Utilization Review Services - Workers Compensation
Early Compensability Review
An Early Compensability Review is a process where the claims adjudicator determines if there is evidence of an injury and, if so, the extent of the injury as supported by the medical documentation.
An Early Compensability Review is a tool available to the claims adjudicator to address if there is evidence of an injury and, if so, the extent of the injury as supported by the medical documentation. This allows for an assessment of compensability in the early stages of the claim as well as an anticipated medical treatment plan before unnecessary medical expenses are incurred..
A Compensable injury is an injury caused by an accident arising from the employment and in the course of employee’s work. Before the employee is entitled to receive compensation, an investigation needs to conducted.
Medical evidence is required to support the findings and is often subject to limitations such as no injury or disease is compensable as a consequence of a compensable injury unless the compensable injury is the major contributing cause of the consequential condition and If an otherwise compensable injury combines at any time with a preexisting condition to cause or prolong disability or a need for treatment, the combined condition is compensable only if, so long as and to the extent that the otherwise compensable injury is the major contributing cause of the disability of the combined condition or the major contributing cause of the need for treatment of the combined condition.
Each State definition of compensable injuries vary and SFUR works with within the parameters of each state following the state statute explaining compensable injury. The tenor across most states appears to define a “compensable injury” is an accidental injury, or accidental injury to prosthetic appliances, arising out of and in the course of employment requiring medical services or resulting in disability or death; an injury is accidental if the result is an accident, whether or not due to accidental means, if it is established by medical evidence supported by objective findings, subject to certain limitations.
The benefit of an assessment of compensability in the early stages of the claim as well as an anticipated medical treatment plan is to avoid unnecessary medical expenses.