Processing Rehabilitation, Claims, and Examination Data

This chapter discusses how to:

Manage claims.
Track rehabilitation plans.
Track employee medical exam results.

Managing Claims

This section provides an overview of claims management and reports and discusses how to:

Open claims.
Enter claim details.
Track claim charges.
Enter claims payment information.
Enter provider reference data.

Understanding Claims Management

Use the Claims Management pages to enter the details of an individual’s status and assessments of the individual’s ability to return to work and to track direct and indirect costs of the claims while they are open. File this information with the government or with an insurance company.

You might need to create claims before you create incidents. For example, you might not learn about an incident until someone files a claim against the organization. You create the claim first. Later, as you learn more about the incident and enter incident details in Human Resources, you can link the claim and the incident in the system by entering the incident number on the Claims Management pages.

Note. For users in British Columbia who report incidents to the British Columbia Workers’ Compensation Board (BC WCB) electronically, claims information is required on the Claims Management pages for all incident outcome types except Dangerous Occurrence.

Claims Reports

You can generate these claims reports:

OHS015, Incident Claim Detail report.
OHS012, Claim Summary Overview report.

Pages Used to Manage Claims

Page Name	Object Name	Navigation	Usage
Claim Details	HS_CLAIM_MGMT1	Workforce Monitoring, Health and Safety, Obtain Incident Information, Open Claim, Claim Details	Open claims.
Claim Details: Appeal Details	HS_CLAIM_APPL_SEC	Click the Appeal Data link on the Claim Details page.	Enter details about the claim appeal.
Claim Charges	HS_CLAIM_MGMT2	Workforce Monitoring, Health and Safety, Obtain Incident Information, Open Claim, Claim Charges	Track charges related to injury claims, including one-time medical treatments and lengthy, multiple claim-incurred costs.
Claim Provider	HS_CLAIM_MGMT3	Workforce Monitoring, Health and Safety, Obtain Incident Information, Open Claim, Claim Provider	Enter provider reference data, the claim assessment date, and its disposition.
Payments and Deposits	HS_CST_IND_SEC	Click the Claim Payment Details link on the Open Claim - Claim Charges page.	Enter specific information about claim payments.
Contact’s Work Address	HS_CM3CAN_SEC	Click the Contact Address link on the Claim Provider page.	Enter additional address details for the claim contact in Canadian claims.

Opening Claims

Access the Open Claim - Claim Details page.

Warning! To avoid maintaining two different sets of claim numbers, PeopleSoft recommends that you either always assign numbers manually or always let the system do it—not both.

If you choose to have the system assign the claim number automatically, it first appears as 00000000. The actual number assigned to the claim appears after you save the information on the Claims Management pages. The last claim number assigned is stored in the Installation Table.

Claim Status	Select whether the claim status is Pending, Approved, or Denied.
Date Opened	The date the claim is opened appears. By default, this is the current date, which you can change if needed.
Date Closed	Enter the date that the claim is resolved.
Person Filing	Select either an EmplID or a Non-EmplID for the person filing.
Investigated	Select if the claim is investigated.

Incident Data

Incident Number

Select an incident number to associate with the claim. The system prompts you only with incidents that are associated with this individual. When you enter the incident number, the incident date, type, location, state and country appear on the page.

You do not have to enter an incident number when you first create a claim. However, you must add an incident and save the information before you can change the Claim Status to Approved.

Appeal Data

If the claim is appealed, click this link to access the Appeal Details page.

Note. For users in British Columbia who report incidents to the BC WCB electronically, the Date Opened, Person Filing, and Incident Number fields are required for all Incident Outcome types except Dangerous Occurrences.

(CAN) Canada

(WCB) Claim Number

Enter the Workers’ Compensation Board (WCB) Claim Number.

(FRA) France

Claimant	Select the claimant type.
Recipient	Select the recipient type.

(USA) USA

Case Number

If the claim concerns an incident to which you previously assigned an OSHA Case Number and Date Filed on the Official Report Details - USA page, then the Case Number and Date Filed fields appear in read-only mode.

(IND) India

Certified	Select if a medical officer has certified the claim.
Date of Certification	Enter the date of certification.
Dependent ID	For dependent claims, select the Dependent ID. Once selected, the Relationship field appears.

Entering Claim Details

Access the Open Claim - Claim Details: Appeal Details page.

Date of Appeal

Enter the date on which the appeal is filed.

Date Claim Re-Opened

Enter the date on which the claim is re-opened.

Appealed By

Select from the available values to indicate who filed the appeal.

Tracking Claim Charges

Access the Open Claim - Claim Charges page.

