CMP.6.4.010 Submission of Claims

Under this Ordinance, all claims made by the Employee for work related injuries/illness must be submitted to his/her immediate Supervisor/Director/Manager as soon as possible, but no later than three workdays after the incident occurs. The Employee is to complete a First Report of Injury/Illness form and a Patient Authorization for Release of Information form and submit them to their Supervisor/Director/Manager, who then co-signs the First Report of Injury/Illness form and immediately forwards both forms on to the Employer's Insurance Office. The Insurance Office will review the Report, and if warranted, will then, in a timely manner, forward the Report to the Claims Administrator/Managed Care Provider for evaluation and determination as to whether it is a valid claim under this Ordinance. The Claims Administrator/Managed Care Provider will, within fourteen (14) workdays of their receipt of the Report, provide written notice to the Employer's Insurance Office as to whether the claim has been approved or denied. The Insurance Office will notify the appropriate personnel of the decision. If approved, the Employer's Insurance Office will process payment of benefits due and related health care expenses incurred as a result of this injury/illness.

If denied, the Claims Administrator shall forward a written notice to the Employee and Plan Administrator. This notice shall contain the specific reason for the denial and clearly state the facts forming the basis of the denial. The denial must include information identifying the Employee, date of claimed injury, claim number, and instructions to the Employee of the rules and time limitations involved in the appeal process. The burden of proof of these facts is on the Employer. The facts arising under this section shall be determined by a preponderance of the evidence.