Claim Completion Unit PDF

Claim Completion Unit  Who is the CCU? The Claims Completion Unit (CCU) assists Long Term Disability (LTD) Claims Specialists (CS). Performs tasks related to the claim setup process for new claims. Initiates the initial LTD investigation based on the agreed-upon involvement level det...

Claim Completion Unit  Who is the CCU? The Claims Completion Unit (CCU) assists Long Term Disability (LTD) Claims Specialists (CS). Performs tasks related to the claim setup process for new claims. Initiates the initial LTD investigation based on the agreed-upon involvement level determined by the claims and CCU teams. Begins the coverage verification process for all claims included in the CCU process. Completes as many steps as possible based on the customer’s level of involvement.  CCU Process Options Levels of Involvement: Claim Set Up Only: Available for DPA claims only. CCU Process, No Calls: Available for DPA and Catalyst claims. Full CCU Process: Available for DPA claims only. Activities Based on Selected Options: Intent to Pursue (Calls): For Third Party Administered (TPA) customers only. Initial Decisions (in scope for CCU team): No Coverage Duplicate Abandoned Claim RTW During EP Coordination and Exclusions: The claims team Unit Leader (UL) collaborates with the CCU team UL to complete the Options Menu for each customer. Certain customers are excluded from the CCU process, as indicated on the Options Menu; the CCU team will not handle claims/tasks for these customers. Customers in Catalyst do not have an Options Menu; the only available option is CCU Process – No Calls. Important Note: If a claim is created under an incorrect customer and that customer is excluded from the CCU process, the CCU Specialist will stop claim setup and return it to the claims team on a priority basis, scheduling a task and sending an email. Daily Review: The CCU team reviews inventory each morning to identify claims/tasks for customers in the CCU process and works on tasks according to the Customer Option Menu for Intellis/DPA. There is no Customer Option Menu for Catalyst customers due to a single available option.  Initial Claim Review Process Inventory Management: The CCU uses the “New Claim Set-Up, LTD” task in DPA and dashboard review in Catalyst to pull inventory for efficient claim setup. Review Checklist: The CCU Specialist evaluates each new claim to identify: Potential Duplicate Claim? Associated Claims? Early Claim Submission? Applicable CCU Option? Actions Based on Review: The CCU Specialist takes appropriate actions from the initial review findings. Begins coverage verification on new claims. Coverage Verification: Confirming LTD coverage is essential during initial claim setup, included in all CCU options. Coverage must be verified within three (3) business days of claim receipt. The CCU Specialist records a coverage verification entry indicating whether coverage is confirmed or requires follow-up. Communication with Claims Team: The CCU Specialist aims to complete claim setup independently. May contact the LTD Claims Specialist (CS) for clarification on specific items. Will reach out to return claims identified as unnecessary for setup (e.g., no coverage, duplicate claims, recurrent claims). Important Note for DPA: The LTD CS must not work on or close the “New Claim Set-Up, LTD” task until the CCU process is complete, as the CCU relies on this task for inventory management. Exceptions: If specific plans or customers necessitate a different process or investigation level, those requirements take precedence over these guidelines.  Early Claim Submissions Early claim submissions require a specialized approach due to system limitations. The Intellis system does not accept claims with a future Date Last Worked (DLW), meaning these claims must remain on the UDS-Tele system until the DLW date is reached. In contrast, claims for Catalyst can be set up even before the future DLW arrives. When a new Long Term Disability (LTD) claim is received with a future DLW, the CCU Specialist follows these steps: 1. Coverage Review: The CCU Specialist first examines the coverage information to determine if the employee has Short Term Disability (STD) coverage. If the LTD claim should have been submitted as an STD claim, this is noted. 2. Notification to Claims Specialist (CS): If STD coverage is identified, the CCU Specialist sends an email to the CS, along with a task notification. The task will specify that the “LTD claim appears to have been created in error with a future DLW, and the employee shows as having STD coverage. CS to review and refer the file to STD for consideration.” 3. Appropriateness for LTD: If it is confirmed that the claim submission is appropriate for LTD, further steps are taken: DLW within Three Days: If the future DLW is within three business days from the initial report date, the CCU Specialist holds the claim and will build it in Intellis once the DLW is reached, specifically the day after the DLW. DLW More than Three Days: If the DLW is more than three days away, the CCU Specialist consults the CCU Unit Leader (UL) or Claims Support Specialist (CSS) for guidance on the next steps. 