Claim Charges

Total Claim

The total charges for the claim (all charges for all types) in the currency that is specified for a User ID in the Operator Preferences Table. If there is no To Currency for the User ID in the Operator Preferences Table, then the system uses the base currency that you specified in the Installation Table. (This is also true for the Currency and Total Type fields.)

Type of Charge

Select one: Medical Costs, Other Costs, or Wage Loss.

To add more charge types, insert additional data rows.

Claim Details

Charge Date	Enter the charge date for the claim.
Charge Amount	Enter a charge amount. Enter multiple charges for each type by adding new data rows.
Total Type	The total charges for this claim type in the currency specified for the User ID in the Operator Preferences Table.

(IND) India

Click the Claim Payment Details link to access the Payments and Deposits page where you enter details about claim payments.

Entering Claims Payment Information

Access the Open Claim - Claim Charges: Payments and Deposits page.

Payment Type

Select if the payment type is Advance Payment, Claim Deposit, Claim Payment, or Provisional Payment.

Payment Date

Enter the payment date.

Amount

Enter the payment amount.

Recipient Type

Select if the recipient of the payment is an Employee, Non-Employee, or Dependent. Once selected, select the ID of the employee, non-employee, or dependent. If you select Dependent, the relationship appears.

Comment

Enter an optional comment about the payment.

Entering Provider Reference Data

Access the Open Claim - Claim Provider page.

Contact ID

Select a Contact ID (Employee ID Number), if one exists within an organization. Available values come from Personal Data.

Provider Claim Nbr (provider claim number)

Enter this, if you know it.

Typical types of providers are government agencies, such as the Workers’ Compensation Board of Canada or insurance companies.

Provider Name

Enter the provider name.

Claims Manager

Enter the name of the claims manager.

Assessment Date

Enter an assessment date.

Disposition

Select the claim disposition from the available values in the list of available options.

Note. (CAN) For users in British Columbia who report incidents to the BC WCB electronically, the Contact ID field is required for all Incident Outcomes other than Dangerous Occurrence. Click the Contact Address link to access the Claim Provider: Contact’s Work Address page.

(IND) India

Claim Filed Date	Enter the date the claim is filed.
Claimed Amount	Enter the amount that is claimed.
Claim Received Date	Enter the date the claim is received by the provider.
Received Amount	Enter the date that the amount is received.
Unapproved Amount	If the amount is an unapproved amount, enter the amount here.
Comment	Enter an optional comment.

Tracking Rehabilitation Plans

This section discusses how to:

Associate an incident and claims data with a rehabilitation plan.
Monitor work restrictions and duties.
Track rehabilitation action details.

You develop rehabilitation plans when an employee or a non-employee is injured, and a compensation claim is filed. Rehabilitation plan information is helpful for government reporting and claims management.

Note. The pages for employee rehabilitation plans and non-employee rehabilitation plans are identical in format and usage.

Pages Used to Track Rehabilitation Plans

Page Name	Object Name	Navigation	Usage
Claims	HS_INJ_REHAB1	Workforce Monitoring, Health and Safety, Obtain Incident Information, Create Employee Rehab Plan, Claims	Associate an incident and essential claims data to rehabilitation plan details.
Restrictions	HS_INJ_REHAB2	Workforce Monitoring, Health and Safety, Obtain Incident Information, Create Employee Rehab Plan, Restrictions	Monitor an employee’s work restrictions and modified duties included in the rehabilitation plan.
Actions	HS_INJ_REHAB3	Workforce Monitoring, Health and Safety, Obtain Incident Information, Create Employee Rehab Plan, Actions	Track the details of actions taken in the rehabilitation plan.
Claims	HS_INJ_REHAB1	Workforce Monitoring, Health and Safety, Obtain Incident Information, Create Non-Employee Rehab Plan, Claims	Associate an incident and essential claims data to rehabilitation plan details.
Restrictions	HS_INJ_REHAB2	Workforce Monitoring, Health and Safety, Obtain Incident Information, Create Non-Employee Rehab Plan, Restrictions	Monitor an employee’s work restrictions and modified duties included in the rehabilitation plan.
Actions	HS_INJ_REHAB3	Workforce Monitoring, Health and Safety, Obtain Incident Information, Create Non-Employee Rehab Plan, Actions	Track the details of actions taken in the rehabilitation plan.

Associating an Incident

Access the Create Employee Rehab Plan - Claims page.

You can enter the Last Date Worked Before Injury and Claims Filed information for each incident in which the individual is involved.

Last Work Date Before Injury	Enter the date for the last day the employee worked before the injury.
Return Date	Enter the date when the employee returned to work.

