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Workers' Comp: A Glossary Of Terms
A B C D E F G H I J K L M
Adjuster — A person who investigates and settles losses for a workers' comp insurance carrier. Allowable amount — Any health expense, part or all of which is covered under any of the plans covering the claimant for whom a claim is made. This means that an expense or service or a portion of an expense or service that is not covered by any of the insurance plans is not an allowable amount. Approved Doctor List (ADL) — In the state of Texas, the workers' compensation commission rules require that starting Sept. 1, 2003, all doctors who participate in any capacity in the Texas workers' compensation system must be on the Approved Doctor List. They must meet the following requirements: Complete commission-prescribed training, file an application to be included on the ADL, and provide financial disclosure. Approved list of workers' comp medical practitioners — The insurance carrier's established list of approved physicians and other practitioners who may render medical services to employees with compensable work-related injuries or occupational diseases. Benefits — Workers' compensation payments or other payments mandated by a state's workers' compensation commission. Such payments include, but are not limited to, the following:
Case manager — A professional assigned by a workers' comp carrier to assess an injured worker's long-term-care needs and provide recommendations for care, monitoring and follow-up as to the quality of services to be provided. Carrier — An insurance company that assumes an employer's legal liability for work-related injuries or occupational disease. Claimant — Any person who makes a claim for workers' compensation benefits for an alleged work-related injury or occupational disease. Claimants are either employees claiming a compensable work-related injury or occupational disease, or surviving dependents of an employee killed by a compensable work-related injury or occupational disease. Compensable — The injury or disease for which liability to pay compensation has been determined. Compensable injury — One that arises out of and in the course and scope of employment for which compensation is payable. The employee specifically is entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the injured employee to return to or to retain employment. Compensable services — Those health-care services for which the claimant is entitled to receive coverage under the terms of workers' compensation benefits. Commissioner — Workers' compensation commissioner, an administrative official authorized by a state's workers' compensation act to have jurisdiction as described in a given section of the act. Consulting doctor — A licensed doctor who examines an injured employee or the employee's medical record in response to a request from the treating doctor or the designated doctor. The consulting doctor must submit a narrative report to the treating doctor, the employee, the employee's representative (if any) and the carrier. Covering doctor — A provider designated by a treating physician to provide services to claimants when the treating physician is not available. Credentialing — A systematic approach to assessing a provider's qualifications and record on issues relating to professional competence and conduct. This includes a review of relevant training, academic background, experience, licensure, certification and/or registration to practice in a health-care field. Current Procedural Terminology (CPT) codes — Standard codes that physicians, hospitals and other providers use to bill insurance companies for services. Each code uniquely identifies a medical service or procedure. The American Medical Association publishes official CPT code books and other materials that are updated annually. Date of injury (DOI) — The date a work-related injury occurs or, for an occupational disease, the date when total or partial disability from work occurs as a result of the disease. Dependent — A family member or next of kin of an employee with compensable work-related injuries or occupational diseases who was wholly or partly dependent upon the employee's earnings at the time of the employee's injury or disease. This includes any presumptive dependent or dependent in fact. Designated doctor — In Texas, a doctor appointed by the Texas Workers' Compensation Commission to recommend a resolution of a dispute regarding the medical condition of an employee. Disability — A condition that renders an insured person incapable of performing one or more material duties of his or her regular occupation. Fee schedule (state) — A list published by a state that sets forth the maximum fee for each specific medical procedure and services performed on an injured worker under the workers' comp system. First report of injury — A report that an employer is required to file in cases of an employee's occupational injury or disease that result in disability from work of one day or more. Impairment — Loss of full or partial function of any body part. Impairment rating (IR) — A rating assigned to an injured worker to indicate the remaining degree of impairment after the worker has reached maximum medical improvement. Impairment rating (IR) doctor — A doctor who has been fully authorized to certify maximum medical improvement and assign an impairment rating when there is permanent impairment as a result of the workers' compensation injury. Independent Medical Examination (IME) — Medical examination of a claimant usually requested by another party (i.e., the respondent in the case or workers' compensation commissioner) and conducted by a physician other than the claimant's attending physician. Sometimes referred to as Required Medical Examination (RME). Maximum medical improvement — When an injured worker has healed from a compensable work-related injury or occupational