4. Claim Creation: When creating the claim from the Tele system, the CCU Specialist updates both the DLW and claim received date to reflect the DLW. 5. Catalyst Claims: For Catalyst claims, the CCU Specialist can set up the claim immediately upon receipt, beginning active work on the claim once the reported DLW has been reached. This structured approach ensures that early claims are handled efficiently while adhering to system constraints and coverage considerations. CCU Process – Claim Setup Only (DPA Claims) For customers designated under the CCU Claim Set Up Only option, the CCU Specialist follows a structured and efficient process to set up the claim, initiate coverage verification, and send the acknowledgment packet. This entire process is completed within three (3) business days, without any direct contact with the customer or claimant, and does not involve making initial claim decisions. Steps for Claim Setup Only Process: Conduct Duplicate Claim Check: Perform an SSN/ALT ID search in DPA, Intellis, and SIR to identify any duplicate claims. If a duplicate is found: Email the Unit Leader (UL) to notify them that setup will not be completed. Document the claim as a duplicate by updating the claim end reason and relevant dates. If there is no duplicate, proceed to step 2. Review Claim Information: Assess all information in DPA, Intellis, and SIR. Look for discrepancies and identify any information that requires further verification. Consult Tip Sheet: Reference the Tip Sheet for any non-standard information and reach out to the claims team with questions as needed. Ensure to include links to relevant plans and riders in the appropriate fields for both DPA and Catalyst. Enter Research Findings: Document the findings in the coverage verification template. Identify the eligible class for the employee and label sources next to the answers. If no coverage is identified, set up the claim under any available structure and note the lack of active coverage. Update Intellis: Enter all information into Intellis and change the claim status to pending. If issues arise during this process, consult the CCU Subject Matter Expert (SME), CSS, or UL for assistance, and consider submitting a support ticket. Schedule the “CCU referral to CS” task for the date the claim will be returned to the LTD Claims Specialist. CCU Process – Claim Setup Only (DPA Claims) Ensure all relevant items in SIR are tagged appropriately for documentation. Close New Claim Setup Task: Work on and close the “New Claim Setup – LTD” task, documenting “Initial Claim Build” in the claim records. Validate Acknowledgment Packet Setup: Check if the “Ack Pack Setup” task has auto-generated for Robotic Process Automation (RPA) acknowledgment packet issuance. If yes, proceed to step 9. If no, check the exclusion list to determine if the customer is excluded from RPA: If excluded, manually issue the acknowledgment packet by Day 3, including all necessary forms. If not excluded, set the “Ack Pack Setup” task to allow RPA to issue the acknowledgment packet. Establish Action Plan: Document findings in the comments section, including ERISA information and details about any alternate claims. Set Follow-Up Tasks: Create the following follow-up tasks: “Review Claim – Pending 35 Day” based on ERISA calculations. “Follow Up for Employer Info” scheduled for two days after claim setup completion. “Follow Up for LTD Packet” scheduled for 15 days after completion. “CCU Referral to CS” task for the return date (Day 5). For Sedgwick customers, create a “Request Medical from 3rd Party” task for the same day. Close Initial Investigation Task: Close the “Initial Investigation” task unless otherwise indicated by the tip sheet. Full CCU Process – ER and EE Contact (DPA Claims) Duplicate Claim Check: Search for duplicate claims in DPA, Intellis, and SIR. If a duplicate is found, notify the assigned UL and document the claim. If no duplicate, proceed to the next step. Comprehensive Review: Review all claim information for discrepancies. Identify any information needing verification. Prepare to clarify or confirm with the employer as needed. Tip Sheet Review: Consult the Tip Sheet for non-standard information. Reach out to claims for clarification if necessary. Document any unique findings for reference. Coverage Verification Template: Enter researched information into the coverage verification template. Identify the claimant’s eligible class and source of information. Draft a consolidated email request if clarification from the employer is needed. Full CCU Process – ER and EE Contact (DPA Claims) Update Claim in Intellis: Enter research findings into Intellis and change claim status to pending. Consult with CCU SME, CSS, or UL if the claim doesn’t update correctly. Schedule a referral task for when the claim