Claims Filed

If the individual has filed any claims, the information that you entered on the Claims Management pages appears here. If this information is not in the system, enter it here for each claim associated with this incident. The most important data is in the Assessment Date and Disposition fields—the governing agency or insurance company that you report the claim to uses the information in conjunction with the rehabilitation plan details.

Close Date	Enter the claim close date.
Claim Status	Select from the list of available options.
Provider Claim Nbr (provider claim number)	Enter the provider claim number.
Assessment Date	Enter the assessment date.
Disposition	Select from the list of available options.

Monitoring Work Restrictions and Duties

Access the Create Employee Rehab Plan - Restrictions page.

Work Restrictions

Select a code for any work restrictions that the employee has as a result of the injury or illness. Create these codes in the Work Restriction Table.

Work Modifications

Select a code for any work modifications the employee has as a result of the injury or illness. Create these codes in the Modified Work Table.

From/To

Enter the dates for the period that each modified work duty must apply.

Tracking Rehabilitation Action Details

Access the Create Employee Rehab Plan - Actions page.

Action Sequence

The system assigns each data row with an action sequence in numerical order.

Type

Select an action type from the list of available options.

Responsible ID

If a person within the organization is coordinating the rehabilitation plan, enter or select a responsible ID (employee ID number). The available values come from Personal Data.

Physician

Select an option from the list of available options; values come from the Physician Table. Or, if you choose not to enter physicians in the Physician Table, enter the physician’s name into the name field.

Provider Description

Enter a description of the provider.

Diagnosis

Select the type of diagnosis in this action; create these values in the Diagnosis Table.

Estimated Completion Date

Enter the estimated completion date of the action.

Actual Completion Date

When the action is complete, enter the actual completion date.

Action Status

Once you enter an actual completion date, change the action status.

Tracking Employee Medical Exam Results

This section discusses how to:

Enter physical examination information.
Enter physical exam results.
Enter hearing exam details.
Enter eye exam details.
Enter respiratory exam details.
Set up drug testing information.
Enter test results and referrals.

An organization can requires employee to have medical examinations for a number of different reasons.

Tracking medical exam results is useful for observing and protecting the health of employees who are at occupational risk due to their work location or job group. Use the results of exams to track risk factors, analyze trends, and compare work groups with one another to monitor work environments. You can also use the information to put together preventive health care programs for educating employees about work-related health issues.

Track this information for employees only.

Common Elements Used in Tracking Medical Exam Results

Baseline	Select if this is a baseline exam.
Referral	Select a physician referral code from the list of available options, or enter a referral directly.

Pages Used to Track Medical Exam Results

Page Name	Object Name	Navigation	Usage
Physical Exam Address/Phone	HS_EXAM_PHYSICAL1	Workforce Monitoring, Health and Safety, Record Medical Exam Results, Physical Exam, Physical Exam Address/Phone Workforce Monitoring, Health and Safety, Review Health Card Info, Hs Exam Physical1	Maintain the exam date and type, indicate the next exam date, and enter physician address information.
Exam Details	HS_EXAM_PHYSICAL2	Workforce Monitoring, Health and Safety, Record Medical Exam Results, Physical Exam, Exam Details Workforce Monitoring, Health and Safety, Review Health Card Info, Hs Exam Physical2	Maintain physical exam results.
Audiometric Exam/Address/Phone	HS_EXAM_AUDIO1	Workforce Monitoring, Health and Safety, Record Medical Exam Results, Audiometric Exam, Audio Exam Address/Phone Workforce Monitoring, Health and Safety, Record Medical Exam Results, Review Health Card Info, Hs Exam Audio1	Maintain audiometric exam results, referrals, and comments. Indicate the next audiometeric exam date, and enter physician information.
Audiometric Exam - Exam Details	HS_EXAM_AUDIO2	Workforce Monitoring, Health and Safety, Record Medical Exam Results, Audiometric Exam, Exam Details Workforce Monitoring, Health and Safety, Record Medical Exam Results, Review Health Card Info, Hs Exam Audio2	Maintain audiometric exam details.
Eye Exam - Exam Details	HS_EXAM_EYE2	Workforce Monitoring, Health and Safety, Record Medical Exam Results, Eye Exam, Exam Details Workforce Monitoring, Health and Safety, Record Medical Exam Results, Review Health Card Info, Hs Exam Eye2	Maintain exam results, referrals, and comments.
Eye Exam - Eye Exam Address/Phone	HS_EXAM_EYE1	Workforce Monitoring, Health and Safety, Record Medical Exam Results, Eye Exam, Eye Exam Address/Phone Workforce Monitoring, Health and Safety, Record Medical Exam Results, Review Health Card Info, Hs Exam Eye1	Maintain exam results, referrals, and comments.
Respiratory Exam - Exam Details	HS_EXAM_RESPIRE2	Workforce Monitoring, Health and Safety, Record Medical Exam Results, Review Health Card Info, Hs Exam Respire2 Workforce Monitoring, Health and Safety, Record Medical Exam Results, Respiratory Exam, Exam Details	Maintain exam results, referrals, restrictions, and comments.
Respiratory Exam - Respiratory Exam Addr/Phone	HS_EXAM_RESPIRE1	Workforce Monitoring, Health and Safety, Record Medical Exam Results, Review Health Card Info, Hs Exam Respire1 Workforce Monitoring, Health and Safety, Record Medical Exam Results, Respiratory Exam, Respiratory Exam Addr/Phone	Maintain exam results, referrals, restrictions, and comments.
Drug Test Data 1	GVT_DRUG_TEST1	Workforce Monitoring, Health and Safety, Record Medical Exam Results, Drug Test, Drug Test Data 1	Set up physician and test information for a drug test.
Drug Test Data 2	GVT_DRUG_TEST2	Workforce Monitoring, Health and Safety, Record Medical Exam Results, Drug Test, Drug Test Data 2 Workforce Monitoring, Health and Safety, Record Medical Exam Results, Review Health Card Info, Drug Test Review	Maintain test results, referrals, and comments.

