Claims Setup Procedures

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Questions and Answers

What is the maximum time allowed for verifying LTD coverage after a claim is received?

One business day

Two business days

Five business days

Three business days (correct)

Under what conditions can the LTD Claims Specialist close the task 'New Claim Set-Up, LTD'?

When the CCU process is nearing completion

Whenever it is convenient for the Claims Specialist

Once the CCU process is complete (correct)

When the claim has been ultimately denied

What action should be taken if an LTD claim is received and it indicates a future Date Last Worked (DLW)?

Cancel the claim entirely

Contact the employee to gather more information

Hold the claim and process it only after the DLW date is reached (correct)

Immediately process the claim as normal

What should the CCU Specialist do if they identify that an LTD claim was submitted in error because the employee has STD coverage?

Send an email to the Claims Specialist, noting the error Signup and view all the answers

In which scenario can claims for Catalyst be set up before reaching the future Date Last Worked (DLW)?

Catalyst claims can always be set up prior to DLW Signup and view all the answers

What must the CCU Specialist do within three business days if the future DLW suggests the claim is appropriate for LTD?

Hold the claim and process once DLW is reached Signup and view all the answers

What should the CCU Specialist include in their coverage verification entry?

Whether coverage is confirmed or needs follow-up Signup and view all the answers

What is an exception in the process of verifying LTD coverage and claim setup?

Different processes are used based on specific plans or customers Signup and view all the answers

What should be done if the customer is excluded from Robotic Process Automation (RPA) for the acknowledgment packet?

Manually issue the acknowledgment packet by Day 3. Signup and view all the answers

What is the primary purpose of the 'CCU referral to CS' task?

To direct the claim back to the Claims Specialist after it is returned. Signup and view all the answers

What documentation should be recorded in the comments section when establishing an action plan?

ERISA information and details about alternate claims. Signup and view all the answers

When should the 'Follow Up for LTD Packet' task be scheduled after claim setup completion?

15 days after claim setup completion. Signup and view all the answers

What is the first step in the Full CCU Process when checking for duplicate claims?

Search for duplicate claims in DPA, Intellis, and SIR. Signup and view all the answers

What should be done if discrepancies are found during the Comprehensive Review?

Prepare to clarify or confirm with the employer as needed. Signup and view all the answers

Which follow-up task should be completed based on ERISA calculations?

Review Claim – Pending 35 Day. Signup and view all the answers

What must be done after closing the 'Initial Investigation' task?

Document the investigation findings in the claim records. Signup and view all the answers

What should be done if a claimant indicates they do not wish to pursue their LTD claim?

Modify the claim status to reflect it as an abandoned claim. Signup and view all the answers

What is the next step if there is no response after sending a second Intent to Pursue letter?

Send a Failure to Pursue letter and document the claim. Signup and view all the answers

What should be done after confirming that a claimant has LTD coverage and wishes to proceed with their claim?

Finalize coverage verification and communicate the decision. Signup and view all the answers

When documenting actions taken on a claim, what is important to ensure?

All actions must be clearly recorded in the claim file. Signup and view all the answers

What is the purpose of sending a letter to the claimant when closing their claim due to abandonment?

To inform them of the claim closure. Signup and view all the answers

What is the initial action to take if a customer is confirmed to not have MetLife coverage?

Call the claimant to confirm the employer/customer name. Signup and view all the answers

What should a CCU Specialist do if a claimant returns to full-duty work during the elimination period?

Close the claim with specific documentation. Signup and view all the answers

Which step must be followed after sending the first Intent to Pursue letter with no contact from the claimant?

Schedule a follow-up and send another Intent to Pursue letter. Signup and view all the answers

What does the letter clarify regarding the continuation of benefits?

It does not imply acceptance of continued liability. Signup and view all the answers

Which system requires the transition code to be set as 'Investigation Continuing'?

Intellis Signup and view all the answers

What should be recorded in the Catalyst system upon sending the letter?

Any Occ Status field as 'Reservation of Rights'. Signup and view all the answers

Which of the following is included in the contents of the letter?

Reservation of Rights language. Signup and view all the answers

What is the purpose of documenting reasons for delayed decision-making?

To ensure clear record keeping. Signup and view all the answers

What is the initial response a claimant should expect after a transition decision is delayed?

A letter explaining the situation. Signup and view all the answers

What selection should be made in the MGI/SBS system to indicate benefits are continued under Reservation of Rights?

Transition (COD) as 'Benefits continued'. Signup and view all the answers

What is NOT a necessary component of the follow-up communication with the claimant?

Assure them of a quick claim resolution. Signup and view all the answers

What is true regarding a claimant's residence when they temporarily stay in another state for treatment?

Disability payments remain taxable in their original work/live state. Signup and view all the answers

Which statement is accurate regarding updating a temporary address in Intellis?

The new address must be marked with a priority code between 1 and 8. Signup and view all the answers

What must happen if a request to change a claimant's address comes from an unauthorized party?

The Claims Specialist must inform the claimant of the request by phone. Signup and view all the answers

What proof is required for a family member to be considered as an authorized representative?

A signed authorization from the claimant specifically designating them. Signup and view all the answers

What is the process for changing a claimant's phone number according to the guidelines?

Additional identifiers must be asked before accepting any phone number change request. Signup and view all the answers

If the caller is unable to provide accurate information for a phone number change request, what should the Claims Specialist advise?

To submit the request in writing for any updates. Signup and view all the answers

Which of the following is NOT a requirement for a Power of Attorney to be valid?