returns to LTD CS. Tagging: Tag all relevant items in SIR as needed. Ensure documentation is complete and accurate. Review tagging for compliance with procedures. Close Claim Setup Task: Work on and close the “New Claim Setup – LTD” task. Document the task as “Initial Claim Build.” Ensure all previous steps are reflected in the documentation. Acknowledgment Packet Setup: Check if the acknowledgment packet is set for RPA issuance. If excluded from RPA, manually issue the packet with required forms. Ensure Intellis is updated to facilitate RPA success. Full CCU Process – ER and EE Contact (DPA Claims) Claimant Email Review Check for Email: If provided, send a Welcome Email and use SignNow for forms. If not, move to the next step. Action Plan Establishment Create Action Plan: Complete within three business days, including ERISA info and relevant claim numbers. Set Follow-Up Tasks Create Tasks: Set tasks for pending reviews based on ERISA timelines. Schedule follow-ups for employer info and LTD packet before the 3-day mark. Close Initial Investigation Task Close Task: Follow guidelines to close the “Initial Investigation” task and document any exceptions. Outstanding Information Review Identify Needs: Determine additional info needed from the employer. Send a standardized email for clarifications and schedule follow-ups. Notify Completion Email UL: Once all actions are complete, email the claims team UL to confirm setup. Verify UL structure in UDS and consult with CCU SME/CSS/UL if needed.  Intent to Pursue – TPA (DPA Claims) Coverage Verification Conduct Coverage Search: Use UIS to verify coverage. If verified, proceed to the next step. If not, notify the UL and do not create a claim. Identify Structure Determine Claim Structure: Based on the date last worked. Obtain Contact Info: Get the claimant's phone number from the TPA report. Scan TPA Report Filter Report: Display only one claim before scanning, following the Scan Only Process in the CMG. Contact Claimant Call Claimant (Day 1): Confirm intent to pursue LTD. If pursuing: verify address and send forms. If declining: document the claim and send closure letters. If unsuccessful: schedule a second call for Day 2. Send Intent to Pursue Letter If No Contact: Schedule Follow-Up & send a Intent to Pursue Letter. Set a follow-up task for 15 days. Responding claimants return to the previous step; non-responders move on. Follow-Up After 15 Days Send Another Intent to Pursue Letter: Schedule a follow-up for another 15 days. If No Response: Send a Failure to Pursue letter and document the claim. Initial Decision – No Coverage Denial (DPA Claims) Customer is Not Covered Call Claimant: Confirm the employer/customer name. Update Claim: Follow the “No MetLife Coverage” guidelines for claim structuring. Customer Has LTD Coverage, Claimant Does Not Complete Documentation: Finalize coverage verification. Set Up Action Plan: Close any Acknowledgment Packet Setup tasks. Update Claim Status: Reflect the denial. Notify Employer: Use the standard template for the claim decision. Communicate with Claimant: Call and write using Template #4301. Notes Documentation: Ensure all actions are clearly recorded in the claim file. Timely Follow-Up: Adhere to timelines to maintain compliance with procedures. Initial Decision – Abandoned Claim (DPA Claims) When a claimant indicates they no longer wish to pursue their LTD claim, the CCU Specialist will take the following steps to close the claim due to abandonment: 1. Update Claim Details: Modify the claim status to reflect it as an initial denial/abandoned claim. 2. Document Decision Summary: Record a summary in the claim file indicating that the claimant has advised they do not wish to pursue the LTD claim. 3. Notify Claimant: Send a letter to the claimant informing them of the claim closure. Reference Consult the Abandoned Claim Handling guideline in the CMG for details on appropriate letters and additional procedures. Note This process does not apply to customers under Catalyst. Initial Decision – Return to Work During Elimination Period (DPA Claims) When a claimant confirms their return to full-duty work without restrictions during the elimination period, the CCU Specialist will take the following steps to close the claim: 1. Update Claim Details: Change the claim status to reflect an initial denial due to the return to work during the elimination period. 2. Document Decision Summary: Record a summary in the claim file indicating the closure is due to the claimant's full-time, full-duty return to work. 3. Notify Claimant: Send a notification letter to the claimant about the claim closure using: CCT: Template #2385 / RTW During the EP. Reference Refer to the Claim Decision – Initial guideline in the CMG for more information. Note This process does not apply to customers under Catalyst. Name, Address Phone Change  Overview Occasionally a Claims Specialist (CS) and/or the Global Customer Solutions (GCS) representative will receive a request to change a claimant’s name, address and/or phone number. Important: If a call and/or documentation is received to update an address/phone number, EFT information, etc., and there is a claim alert present indicating “ATO/Identity Theft Fraud Alert”, or the CS suspects or identifies ATO Fraud red flags, refer to the guideline Fraud, Waste and Abuse (FWA) located in the CMG for additional actions required by the CS prior to making any updates.  