disease as fully as he or she is expected to heal. At this time, the doctor determines whether or not the worker has a permanent disability and the degree of impairment. Modified duty — Work prescribed by an employee's attending or treating physician to fall within certain physical restrictions while the employee continues to heal from a compensable work-related injury or occupational disease. Occupational disease — A disease contracted or aggravated by characteristics or conditions of a particular occupation and arising out of and in the course of employment. Occupational health clinic — A medical clinic specializing in the diagnosis and treatment of occupationally related injuries and illnesses. Occupational injury — An accidental injury that occurred at a definite, known time and place and is causally connected with the injured person's employment, or is the direct result of repetitive trauma or repetitive acts in the course of such employment. OSHA (Occupational Safety & Health Administration) — The U.S. government's OSHA inspects private-sector workplaces for health and safety violations. Permanent partial disability — Permanent loss of, or loss of use of, one or more body parts of an employee with a compensable work-related injury or occupational disease. Peer review/utilization review (PR/UR) doctor — A physician who evaluates medical and health-care services, including evaluation of the qualifications of professional health-care practitioners and of health care provided by those practitioners. A PR/UR doctor generally evaluates any or all of the following through a paper review:
Preauthorization — Approval obtained from an insurance carrier by a health-care provider or injured employee before health-care treatments or services are provided. Referral doctor — A licensed doctor who examines and treats an injured employee in response to a request from the treating doctor. Relapse or recurrence — A situation in which an employee with a compensable work-related injury or occupational disease who has improved and returned to work experiences a return of some medical problem(s) caused by the injury or disease. This return of symptoms results in another period of disability from work and/or requires further medical treatment. An employee is eligible for wage-replacement benefits for a relapse or recurrence. Respondent — An employer or its workers' compensation insurance carrier in a workers' compensation case. Risk manager — An individual, acting on the employer's behalf, who has total responsibility for safety and financial risk as it relates to workers' comp. Settlement — A term used for partial disability benefits or to refer to a stipulation, which is a final close-out of a workers' compensation case. Statement of Medical Necessity (SMN) — A written statement and supporting documentation from the prescribing doctor to establish the need for treatments, services or prescriptions, including the need for a brand-name drug where applicable. Stipulation — The final close-out of a workers' compensation case by an employee with a compensable work-related injury or occupational disease and by the employer (and/or its workers' compensation insurance carrier). Close-out happens when an employee is paid a sum of money and/or provided certain medical treatment(s) and, in return, signs away any future right to benefits for the stipulated injury or disease. Some stipulations close out all aspects of a case (benefits and medical treatment) while other stipulations close out portions of available benefits (i.e., benefit payments or medical treatment), leaving the remaining benefits "open." Temporary partial disability — A temporary, but only partial, disability from work of an employee with a compensable work-related injury or occupational disease. During a period of partial disability, an employee can perform some types of work and may be eligible for temporary partial disability benefits. Temporary total disability — A temporary, but total, disability from work of an employee with a compensable work-related injury or occupational disease. During a period of total disability, an employee is unable to perform any type of work and is eligible for temporary total disability benefits. Third party — A party other than an employer or employee who is or may be responsible in some degree for an employee's compensable work-related injury or occupational disease. Treating doctor/physician — A doctor who is primarily responsible for the efficient management of health care and for coordinating the health care for an injured worker's compensable injury. Usual, Customary and Reasonable (UCR) — The amount customarily charged for the service by other providers in the same geographic area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient as set by the carrier or its designee. Utilization review — A review of the accuracy of a diagnosis, the quality of the care provided by a health-care provider, and the reasonableness and medical necessity of health care provided to or proposed for an employee. Vocational rehabilitation — Services that may include but are not limited to vocational testing, counseling, job-placement services, retraining or work-site modifications. Sometimes called voc rehab or rehab. The goal of vocational rehabilitation is a return to work. Work Status Report (TX) — A standard reporting system for work status within the Texas workers' compensation system. This system is designed to improve communication among doctors and employees to help them facilitate injured employees' effective and appropriate return to work. It also provides an assessment of the employee's capabilities so that the employer can make the appropriate employment decisions. Sources: State of Connecticut Workers' Compensation Commission glossary; Texas Workers' Compensation Commission; Aetna Inc. internal glossaries. |
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