Glossary

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Glossary of Terms

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A


accident

An event, arising out of and in the course of employment, which results in personal injury to a worker.

 

accident date

Refers to either (a) the date the accident is deemed to have occurred or (b) the date of onset assigned to an occupational disease. For cumulative injuries or disease injuries there may not be an actual accident date. In these cases the accident date may be the last date of exposure or last day of policy.

accident state

A state or foreign location that identifies where the accident took place or where a disease was first contracted.

 

ACOEM

American College of Occupational and Environmental Medicine. Until the state Division of Workers’ Compensation (DWC) adopts medical treatment guidelines, the guidelines published by ACOEM, called “Occupational Medicine Practice Guidelines,” are the guidelines used in most cases to decide the type and amount of treatment you’ll receive for a work injury or illness.

 

adjuster

an individual representing the insurance company in discussions to reach agreement on the loss amount. (Sometimes called a claim representative or claim adjuster.)

 

American Medical Association (AMA)

A national physician’s group. The AMA publishes a set of guidelines called “Guides to the Evaluation of Permanent Impairment.” If your permanent disability is rated under the 2005 rating schedule, the doctor is required to determine your level of impairment using the AMA’s guides.

 

AOE/COE (Arising out of and occurring in the course of employment)

Your injury must be caused by and happen on the job.

 

Applicant

The party — usually you — that opens a case at the local Workers’ Compensation Appeals Board (WCAB) office by filing an application for adjudication of claim.

 

Appeals board

A group of seven commissioners appointed by the governor to review and reconsider decisions of workers’ compensation administrative law judges. Also called the Reconsideration Unit. See Workers’ Compensation Appeals Board.

 

Applicants’ attorney

A lawyer that can represent you in your workers’ compensation case. Applicant refers to you, the injured worker.

 

Application for adjudication of claim (application or app)

A form you file to open a case at the local Workers’ Compensation Appeals Board (WCAB) office if you have a disagreement with the insurance company about your claim.

 

Apportionment

A way of figuring out how much of your permanent disability is due to your work injury and how much is due to other disabilities.

 

B


bill

represents a request for services rendered on an eBill, (submitted on an electronic professional, institutional or dental claim form).

 

C


carrier

An insurance company.

 

certificate of insurance

A document that provides evidence of the existence and terms of a particular policy.

 

claim

Is a property and casualty case or claim file that represents the demand represents the demand by the injured party against the property and casualty policy (not a bill).

 

claimant

A person who submits a claim to an insurance company for a loss.

 

claim number

An alphanumeric code that uniquely identifies the claim.

 

claims adjuster

The term for insurance companies and others that handle your workers’ compensation claim. Most claims administrators work for insurance companies or third party administrators handling claims for employers. Some claims administrators work directly for large employers that handle their own claims. Also called claims examiner or claims administrator.

 

CPT (Current Procedural Terminology)

The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals.

 

D


date of injury

When you got hurt or ill. If your injury was caused by one event, the date it happened is the date of injury. If the injury or illness was caused by repeated exposures (a cumulative injury), the date of injury is the date you knew or should have known the injury was caused by work.

 

deductible

A policy provision that requires an insurer to only pay that amount of any loss which is in excess of a specified amount.

 

disability

A physical or mental impairment that limits your life activities. A condition that makes engaging in physical, social and work activities difficult.

 

E


eBill

Represents an electronic request for services rendered on an eBill, (submitted on an ASC X12 837 professional or institutional claim).

 

Employee

A person whose work activities are under the control of an individual or entity. The term employee includes undocumented workers and minors.

 

Employer

The person or entity with control over your work activities.

 

EOR

Explanation of Reimbursement/Review

 

Essential functions

Duties considered crucial to the job you want or have. When being considered for alternative work, you must have both the physical and mental qualifications to fulfill the job’s essential functions.

 

F


Findings & award (F&A)

A written decision by a workers’ compensation administrative law judge about your case, including payments and future care that must be provided to you. The F&A becomes a final order unless appealed.

 

Fraud

Any person who, knowingly and with intent to defraud, presents causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer or purported insurer, or any agent thereof, any written statement as part of or in support of, an application for the issuance of or the rating of an insurance policy for compensation insurance or a claim for payment or other benefit pursuant to a compensation policy which he or she knows to (i) contain a materially false statement or representation concerning any fact material thereto, or (ii) omits any fact material thereto, shall be guilty of a class E felony.

 

FROI

An acronym used in the insurance industry for First Report of Injury.

 

G


general contractor

An individual or business firm who contracted to perform all or part of a specified job.

 

General Liability Insurance

Coverage for an insured when negligent acts and/or omissions result in bodily injury and/or property damage to a third party.

 

H


Health care organization (HCO)

An organization certified by the Department of Industrial Relations to provide managed medical care within the workers’ compensation system.