Name Change Request Process for Changing Claimant's Name 1. Obtain Written Request: The Claims Specialist (CS) must get a signed request from the claimant or their authorized representative. The request must include: Claim number New name Signature of the claimant or authorized representative 2. Signature Verification: Verify the signature by comparing it to the signature already on file. Notes No Signature on File: If there’s no existing signature, the CS should call the claimant to confirm the name change request. Signature Discrepancy: If unsure about the signature match, refer the matter to the Unit Leader for further assistance.  Permanent Address Change Request Process for Changing Claimant's Mailing Address 1. Receive Request: Update the claim upon receiving a written or verbal request from the claimant to change their permanent mailing address. 2. Verbal Requests: When a verbal request is made, the Claims Specialist (CS) must ask for the following additional identifiers: Date of Hire: Approximate month and actual year accepted. Date of Disability on Claim: Dates within a week of the actual date accepted. Current Treating Physician. 3. Inability to Provide Information: If the caller cannot accurately provide the requested information, the CS should advise them to submit the address change request in writing. 4. Send Notifications: After updating the claim, send the appropriate letter notifications based on the claim facts.  Permanent Address Change Request Process for Updating Claimant's Address in Intellis Update Intellis: The Claims Specialist (CS) should update the claimant's address in the Intellis claim system. Send Notifications: First Notification: Send a letter to the new address confirming the address update. Second Notification: Generate and send a letter to the prior address to inform the claimant of the change. Special Handling for Domestic Abuse: If there is domestic abuse associated with the claimant or claim, the CS must follow specific protocols for address changes. Refer to the "When Claim is Associated with Domestic Violence" section and the "Requirements for Victims of Domestic Abuse" guidelines in the Claim Management Guidelines (CMG) for detailed processing instructions. Written Notification: Send a written notification to the claimant using the appropriate letter template to confirm that their address change request has been received and processed. Address Change Request When PO Box is Used If a request is received to change a claimant’s address to a Post Office Box (PO Box), the claimant’s actual street address must be obtained/retained when a PO Box is used in a mailing address. The actual street address should be included in the “Comments” section of the Action Plan template. Obtaining a street address will assist with the following: To enable expedited delivery of mail if needed, To facilitate labor market research for potential return to work assistance, and To provide a residential address if a home visit is appropriate. When a claimant refuses to provide an actual street address due to safety or other reasons, it is appropriate to accept a “PO Box” mailing address; the claim file should be documented with this information. Note: When a Claimant’s address contains a “Rural Route” or “RR” designation, this is not the same as a “PO Box”.  Temporary Address Change Tax Implications: A claimant temporarily staying in another state for treatment does not change their residence for tax purposes. They are not taxable in the new state; disability payments remain taxable in the claimant's work/live state. Updating Temporary Address: In Intellis: Select "PAYEE 99 - EMPLOYEE'S 2ND ADDRESS" in the Payee Type field. Enter any number between 1 and 8 in the Priority Code field. Enter the new address in the Payee Name and Address section. Note: The Master Tax File does not need to be updated for a temporary address change. Authorized Representative Requirements Requests from Unauthorized Parties: Any request to change a claimant’s address from someone other than the claimant, their employer, or an authorized representative is not accepted. The Claims Specialist (CS) must contact the claimant by phone to inform them of the request. Authorized Representative Requirements: Power of Attorney: Must have a signed Power of Attorney authorization on file. Attorney: Must have signed attorney authorization on file. Family Members: Must have signed authorization from the claimant specifically designating the family member. Proof Requirement: If required proof is not on file at the time of the request, it must be obtained before updating the claimant’s contact information. Reference: Consult the Claimant Representation guideline in the CMG for more information on authorized representatives.  