The status of a claim may determine how issues, such as the authorization of referrals, are handled. This section should help you figure out what you need to do, and when.
Note: We use the term "claim" to refer to a worker's request for various types of compensation for a workplace injury or illness. We will never use "claim" to refer to a single bill for medical services.
A claim is in "new" status while it's being evaluated for acceptance or denial. During this time, the insurer gathers information to determine if the claim should be accepted or denied. The law allows an insurer up to 60 days from the date the worker's employer knew about the injury or disease to determine whether or not to accept the claim.
SAIF will notify all medical providers in writing when we make a decision on a claim. Decisions are usually made within 30 days of the employer's date of knowledge of the injury. Complex claims can take longer.
Pharmacy (First Fill)
Limited pharmacy benefits are available to the injured worker while the claim is in new or deferred status. First Fill pays for some claim-related medication even if the claim is ultimately denied.
If a claim-related medication is not on the First Fill formulary, the worker can ask the AP to prescribe an alternative that is on the formulary, if applicable. Otherwise, the worker can pay for it out of pocket, then submit it for possible reimbursement if the claim is accepted.
In "new" status, payments for medical services are not guaranteed until a claim is accepted. However, you are allowed to bill a private carrier before a decision has been made.
According to state workers' comp rules, the adjuster may request all relevant medical records, past and present, for any condition related to the claimed body parts. The provider must send all requested records within 14 days.
Authorizations need to go to both private carriers and SAIF. The private carrier is responsible for bills until the claim is accepted.
As the result of a January 2015 rule change, providers can send bills and request authorization from other sources prior to the denial.
A claim is "open" once the insurer has determined that the claim meets the definition of a compensable workers' comp claim under the statutes, administrative rules, and case law.
A claim remains open until the injured worker is medically stationary. Read more about claim closure.
While a claim is open, the injured worker can receive covered pharmacy benefits.
If a claim is enrolled in an MCO, please contact the MCO with questions about an authorization. If it is not enrolled in an MCO, contact the SAIF adjuster.
To check on the status of a referral, contact the MCO if the claim is enrolled, or contact the claims adjuster.
Referrals do not count as a change of attending physician.
Read more about the details of referrals, including ancillary services.
A claim is usually enrolled in an MCO at the time the claim is accepted. But it can be enrolled at any time after the date of injury.
New or omitted conditions
An injured worker or the attending physician may request a "new" or "omitted" condition following acceptance of the original claim. A new condition is diagnosed during the course of the treatment; an omitted condition is one the worker believes was incorrectly omitted from the notice of acceptance.
The attending physician must submit an 827 form for the new or omitted condition(s). The request must be for specific conditions, not body parts or general conditions.
A worker can request these conditions at any time.
While the insurer is determining the compensability of these conditions, that portion of the claim is treated like a new claim. (See "New (deferred)" above.)
The "open" status of the claim does not change while the insurer is reviewing the conditions; however, payment for medical treatment is not guaranteed for any new or omitted conditions until a decision is made.
Claims disposition agreement (CDA)
This type of settlement is sometimes used to bring an open claim to closure. This settlement does not affect medical benefits.
The worker does not have to reach medically stationary to enter into a CDA, and the attending physician can still treat the worker. Treatment will be covered if it's related to the accepted condition(s). (This is not necessarily true for other kinds of settlements.)
A written notice to the injured worker which describes why the workers' compensation claim does not meet the definition of a compensable claim under the law
On accepted claims, the insurer may deny certain conditions only (known as a "partial denial"). Only the worker can appeal a denial of a claim.
Medical providers are notified within 60 days of a claim denial. If the worker does not appeal the denial, it becomes final, and providers are notified in writing.
If a denial is appealed, a hearing is set within 90 days of the request for hearing. Some hearing dates are postponed at the request of the injured worker or his representative. Please keep sending records and bills during the litigation phase. However, SAIF doesn't reimburse injured workers or private carriers for treatment pending litigation. We will pay for reports that we solicit from the medical provider.
You can review the status of litigation in Business Online.
Disputed claim settlement (DCS)
When a worker enters into a DCS for a full claim denial, medical providers may be paid a portion of the settlement towards the unpaid medical bills that are in the insurer's possession at the time of the settlement. This rule also permits you to bill the balance to the worker if there are unpaid charges after the settlement.
DCS is a method of finalizing a denial; therefore, no future treatment is covered.
- Any bills received prior to denial will be reviewed at the time of the decision.
- As of January 1, 2015, providers can bill and seek authorization from the health benefit plan while the claim is in "new" status.
A claim is closed when the worker is medically stationary. The worker is no longer eligible for time-loss benefits and permanent disability may be awarded if not fully recovered. A claim is also closed if the worker enters into a claims disposition agreement (CDA).
Injured workers are entitled to certain benefits following closure of the claim, including palliative care.
Reopening a claim
The injured worker may be eligible to reopen her claim for a worsened condition. If it is within five years from the first valid closure in the claim, this is known as an aggravation. After five years, different criteria must be met. This is known as "Board's own motion."