 

HIPAA

The Health Insurance Portability and Accountability Act of 1996. A law enacted by Congress requiring the U.S. Health and Human Services Department to adopt standards for transmission of information between parties while carrying out financial or administrative activities related to health care. These standards also must address security of protected health information.

 

I


Impairment rating

A percentage estimate of how much normal use of your injured body parts you’ve lost. Impairment ratings are determined based on guidelines published by the American Medical Association (AMA). An impairment rating is used to calculate your permanent disability rating but is different from your permanent disability rating.

 

Incurred cost

The total anticipated ultimate cost of a claim. The incurred cost is the sum of all past payments and a reserve for all future payments.

 

Insurance

A contractual arrangement under which one party agrees to indemnify another against loss or damage from an unknown event for a certain sum called a premium.

 

J


jurisdiction

Jurisdiction means the state in which the insured event occurred and the property and casualty policy has authority.

 

K


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L


Lien

A right or claim for payment against a workers’ compensation case. A lien claimant, such as a medical provider, can file a form with the local Workers’ Compensation Appeals Board to request payment of money owed in a workers’ compensation case.

 

Longshore and Harbor Workers’ Compensation Act

Federal law which provides for payments of compensation and other benefits to employees such as longshoreman, harbor workers, and ship repairers. It applies to such employees while working on navigable waters, adjoining piers, and terminals. It does not cover members of a crew of a vessel. U.S. Code (1946), Title 33 § 901-950.

 

M


Medical Provider Network (MPN)

An entity or group of health care providers set up by an insurer or self-insured employer and approved by DWC’s administrative director to treat workers injured on the job.

 

Medical treatment

Treatment reasonably required to cure or relieve the effects of a work-related injury or illness. Also called medical care.

 

Modified work

Your old job, with some changes that allow you do to it. If your doctor says you will not be able to return to your job at the time of injury, your employer is encouraged to offer you modified work instead of supplemental job displacement benefits or vocational rehabilitation benefits.

 

N


National Drug Code

The National Drug Code (NDC) is a unique code that identifies the vendor (manufacturer), product and package size of a drug recognized by the Food and Drug Administration.

 

National Provider Identifier

Standard unique identifier that must be used by health care providers for electronic health care transactions covered under HIPAA.

 

O


OSHA

Occupational Safety and Health Act of 1970. Under this federal law, the US Department of Labor has responsibility of formulating safety and health standards for all businesses engaged in interstate commerce. www.osha.gov

 

P


Partial disability

Disability which allows a claimant to engage in some kind of gainful employment. The difference between the claimant’s pre-accident earnings and post-accident earnings is determinative of the reduced earnings rate. (WC law § 15, Sub.5, 5-a)

 

Permanent disability

Any lasting disability that results in a reduced earning capacity after maximum medical improvement is reached.

 

Permanent disability rating (PDR)

A percentage that estimates how much a job injury permanently limits the kinds of work you can do. It is based on your medical condition, date of injury, age when injured, occupation when injured, how much of the disability is caused by your job, and your diminished future earning capacity. It determines the number of weeks you are entitled to permanent disability benefits.

 

Prescription Benefits Manager (PBM)

A network of pharmacies and mail order services under the direction of an organization, which provide prescription benefits under contract or agreement with a carrier or employer.

 

Physician

A medical doctor, an osteopath, a psychologist, an acupuncturist, an optometrist, a dentist, a podiatrist or a chiropractor licensed in California.

 

Property and Casualty (P&C) Coverage

Broad insurance coverage for Personal and Commercial lines of business. P&C coverage includes workers’ compensation and auto injury insurance coverage.

 

Q


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R


Rehabilitation

The process of restoring injured workers to productive employment through physical means, medical procedures, vocational retraining, selective placement, and social readjustment. Rehabilitation is an integral part of the medical care and other services furnished a claimant under the law. (WC law §13, Sub. a)

Reserve

The amount of money set aside to pay the potential future cost of a claim.

Risk

The entity, property or other exposure to be insured. Also used to signify uncertainty about financial loss.

 

Return to Work (RTW)

A Return to Work program is a written plan designed to get employees back to work as soon as medically possible following an on-the-job injury or illness, and can be initiated by either the employer or the carrier. It is mutually beneficial to both employees and employers.

 

S


subscriber

In workers compensation, the subscriber is always the employer that holds the coverage. The subscriber is always the insured organization (subscriber), never a person. In auto injury, the subscriber is the named entity on the applicable policy.

 

T


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U


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V


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W


workers’ compensation

Employer (subscriber) insurance assumes liability for injuries incurred as the injured worker does not pay the incurred medical cost.

 

X/Y/Z


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**Glossary terms have been compiled from multiple sources. Definitions may vary by state. Please contact your local authorities for specific usage This is provided as a general guide only and not to be used as legal definitions of the terms.