate documentation and copies of signed agreements
The purpose of the above procedure is to lower the frequency of the claims experience by
paying medical only claims. In addition, reserves are controlled by obtaining medical
information on the claimant before the reserve is set by the carrier. In addition,
determinations may be made in regard to appropriate follow-up medical care including
rehabilitation for injured claimants in appropriate litigation and settlement positions in
regard to closing claims.
National Risk Services will work with an appointed claims coordinator at client firm.
The coordinator will be responsible for submitting the above information to National
National Risk Services will review quarterly loss runs and check the reserves in those
loss runs against the claimant’s files. NRS will examine Reserves as they are initially
calculated and will work with the adjuster where appropriate. Other services including
claim file reviews and medical bill reviews in status of claim adjusting negotiations will
be reviewed on a quarterly basis.
WORKER’S COMPENSATION CLAIMS ADMINISTRATION
1. MEDICAL DEDUCTIBLE-MED.ONLY CLAIMS-MARKED “FOR RECORD
2. MEDICAL AUTHORIZATION LETTER – UTILIZATION REVIEW
3. LETTER TO CLAIMANT AND/OR CLAIMANT CONTACT BY
TELEPHONE BY UTILIZATION REVIEW NURSE
4. SUPERVISOR’S REPORT OF ACCIDENT
5. RESERVE FILE CREATION
6. FOLLOW-UP MEDICAL REPORT AND APPROXIMATE RETURN TO
7. FORWARD COPY OF REPORT TO INSURED
8. REVIEW QUARTERLY LOSS RUNS
9. OBTAIN COPY OF THE UNIT STATISTICAL REPORTS
10. CHALLENGE RESERVES WHERE NECESSARY
CONSENT FOR THE RELEASE
OF CONFIDENTIAL INFORMATION
(Other than New Jersey claims)
I, _________________, do hereby authorize any physician, hospital, nursing home
facility, outpatient therapy/treatment center, or any other health care provider to release
any medical, mental health, substance abuse, testing and/or vocational information
relating to the following client:_______________ to National Risk Services, Inc. for
purposes of performing Case Management Services.
This authorization permits the release of written reports, medical and hospital records, as
well as verbal reports and discussion on the patient’s condition.
This authorization is valid from the date signed below, for the duration of the Case
I understand the information obtained pursuant to this release may be further disclosed by
National Risk Services, Inc. to the employer, insurance carrier, physicians, and other
relevant parties in order for National Risk Services, Inc. to perform Case Management
I agree that a photocopy of this authorization shall be as valid as the original.
Signature of Patient_______________Date______
Signature of Witness______________Date______
We have established a Claims Administration Service at _______________(your
company name). National Risk Services, Inc. will be administering our Worker’s
Compensation claims. A Claims Examiner from their office will be reviewing your claim
so that it may be paid more quickly and efficiently.
We at ____________________________(name of your company) are looking forward to
your prompt recovery and return to work. Please call our offices if you have any
questions or problems.
Very Truly Yours,
To be signed by Director of Worker’s Compensation Claims Administration
Se ha establecido un servicio de reclamo compensatorio en
_____________________(your company name). National Risk Services, Inc. sera la
empresa eneargada de administrar los reclamos compensatorios de nuestros empleados.
Un empleado especializado en reclamos compensatorios de dicha empresa, se eneargara
de rever su reclamo; de esta manera el proceso sera mas espectivo y rapido.
Nosotros________________________________(your company name) le deseamos una
pronta mejoria y un rapido retorno al trabajo.
Por favor, llama a nuestras oficinas se tiene preguntas o cualquier otro problema.
To be signed by Director of Worker’s Compensation or Corporate Officer
This letter is to authorize National Risk Services, Inc/CriticalPath
Claims Services to obtain any and all information in regard to a
medical review for Worker’s Compensation.
_____________________________________Date of Accident
Signature Title Date
SUPERVISOR’S ACCIDENT INVESTIGATION REPORT
The unsafe acts of persons and the unsafe conditions that cause accidents can be corrected only
when they are known specifically. It is your responsibility to find them and to correct them.
PART I – GENERAL INFORMATION
NAME OF INJURED_________________AGE_______DEPT___________
DATE OF ACCIDENT___________HOUR____A.M._____P.M.
JOB OR ACTIVITY AT TIME OF ACCIDENT_______________________
PART II – DESCRIPTION OF ACCIDENT (WHAT HAPPENED)
PART III – WHAT IS THE CAUSE OF ACCIDENT? (Determine the cause by analyzing all
the factors concerned. If either the injured person, a machine, or other physical condition was at
fault, find out How and Why).
A. Describe any UNSAFE Acts:____________________________________________________
B. Describe any UNSAFE Conditions:______________________________________________
C. FUNDAMENTAL CAUSE:___________________________________________________
PART IV – CORRECTIVE ACTION TAKEN (What have you done or what do you
recommend to prevent a reoccurrence of a similar accident?).
Has it been done?__________________If not, give reason_______________________
SUPERVISOR REVIEWED AND DATE REPORT PREPARED
POLICY STATEMENT – WORKER’S COMPENSATION
We have established a Claims Administration Service at ______________.
National Risk Services, Inc. will be administering our Worker’s Compensation Claims.
A Claims Examiner from their office will be reviewing your claim so that it may be paid
more quickly and efficiently.
Emergency Medical Treatment may be obtained at any facility. Follow-up medical
services are to be obtained at the following medical providers______________. A list of
locations is attached. In the event of a medical emergency, dial 911.
We at ______________________are looking forward to your prompt recovery and return
to work if there is an injury.
We are committed to the safest operation possible. We will aggressively seek to avoid
injury to our employees.
Very Truly Yours,