Telephone Number Change Request To complete a request to change the claimant’s phone number, the CS can accept a verbal request from the claimant, their employer or an authorized representative. Prior to updating a claimants phone number, the CS is required to ask for additional identifiers in the order listed below: Date of hire Date does not have to be exact, can accept approximate/adjacent month, actual year). Date of disability on claim Can accept dates within a week of actual DOD. Current treating physician Note: If the caller is unable to provide accurate responses to any or all of the above questions, the CS will advise the caller to submit the request in writing. A letter is not required for a phone number change only.  Transition – Change in Definition Review  Transition Review Here’s a concise bullet point summary of the definition of disability as per MetLife's group disability certificates (GCERT2000): Definition of Disability: Changes after 24 months of benefits. Two key components: Earnings Test: Transition to a different percentage of pre-disability earnings. Gainful Occupation: Claimant must be unable to perform any gainful occupation for any employer in the National Economy. Considerations for Transition Review: Claims Specialist (CS) assesses: Prior education. Work experience. Training. Sample Language from GCERT2000: During the first 24 months: Unable to earn more than 80% of pre-disability earnings in their own occupation. Unable to perform the material duties of their own occupation. After 24 months: Unable to earn more than 60% of pre-disability earnings at any gainful occupation. Unable to perform duties of any gainful occupation for which reasonably qualified (considering training, education, and experience). Accidental Injury: Disability must occur within 90 days of the injury and result directly from it. Important Note: Disability definitions can vary by plan; CS should review plan documents (Certificate of Insurance, SPD, riders/amendments) for applicable definitions.  Transition Review Transition Consideration: The Claims Specialist (CS) must consider the transition in the definition of disability throughout the disability period. The claim action plan should reflect this consideration and any actions taken. Example Scenario: LTD plan changes from own occupation to any occupation after 24 months. If a claimant has permanent restrictions preventing them from performing their pre-disability job duties during the own occupation period: The CS should reassess the claimant’s functional ability. Consult a vocational resource to evaluate potential for alternate work and job search support. Communication with Claimant: Educate the claimant about the upcoming change in the definition of disability. Discussions should occur at least 60 days prior to the transition date. Approval Criteria: Claimants must demonstrate: Inability to perform material duties of gainful occupations in the National Economy. Inability to earn more than the specified percentage of pre-disability earnings at any gainful occupation. Timing of Decisions: CS can approve the claim under the "Any Occupation" definition sooner than 60 days prior if supported by sufficient information. Adverse transition decisions should generally not be made earlier than 60 days before the transition date unless criteria for advance closure termination are met.  Investigation and Assessment Throughout the life of the claim, including the transition investigation, the CS should evaluate and determine if the claimant: continues to satisfy the current definition of disability (i.e., both components - inability to perform material duties of occupations in the National Economy, and the inability to earn more than the stated percentage of Predisability Earnings per the plan); has had a change in functional ability; has the ability to return to work in some capacity to their own occupation; has the ability to return to work in an alternative occupation; satisfies all applicable plan provisions; and is a candidate for a vocational rehabilitation program. If new information is received, the CS must review and analyze this information to determine if it impacts the transition decision. The CS can engage the appropriate Return to Health (RTH) resources if the CS decides that assistance is needed concerning functionality for the CS to make determination. If the CS determines that additional information needs to be obtained and/or evaluated, the action plan should be updated accordingly.  