State Fund Quality Assurance Standards

Two-Point Contact
- Measurement of process time of all points of contact.
Proper Investigation
- Within 7 days to determine compensability
- Index check
- Proper referral for surveillance
- Secure statements when warranted
- Obtain client position statement
Action Plan
- Initial plan of action timely (30 days)
- Current plan identifies outstanding issues, resolution and expected closure
- Notes reflect appropriate follow up on all open items
- Plan of action is created in every lost-time claim
Subrogation
- Subrogation potential recognized and pursued
Cost Containment
- Appropriate strategies are utilized
Medical Documentation
- Supporting documentation obtained
Disability Management and Vocational Rehabilitation
- Utilization of disability management tools
- Return-to-work strategies focused on early return to work
- Independent medical exams, independent medical reviews and peer reviews as needed
Impact Studies
- Lost-time claims reviewed for premium impact
- Impact study imaged and documented in claim notes
Communication
- Appropriate and timely communication with employer, injured worker and physician
Documentation
- Appropriate and timely documentation
- Written in a logical and sequential order
- Explains all actions and decisions
Litigation Management
- Litigation management controlled by examiner and cases are referred to counsel in a timely fashion
- Examiner maintains control, assisting with counsel activity and reviewing status reports from counsel
Adherence to Client Special Instructions
- Compliance with special instructions reviewed
- Specific instructions based upon category