The claimant must be present during the authorization. Signup and view all the answers

What is indicated regarding the temporary address change in relation to the Master Tax File?

No updates are needed in the Master Tax File for temporary address changes. Signup and view all the answers

Study Notes

Coverage Verification

Coverage verification is mandatory during initial claim setup and must be completed within three business days of claim receipt.
The CCU Specialist records the verification status, indicating whether coverage is confirmed or requires further action.

Communication with Claims Team

The CCU Specialist aims to handle claim setup independently but can consult the LTD Claims Specialist for clarification on specific items.
The Specialist will return claims deemed unnecessary for setup, such as those with no coverage, duplicates, or recurrent filings.
The LTD Claims Specialist should not process or close the "New Claim Set-Up, LTD" task until the CCU process is complete.

Early Claim Submissions

Claims with a future Date Last Worked (DLW) require a special process due to system limitations.
Claims with a future DLW cannot be processed in Intellis until the DLW date is reached and must remain on the UDS-Tele system.
Claims for Catalyst can be set up even before the future DLW.
If an LTD claim has a future DLW, the CCU Specialist reviews the coverage information to determine if Short Term Disability (STD) coverage exists. If STD coverage is identified, the CCU Specialist sends a task notification to the CS.

CCU Process – Claim Setup Only (DPA Claims)

Ensure all relevant items in the SIR are correctly tagged for documentation.
Close the "New Claim Setup – LTD" task, documenting "Initial Claim Build" in the claim records.
Validate the "Ack Pack Setup" task's auto-generation for Robotic Process Automation (RPA) acknowledgment packet issuance.
If RPA is not available for the customer, manually issue the acknowledgment packet by Day 3.
Document findings in the comments section, including ERISA information and details about any alternate claims.
Create these follow-up tasks: "Review Claim – Pending 35 Day", "Follow Up for Employer Info", "Follow Up for LTD Packet", and "CCU Referral to CS".
For Sedgwick customers, create a "Request Medical from 3rd Party" task.
Close the "Initial Investigation" task unless otherwise specified in the tip sheet.

Full CCU Process – ER and EE Contact (DPA Claims)

Search for duplicate claims in DPA, Intellis, and SIR.
Review claim information for discrepancies and any information needing verification.
Consult the Tip Sheet for non-standard information, reaching out to claims for clarification if needed.
Enter researched information into the coverage verification template.
Identify the claimant’s eligible class and source of information.
If pursuing the claim: verify address and send forms.
If declining, document the claim and send closure letters.
If unsuccessful: schedule a second call for Day 2.
If no contact, schedule a follow-up and send an Intent to Pursue Letter.

Follow-Up After 15 Days

Send another Intent to Pursue Letter and schedule a follow-up for another 15 days.
If there is no response, send a Failure to Pursue letter and document the claim.

Initial Decision – No Coverage Denial (DPA Claims)

If the customer is not covered, confirm the employer/customer name and follow the "No MetLife Coverage" guidelines for claim structuring.
If the customer has LTD coverage, but the claimant does not, finalize coverage verification, close any Acknowledgment Packet Setup tasks, update the claim status to reflect the denial, notify the employer, and communicate the decision to the claimant.

Initial Decision – Abandoned Claim (DPA Claims)

If the claimant indicates they no longer want to pursue their claim, modify the claim status to reflect it as an initial denial/abandoned claim.
Record a summary in the claim file indicating the claimant's decision to abandon the claim.
Send a letter informing the claimant of the claim closure.

Initial Decision – Return to Work During Elimination Period (DPA Claims)

When a claimant confirms a full-duty return to work without restrictions during the elimination period, modify the claim status to reflect the claim closure.

Temporary Address Change

A claimant temporarily staying in another state for treatment does not change their residence for tax purposes.
Disability payments remain taxable in the claimant’s state of work/residence.
Update the temporary address in Intellis and identify the claimant’s eligible class and source of information.

Authorized Representative Requirements

Requests to change a claimant’s address from someone other than the claimant, their employer, or an authorized representative are not accepted.
To update a claimant’s contact information, require proof of authorization such as Power of Attorney, attorney authorization, or signed authorization from the claimant designating a family member.

Telephone Number Change Request

To update a claimant's phone number, the CS can accept a verbal request from the claimant, their employer, or an authorized representative.
The CS should ask for additional identifiers, such as date of hire, date of disability, and current treating physician.
If the caller cannot provide accurate information for the above questions, the CS should advise the caller to submit the request in writing.

Required Communication

Issue a Reservation of Rights letter, clarifying that benefit continuation does not imply acceptance of continued liability and providing details on outstanding items needed to complete the determination.
Include the statement "We are currently reviewing your claim to determine if you satisfy the Plan provision above. We will pay your benefits until we complete our review. We are paying benefits in good faith. This is not an admission of further liability or a waiver of any plan requirements. In addition, we reserve all of our rights and defenses we have under the terms of the Plan. We will contact you when our review is complete."

Untimely Transition Decisions – Reservation of Rights

Document the reasons for the inability to make a decision before the transition date.
Update the system to reflect the status of investigations continuing until a decision is made.
Notify the claimant about the forthcoming letter, explain the reasons for sending it, discuss implications for their claim, and assure them that they will be informed once the transition decision is finalized.

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Description

This quiz covers the essential procedures for claims setup, including coverage verification and communication protocols among specialists. It highlights important timelines and special processes for claims submissions, ensuring specialists understand their responsibilities. Test your knowledge on handling claims accurately and efficiently.