Entering Physical Examination Information

Access the Physical Exam Address/Phone page.

Note. The only difference on the Address/Phone page of each exam group is the name: depending on the component that you open, the page name is Physical, Audiometric, Eye, Respiratory, or Drug Exam. The information below applies to all of the Address/Phone pages.

Exam Date	Enter the date of the exam. The current date appears by default. You can override it, if necessary. The system sorts exam result data rows by exam date.
Exam Type	Select an option from the available values.
Next Exam	The next exam date appears by default for the following exam types. You can override the defaults if the actual dates are different. Annual: Next exam is one year later. Exposure: Next exam is six weeks later. Periodic Surveillance: Next exam is six months later.
Physician ID	Select from the available values, which come from the Physician Table. If you select a physician ID, the physician’s address information from the Physician Table automatically fills in the address block. You can edit this address.
Edit Address	Click this link to enter or modify an address. The appropriate address fields appear in the standardized address formats that you previously set up in the Country Table.

(FRA) France

Medical Organization Code

Select the medical organization that completed the physical exam.

(FPS) French Public Sector

Next Medical Exam Type

Select the next type of exam.

Entering Physical Exam Results

Access the Physical Exam - Exam Details page.

The employee’s name and employee ID appear at the top of the page.

Organ Donor	Select if the employee is an organ donor.
Blood Donor	Select if the employee is a blood donor.
Blood Type	Select an option from the list of available options.

(FRA) France

This Exam	Enter the time for this exam.
Next Exam	Enter the time for the next exam.
Work Capability	To enter information about the employee’s ability to work, select the appropriate option: Able to Work Normally, Able to Work With Restrictions, Unable to Work.
Reg Region (regulatory region)	Enter the regulatory region in which the employee works. Select from the available values, which come from the Regulatory Region Table.
Work Modification	Enter this by selecting from the available values, which come from the Modified Work Table. Then enter the To and From Date for which the modification applies.
Work Restriction	Enter this by selecting from the list of prompt values, which are from the Work Restrictions Table. Then enter the To and From Date for which the restriction applies.

(DEU) Germany

Result / Empl Rcd# (employee record number)

For each employee record number that you enter, enter the result of the examination by selecting an option from the list of available options.

Entering Hearing Exam Details

Access the Audiometric Exam - Exam Details page.

Decibels

For each ear, enter the decibels the employee cannot hear.

Trouble Frequency

For each decibel selection, select each trouble frequency.

Hearing Classification

Select a hearing classification.

Entering Eye Exam Details

Access the Eye Exam - Exam Details page.

Color Vision

Indicate if the patient’s color vision is Normal or Abnormal.

Correction Required

Select this check box if the exam results indicate that this employee needs lenses or other corrective treatment.

Far Sight/Near Sight

Enter the specific exam results for the Left and Right eyes, both Corrected and Uncorrected.

Entering Respiratory Exam Details

Access the Respiratory Exam - Exam Details page.

Smoker

Information about the employee’s history as a smoker comes from Personal Data. If the check box is unavailable, the employee is not a smoker. Select an available Smoker check box to indicate that the employee is a smoker.

