The 6th Thing That A California Investigator Needs…

from their worker's compensation adjuster/examiner is an

EDEX and a Claims Index Report

So what is an EDEX?  EDEX stands for Electronic Data Exchange System.  This system is employed by the California State Division of Worker's Compensation as a means for permissible end users to request and receive data through purchase regarding worker's compensation cases that are under the jurisdiction of the California Worker's Compensation Appeals Board (WCAB).  The Worker's Compensation Appeals Board is the judicial administrative board that hears and resolves disputes on worker's compensatio cases between an applicant and the defendant insurance company or employer.  The WCAB also issues awards for benefits to those applicant's that are entitled to those benefits.

When I say "under the jurisdiction" of the WCAB, I mean only cases in which pleadings have been filed with the board (i.e. Application for Adjudication, Stipulation with Request for Award, Compromise & Release, etc.).  EDEX will only have data on cases in which these have been filed.  EDEX will not have any data on any claim that has not been filed with the WCAB.  Claims not filed with the WCAB may include incident only files (no medical treatment, no lost time), medical only files, files that do not have any settlement, and other new or ongoing indemnity claim files in which the claimant and the claims administrator may or may not be represented and have not filed any of the initiating documents named above.

Investigators may obtain the EDEX report from their adjuster clients but may also obtain them directly from the authorized approved vendors if they have a permissible reason.  See the vendors below (http://www.dir.ca.gov/dwc/edex.html)

Information brokers::

Company

Phone #

Fax #

Website Address

CompData EDEX & EAMS Services

P.O. Box 729
Seal Beach
CA 90740

(562) 493-4000

(562) 493-1550

http://www.compdataedex.com

Computer Services Group

1927 Harbor Blvd. #395

Costa Mesa, CA 92627

(800) 798-1880

(949) 646-7029

http://www.csg2000.com

EDEX Information Systems, Inc.

P.O. Box 665
Jackson, CA 95642

Toll-free

(866) GET-EDEX

(866) 438-3339

(209) 231-6700

http://www.edexis.com

Grey Wolf Laboratories Wolf Schubert

4006 Claitor Way
San Jose CA 95132

(408) 904-8731

http://greywolflabs.com

wolf.schubert@greywolflabs.com

Medical Lien Management, Inc.

P.O. Box 6829

Norco, CA 92880

(951) 808-3054

(760) 406-4807

http://www.dwcexchange.com/info@dwcexchange.com

SpeedComp EDEX & EAMS Services

P.O. Box 6886
Malibu, CA 90264-6886

(310) 457-3300

(310) 457-0500

http://wcabonline.com

Workcompcentral

1320 Flynn Rd.
Ste. 403
Camarillo, CA 93012

Toll-free

(866) WRK-COMP

(866) 975-2667

(805) 484-9322

http://www.workcompcentral.com

Inquiries are made with the EDEX system by submitting the claimant's Social Security Number and/or WCAB Case number (aka EAMS Number).  EDEX data can provide the following information:

Claimant's Name

Claimant's Date of Birth

Claimant's Gender

ADJ (EAMS #) or legacy WCAB Case Number

Body Parts Claimed

WCAB Current Case Status

The last five recent significant case events with dates.

A list of any hearings both past and future.

The official address record for each party to the case filing

Claims administrator

Insurance company if different from the claims administrator

Claimant's attorney

Defense attorney

Applicant's attorney or representative

Lien claimants

WCAB Jurisdictional Location (i.e. San Jose, San Francisco, Los Angeles, San Diego, etc.)

Date of the claimed injury

Type of injury (i.e. specific injury, cumulative trauma, occupational illness/disease)

The above vendors offer access to EDEX information as a fee for service.

The Division of Worker's Compensation also has a "free" public search tool to obtain similar information above but it is more limited in what it provides and depending on the credibility of the search criteria may not provide all available results.  This free search tool is called the EAMS (Electronic Adjudication Management System).

Information about the tool and its capabilities can be found at the following link:  (http://www.dir.ca.gov/dwc/eams/EAMS_PublicInformationSearch.htm)

The following is language is taken from the California DWC's Website regarding the public search tool:

"Requestors can search on all cases, including archived cases. If the case is archived the archived box will be checked on the general case information screen. If a Disability Evaluation Unit (DEU) case exists, the DEU box will be checked on the general case information screen. This is for informational purposes only—no DEU information is provided through this search.

Other criteria include:

Minimum search criteria is the EAMS case reference number or injured worker name

Partial name search is allowed

Date of birth, city, and ZIP code can be used with injured worker first and last name to refine search

Search result will be limited to 50 body part codes, active participants and events.

Since search results are limited to 50 it is best to be as specific as possible when searching. If the EAMS case number is not known, but the legacy case number is known, the EAMS and legacy case number lookup tool can be used to find the EAMS case number."

The search tool may be accessed by the following link:  https://eams.dwc.ca.gov/WebEnhancement/

On this screen the requester of the information must provide their information.  Their first and last name, a Uniformed Assigned Name (UAN) if one was assigned, their e-mail address, and then select a reason for their inquiry.  A private investigative firm will not likely have a UAN.  You would not have a UAN unless you have requested one.  These UANs are usually reserved for attorneys, law firms, insurance companies, and/or claims administrators.

After entering your information and clicking submit you will be brought to the next screen.  There are two tabs:  Case Search and Lien Search.  For the purposes of this blog posting we will only be presenting the Case Search tab.  There are six search fields.  Three of the search fields have an asterisk next to them.  At minimum you must enter an EAMS Case number or claimant's first and last name.  If you are searching by name you may input a partial name in either or both the first name or last name field.  The public information tool differs from the EDEX search in that you cannot search by Social Security Number.  In addition, as with all databases, if the incorrect information is initially entered or misspelled than it will be more difficult to find the information that you are looking for.