Investigation and Assessment Reminders: A transition approval decision may be made at any point in the claim; however, an adverse transition decision cannot be made sooner than 60 days prior to the transition date unless the claim is managed under the Advance Closure Notification process. The CS is responsible for making the claim decision and communicating that decision to the claimant via letter and phone call. The employer must be notified when applicable. The following letters are available to send to the claimant: CCT: Template #931 / LTD Transition Approval Template #7022 / LTD Transition Approval – Spanish Template #6948 / LTD Transition Termination Template #7023 / LTD Transition Termination – Spanish Quadient: Approval/Denial template Closure/Termination template  Return to Work Analysis Claims Specialist (CS) Responsibilities: Assessment During Own Occupation Period: Work with the claimant to evaluate their ability to perform material duties of their occupation or an alternative occupation, even with restrictions. Collaboration with VHS: Consult a VHS if deemed appropriate to assist in determining the claimant’s work capacity. VHS Assistance with RTW: Clarification of Job Duties: Clarify job functions and material duties with the employer if initial information is insufficient. Job Analysis: Analyze claimant’s job requirements against occupational demands. RTW Plan Coordination: Coordinate complex RTW plans, including accommodations and vocational rehabilitation. Vocational Services: Provide vocational counseling, testing, retraining, and job placement assistance. Assessment Coordination: Complete and coordinate Employability Assessments (EAs) and Labor Market Analysis. Employability Consultation: Consult on employability based on the claimant’s restrictions and limitations. Rehabilitation Plan Assistance: Assist with the application of mandatory rehabilitation plan provisions and incentives.  Return to Work Analysis Additional Considerations: The VHS may consult with a Return to Health Specialist (RTH Specialist) for insights on the claimant’s functional ability based on medical information. The CS is responsible for making the final claim decision and communicating it to the claimant after considering inputs from RTH resources. If the RTW intervention does not require in-depth clinical or vocational involvement, the CS can proceed without a VHS referral. Be aware of different requirements in the CA 2008 Variations regarding the definition of disability, but the same investigation principles apply  Important Transition Considerations Examples of Transition Investigations 1. Claimant with Potential for Return to Work: If a claimant has restrictions but can return to work with support, the CS should: Monitor medical and non-medical issues impacting return-to-work efforts. Engage Vocational Health Specialists (VHS) for job accommodations and employer interactions. 2. Claimant Not Likely to Return to Own Job: If it’s unlikely the claimant can return to their own job but disability may not extend beyond the Own Occupation period: The CS may skip some transition milestones but must document the claim's direction and steps taken. 3. Claimant Likely to Remain Disabled: If a claimant is expected to remain disabled but can work in an alternative occupation: Follow transition milestones (e.g., starting the investigation 8 months prior) to gather necessary information for a transition decision. Communication and Documentation Educate the Claimant: Ensure the claimant understands the potential for return to work and what additional information is needed for decision-making. Documentation: Clearly document all findings, the direction of the claim, and steps taken to reach a determination to support transparency and compliance.  Limited Disability Benefit (LDB) and Transition When the claimant is disabled due to a limited condition according to the LDB provision in the plan, the CS should always consider and analyze the following in relation to the transition investigation: the LDB limit date in relation to the transition date (i.e., if the LDB limit date is before, the same as, or after the transition date) exclusions to the limitation (i.e., has the diagnosis changed/progressed to radiculopathy, schizophrenia, seropositive arthritis, etc.) co-morbid conditions that are not limited that may become disabling prior to the LDB limit date if the claimant remains compliant with limitation provisions (i.e., recovery program) If the LDB limit date is prior to the transition date, the claim may end in the Own Job/Own Occupation/Usual Occupation period, however if the LDB limit date is the same as, or after the transition date, the transition investigation and when appropriate, the transition decision is expected to be completed at the appropriate time. Reference: For claims that have the LDB provision, refer to the Limited Disability Benefits (LDB) guideline in the CMG concerning LDB limitations that run concurrently with transition. Transition Investigation Milestones Purpose of Investigation: Gather and analyze claimant information Evaluate functional restrictions and limitations Determine eligibility for disability definitions. Importance of Timely Decisions Milestone Timframes: 8 