Date of Exposure

If it applies, enter the exposure date.

Exposure Type

If it applies, select an option from the list of available options.

Contaminant Agent

If it applies, select an option from the list of available options.

Business Unit

Select a business unit for the employee’s work location. Define business units in the Business Unit Table. The system automatically enters the associated description.

Location Code

Select a location code for the employee’s work location. You define location codes in the Location Code Table. The system automatically enters the associated description.

Setting Up Drug Testing Information

Access the Drug Test Data 1 page.

Exam Date

Today's date appears by default; change appropriately. The system sorts exam result data rows by exam date.

Physician

Enter the name of the employee's physician.

Testing Type

Select one: For Cause, Mandatory, or Random.

Next Exam

Indicate when the next exam is scheduled.

Union Negotiated

Select to indicate that the test is mandated by a union agreement.

Entering Test Results and Referrals

Access the Drug Test Data 2 page.

Exam Results

Select an option to indicate the exam results: Pass, Fail, No Show for Exam, or Monitoring Required.

Date of Appeal	Enter the date on which the appeal is filed.
Date Claim Re-Opened	Enter the date on which the claim is re-opened.
Appealed By	Select from the available values to indicate who filed the appeal.

Payment Type	Select if the payment type is Advance Payment, Claim Deposit, Claim Payment, or Provisional Payment.
Payment Date	Enter the payment date.
Amount	Enter the payment amount.
Recipient Type	Select if the recipient of the payment is an Employee, Non-Employee, or Dependent. Once selected, select the ID of the employee, non-employee, or dependent. If you select Dependent, the relationship appears.
Comment	Enter an optional comment about the payment.

Contact ID	Select a Contact ID (Employee ID Number), if one exists within an organization. Available values come from Personal Data.
Provider Claim Nbr (provider claim number)	Enter this, if you know it. Typical types of providers are government agencies, such as the Workers’ Compensation Board of Canada or insurance companies.
Provider Name	Enter the provider name.
Claims Manager	Enter the name of the claims manager.
Assessment Date	Enter an assessment date.
Disposition	Select the claim disposition from the available values in the list of available options.

Work Restrictions	Select a code for any work restrictions that the employee has as a result of the injury or illness. Create these codes in the Work Restriction Table.
Work Modifications	Select a code for any work modifications the employee has as a result of the injury or illness. Create these codes in the Modified Work Table.
From/To	Enter the dates for the period that each modified work duty must apply.

Action Sequence	The system assigns each data row with an action sequence in numerical order.
Type	Select an action type from the list of available options.
Responsible ID	If a person within the organization is coordinating the rehabilitation plan, enter or select a responsible ID (employee ID number). The available values come from Personal Data.
Physician	Select an option from the list of available options; values come from the Physician Table. Or, if you choose not to enter physicians in the Physician Table, enter the physician’s name into the name field.
Provider Description	Enter a description of the provider.
Diagnosis	Select the type of diagnosis in this action; create these values in the Diagnosis Table.
Estimated Completion Date	Enter the estimated completion date of the action.
Actual Completion Date	When the action is complete, enter the actual completion date.
Action Status	Once you enter an actual completion date, change the action status.

Decibels	For each ear, enter the decibels the employee cannot hear.
Trouble Frequency	For each decibel selection, select each trouble frequency.
Hearing Classification	Select a hearing classification.

Color Vision	Indicate if the patient’s color vision is Normal or Abnormal.
Correction Required	Select this check box if the exam results indicate that this employee needs lenses or other corrective treatment.
Far Sight/Near Sight	Enter the specific exam results for the Left and Right eyes, both Corrected and Uncorrected.

Smoker	Information about the employee’s history as a smoker comes from Personal Data. If the check box is unavailable, the employee is not a smoker. Select an available Smoker check box to indicate that the employee is a smoker.
Date of Exposure	If it applies, enter the exposure date.
Exposure Type	If it applies, select an option from the list of available options.
Contaminant Agent	If it applies, select an option from the list of available options.
Business Unit	Select a business unit for the employee’s work location. Define business units in the Business Unit Table. The system automatically enters the associated description.
Location Code	Select a location code for the employee’s work location. You define location codes in the Location Code Table. The system automatically enters the associated description.

Exam Date	Today's date appears by default; change appropriately. The system sorts exam result data rows by exam date.
Physician	Enter the name of the employee's physician.
Testing Type	Select one: For Cause, Mandatory, or Random.
Next Exam	Indicate when the next exam is scheduled.
Union Negotiated	Select to indicate that the test is mandated by a union agreement.