What should a claims adjuster do if medical treatment is denied initially?

• A. File an appeal on behalf of the employee
• B. Negotiate with the medical provider directly
• C. Inform the employee about the denial and options available
• D. Automatically approve the treatment to avoid conflict

Answer: (C)

When medical treatment is denied initially, one of the primary responsibilities of a claims adjuster is to inform the employee about the denial and the options that are available to them. This step is crucial because it ensures that the employee is aware of why the treatment was denied and outlines the next steps they can take. By doing so, the adjuster fulfills their duty to provide clear communication and support to the employee, helping them understand their rights within the context of the claims process.

This approach not only fosters transparency but also empowers the employee to take any necessary actions, such as filing an appeal or seeking further clarification on the denial. It is essential for the claims adjuster to maintain open lines of communication, as this can build trust and help navigate the complexities often involved in workers' compensation cases.

While appealing on behalf of the employee or directly negotiating with the medical provider may seem like proactive measures, these actions may not be the adjuster's primary responsibilities unless specifically authorized in their role or unless the appeals process is clearly defined. Automatically approving treatment to avoid conflict can lead to significant issues, including potential financial liability and undermining of proper procedural standards, making it an inappropriate choice in this context.