Months, 6 Months, and 3 Months prior to transition Complete decisions by 60 days before the transition date Key Actions: Update action plan: New definition of disability Confirm job information Verify claimant’s current restrictions and work history Conduct a detailed interview: Educate claimant on upcoming changes Inform about requested information Inquire about current health status Documentation: Issue written confirmation to claimant Document interview in the claim file  Transition Investigation Milestones 6 Months Prior to Transition Recommended Actions: Conduct a Multi-Disciplinary Claim Discussion (MCD) Proceed with the transition investigation Communicate with the claimant: Advise on status of the investigation Request any outstanding information Follow-Up Documentation: Issue follow-up letter outlining needed information 3 Months Prior to Transition Final Actions Required: Address any outstanding issues Communicate with the claimant about unresolved information Inquire about any changes in the claimant’s condition Important Considerations: Transition decision should be made timely (60 days prior) Avoid adverse decisions before 60 days due to potential changes in claimant's condition  Early Transition Approval Decisions Transition Decision Criteria Initial Decision Timing: The CS should only make a transition decision at the onset of a new claim if: The claimant's prognosis is unlikely to change during the Own Occupation period. The claimant is likely to remain disabled beyond the transition. 2. Early Transition Considerations Compassionate Allowance Diagnoses: An early transition decision may be considered if the claimant has a primary diagnosis that meets the Compassionate Allowance criteria set by the Social Security Administration (SSA). Review relevant facts of the claim and applicable plan documents, including: Certificate of Insurance Summary Plan Description (SPD) Any riders or amendments to the Certificate of Insurance 3. Tools and Resources Identification Assistance: Utilize a monthly report to identify claims with Compassionate Allowance Diagnoses. 4. Additional Evaluation Referral Considerations: For claims under early transition review, the CS should assess the need for a referral to: The Migration team Special Handling Unit (SHU)  Early Transition Approval Decisions 1. Early Investigation Initiation When to Review Actions: Upon suspicion that the claimant may not perform any gainful occupation for any employer. Do not wait for the 8-month mark to start the investigation. 2. Key Actions for Early Investigation Evaluate Claimant’s Work Capacity: Assess if the claimant has any potential work capacity that could translate to being able to perform an occupation for any employer. 3. Reevaluation Process Reassessment Near Transition Date: If initial findings indicate potential work capacity, re-evaluate the claim as the transition date approaches. 4. Important Considerations Timeliness of Decisions: An adverse transition decision cannot be made until 60 days prior to the transition date. This allows for consideration of any changes in the claimant’s condition before making a decision. Untimely Transition Decisions – Reservation of Rights 1. Timing for Transition Decisions Completion Deadline: Transition decisions should ideally be made no later than 60 days prior to the transition date. Unforeseen Circumstances: If further information or evaluation is required, the decision may not be made by the transition date. 2. Notification Requirements 30 Days Prior Notification: As the claim approaches 30 days before the transition date, the CS must notify the claimant if the decision may not be made on or before the transition date. 3. Required Communication Letters to Issue: CCT: Template #1038 / LTD Reservation of Rights Template #7021 / LTD Reservation of Rights – Spanish Quadient: Pending Decision template Contents of the Letter: Clarification that the continuation of benefits does not imply acceptance of continued liability. Detailed information on outstanding items needed to complete the determination. Include Reservation of Rights language: “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 4. File Documentation Clear Record Keeping: Document reasons for the inability to make a decision before the transition date. 5. Status Updates System Updates: Intellis: Keep transition code as “Investigation Continuing” until a decision is made. Catalyst: Update Any Occ Status field to “Reservation of Rights” when the letter is sent. MGI/SBS: Record the decision using Transition (COD) selection; choose “Benefits continued” and “Temp extension under reservation of rights.” Use Transition (COD) again to record the final decision once reached. 6. Follow-Up Communication CS Call to Claimant: Notify the claimant about the forthcoming letter. Explain reasons for sending the letter and discuss implications for their claim. Assure the claimant that they will be informed once the transition decision is finalized. Thank You