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Claim Office Administrator Underwriter Designation Form O - Arkansas

Claim Office Administrator Underwriter Designation Form Form. This is a Arkansas form and can be used in Workers Comp .
 Fillable pdf Last Modified 12/12/2013
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Form O Eff 1/01/2013 ARKANSAS WORKERS' COMPENSATION COMMISSION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-2783 / 1-800-622-4472 Rule 099.29 O CLAIM OFFICE / MEDICAL BILLING /ADMINISTRATOR / UNDERWRITER Designation Form Please see the reverse side of this form for completion instructions This form is being filed for: An Insurance Carrier A Self-Insured Employer or Group Insurance Carriers - Please complete the following NAIC Company Number NAIC Group Number Company Name (full legal) FEIN Claim Office: Claims are: 9 Self-Administered 9 Handled by a TPA Company Name Mailing Address _____________________________ _____________________________ ______________________________ Complete the following only if self-administered: Contact Name (Mr/Ms.) ______________________________ Direct Dial Phone # ______________________________ Contact Fax # ______________________________ Toll Free # ______________________________ Contact E-mail ______________________________ Medical Billing: Company Name Mailing Address Direct Dial Phone # Billing Fax # Toll Free # Billing E-mail ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Administrator: ______________________________ ______________________________ _______________________________ Contact Name (Mr/Ms.) ______________________________ Direct Dial Phone # ______________________________ Extension # ______________________________ Contact Fax # ______________________________ Toll Free # ______________________________ Contact E-mail ______________________________ Company Name Mailing Address Underwriting: ______________________________ ______________________________ _______________________________ Contact Name (Mr/Ms.) ______________________________ Direct Dial Phone # ______________________________ Extension # ______________________________ Contact Fax # ______________________________ Toll Free # ______________________________ Contact E-mail ______________________________ Company Name Mailing Address I, ____________________________________________(printed name), as an employee of the above carrier/self-insured employer (or its parent company), make the above designations in compliance with Commission Rule 099.29. Further, we agree to promptly notify the Commission of any changes to the above designations by re-completing and submitting this form. Phone Date Form O (Eff 10/1/12) American LegalNet, Inc. www.FormsWorkFlow.com Signature Title Completion Instructions Commission Rule 099.29 requires the designation of certain contacts to facilitate compliance with Arkansas law, Commission Rules and the processing of claims. Each insurance carrier (underwriting company) or approved self-insured employer/group is to complete the Form O. The designations below are to be made only by insurance carriers or self-insured employers/groups. This form is not to be completed by third party administrators, insurance agents or brokers. Please complete all four (4) sections. When submitting the Form O, only page 1 need be submitted (do not send the completion instructions). Company Name: This is the insurance carrier or approved self-insured employer/group for which the Form O is being completed. Claim Office: This is the office designated, by the carrier or self-insured employer/group, to be responsible the receiving, processing, adjusting, and submission of forms, or otherwise handling of any Arkansas workers' compensation claim. Any office whether serving as the designated claim office or reporting claim office shall be approved by the Commission prior to handling any Arkansas workers' compensation claims. The person named as the contact person should have sufficient authority to address and resolve any issues that may arise regarding claim adjusting, payment of medical bills, timeliness/accuracy of form filings, or any other claim specific issue or process relating to claims. The e-mail address listed is to be the e-mail address of the person serving as the contact. No general or generic e-mail addresses will be accepted. If the designated claim office is that of a Third Party Administrator (TPA), only the company name and address of the office that will actually handle the claims needs to be provided in this section. The TPA companies have previously provided a contact person for each approved location to serve as the contact person. If an insurance company designates its own claim office (or claim office within the corporate family of the underwriting carrier) and also utilizes the services of a TPA for specific insured employers, the designated claim office is to have the ability to identify and refer any claim specific item to the TPA office handling the claim (reporting office). Administrator: This person is to be an employee of the underwriting carrier, or an employee within the underwriting company's corporate family. For Self-Insurers, this is the person responsible for the self-insurance program. This person is to have overall compliance role with the authority to resolve any workers' compensation matter, including, but not limited to, claims. Typically, this person is responsible for maintaining the company's license to write workers' compensation or to self-insure in Arkansas. Medical Billing: Each insurance carrier or approved self-insured employer/group is to provide a designated billing location, including: mailing address, e-mail address, fax number, and phone number, for medical billing. This is to be a location under the direct control of the insurance carrier or self-insurer/group. Location/contact information of a TPA or bill review company will not be acceptable. This contact information will be provided to medical providers and/or any other person for the submission of medical or claim related bills. The e-mail address provided in this section may be a general or generic e-mail address. The designated billing location shall be responsible for forwarding any bill to the appropriate office for processing. As an exception to the requirement that a designated billing location being under the direct control of the carrier or self-insurer/group, any carrier or self-insurer/group that designates a TPA as its designated claim office, may provide, as a designated billing location, information provided by TPA; however, that information may
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