CLAIMS INDEX:

Obtaining a claims index report is a means to not only uncover prior worker’s compensation injuries but also uncover other personal injury claims that the claimant may have been involved with such as auto accidents, slip and falls, property claims, and general liability claims.   The claims index often also called ISO Claims Index because ISO is the largest vendor for this service.  The claims index is a database that many insurance companies and third party administrators subscribe to.  These members submit data on claims they receive from their insured, claimants and or third party claimants to add to the database.  Later they can search the database for claims history that may be pertinent to a current claim for the purposes of combating fraud, abuse, and mitigating loss on future claims that are filed.  One of the downsides of the index system is that not all insurers and claims administrations provide their claims data to the data base.

When a claim is submitted by an insurer or third party administrator the system searches the database and pulls claims information that matches any individual information or a combination of information submitted.  For example hits will be generated if there are matches in the claimant’s name, claimant’s address, claimant’s phone number, claimant’s date of birth, Vehicle Information Number, Vehicle license number, tax identification number, other parties to the loss, and/or the claimant’s Social Security Number.

Typically claims index information is only available to insurers, self-insured entities, and third party claims administrators.  That is why this information should be obtained from your client insurer, self-insured employer, or third party administrator.

For more information on the ISO Claims Index check out the following link: http://www.iso.com/Products/ISO-ClaimSearch/ISO-ClaimSearch-Facts-and-Figures.html

Why are the EDEX & the Claims Index Important for the Investigator?

Can be used to identify possible fraud.  Can be used with questioning a claimant regarding prior claims and injuries to see if they are forthcoming regarding those claims prior to asking them directly about them.  Can identify claims history that may not necessarily uncover fraud, but provide an apportionment to a preexisting disability.  Can be used to identify prior or concurrent employment.

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The 4th Thing That A California Investigator Needs…

to obtain from their claims adjuster [on a litigated claim] in the process of their worker’s compensation investigation is the:

Application For Adjudication Of Claim

The Application For Adjudication Of Claim, hereafter "Application" is the state form that an injured worker/claimant or their representative must file with the nearest local office of the California Worker's Compensation Appeals Board (WCAB).  The filing of the Applicant grants jurisdiction of the WCAB over the injured worker's/claimant's claim.  Once the Application is filed at the board the injured worker/claimant is often now called "the Applicant" by the work comp professionals.


One or more Applications are usually filed by the applicant's attorney after they are retained by the applicant to represent their interests against the claims administrator/insurer/employer before the WCAB.  However, there are some instances in which the claims administrator will file the Application in behalf of the injured worker with or without their consent or a service provider (aka Lien Claimant) may also file an Application if they have provided services related to an injured worker's compensation injury and they have not been paid in full or in part and they are seeking the WCAB's assistance in resolving the dispute.


To initiate proceedings before the WCAB for the collection of worker's compensation benefits the Applicant Employee or Lien Claimant must file the Application For Adjudication Of Claim with the WCAB within one year of the date of injury or within one year from the expiration of the period covered by payment of any worker's compensation benefits***, or within the last date in which benefits were provided (Labor Code Section 5405).  This section of the Labor Code is often referred to as the Statute Of Limitations Defense section.


The Application can be used by the investigator to inform and direct their investigation into the Applicant and their claims.  The Application may be used with other documents obtained or other non-document evidence obtained in the course of the investigator's investigation to corroborate the Applicant's claims or perhaps bring to light inconsistencies in the Applicant's claim.  The Application informs its reader about the employee demographics, their claims that includes the nature of injury(ies) they are claiming (cumulative versus specific), their claimed date(s) of injury(ies), their claimed employer at time of injury, the body parts or systems they are claiming injury or illness to, the claims administrator and/or insurance company(ies) claimed to have worker's coverage for one or more of the claimed injuries, and the Applicant's claimed earnings at the time of injury.


In addition, the Application informs its reader as to what disability the Applicant is claiming (see section or paragraph 4) and whether or not they were paid worker's compensation disability benefits for those disability periods.  Section or paragraph 6 inquire if State Disability or Unemployment Insurance Benefits have been paid to the Applicant.  Paragraph or section 7 inquires if medical treatment was provided to the Applicant and whether or not the employer or insurance carrier had provided the medical treatment.  If the employer or insurance carrier was not providing treatment, the Applicant may have been receiving medical treatment from their personal health insurance or State Medical Program (Medi-Cal) if hey are uninsured.   This informs the adjuster/examiner that they can possibly expect a Lien to be filed by EDD (Employment Development Department) in section 6 or by Medi-Cal Program or the Applicant's personal health insurance company as reflected in section 7 medical section.  Answers to section 6 and 7 will also provide the investigator of possible additional leads of information to pursue such as obtaining copies of benefit applications and medical information and records submitted to these respective programs that reflects what the Applicant has claimed to those program administrators and the respective medical providers they used in order to obtain those benefits from those programs.  The Application will tell you if the employee has filed any other Applications at the WCAB in section 8.  Finally, section 9 tells the adjuster or investigator what issues are disputed between the Applicant and the Claims Administrator/Employer.


Overall, the Application For Adjudication Of Claim is another resource available to the investigator for information that will inform and direct the investigator's investigation into the claim(s) of the injured worker/Applicant that will go towards the evidence needed by the adjuster so that they can make the proper decision regarding the Applicant's eligibility and extent of benefit due if eligible.

***  The Five (5) Benefits of California Worker's Compensation Benefits are

1.  Temporary Disability Benefits
2.  Permanent Disability Benefits
3.  Medical Treatment Benefits
4.  Supplemental Job Displacement Benefits
5.  Death Benefits