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Disability Claims Processing System


SSI's Disability and Supplemental Income Claims Processing System (DBL) is designed to handle the needs and functions required for a Fund Administrator. The system gives the user the ability to process either LTD or STD weekly benefits (statutory or otherwise) and can also be used for Supplemental Income claims or Death Benefits. If the client has an integrated imaging system, there will be easy links throughout the system to retrieve relevant documents, e.g., the actual claim form. DBL includes:

Plan Maintenance
This function stores and maintains the various benefit levels and descriptions of each particular Disability and Supplemental Income Plan in the system. This allows for total flexibility in handling multiple plans within the system and setting up a number of variables in order to define the plan design, such as:

  • Elimination periods based upon type of illness or accident
  • Credit of the elimination period, if withheld
  • Tracking of maximum payment period, by claim, by 12 month cycle or lifetime
  • Number of days in a week / Number of days full time
  • Payment flexibility, i.e. percentage of salary, carve out, flat amount, minimum, maximum, use of a benefit rate table
  • Automatic tax calculation
  • Breakpoint by days to alternate plan
  • Ability to ‘hold’ claims after each check run for review prior to next check run
  • Automatic recalculation of benefits during payment period


Code Maintenance
  • Ability to interface with CPT and/or ICD9 coding systems or user-defined codes
  • Reject or Hold codes with description of why claim is being rejected / held
  • Alternate Payee codes


Claim Entry or Change This function is used to enter a Disability, Supplemental Income or Death Benefit Claim for payment, or to make changes to a current claim. The information entered for each claim includes:
  • Member's Social Security Number or Alternate ID#
  • Automatic system check for open claim
  • Name of employer, primary and secondary
  • Claim number, either assigned by the system or the client
  • Automatic release flag of weekly checks with 'as of' date
  • Claim status description: Active, Inactive, Held, Reject, Paid Up
  • Date received, Date entered, Date changed
  • Audit trail of claim entry/change
  • Diagnosis (ICD9 code) tracking of primary and secondary diagnoses
  • Surgery (CPT code) tracking of the procedure performed
  • Reject or Hold reason code with description
  • Type of claim: illness, accident, maternity, worker’s compensation, statutory, relapse
  • Last date worked, first date out, first date of treatment, date disability began, first date paid, dates of hospital confinement, last medical evaluation date, next medical evaluation date, return to work date, proposed and actual, last date to be paid.
  • FICA and other taxes withheld, along with complete calculation using exemptions
  • Salary (used to automatically determine system calculated weekly benefit)
  • Offset amount for Supplemental Income Claims
  • Attending physician data - address, tax ID, specialty codes, management review
  • Medical follow-up evaluation - diary capability with bypass indicator
  • Physician referral capability - fee, date, audit trail, results, treatment notes
  • Alternate payee/address capability - date sensitive - reason code
  • Unlimited notes and comments
  • Check by check history data per claim


A member will continue to receive weekly payments until the last date to be paid has been reached or as long as periodic medical evaluation reports are received based upon the Fund’s policy.

Employer Verification Report This function generates a list of all members, by employer, that the system shows as ‘active’ who has an active claim for Disability or Supplemental Income. This report allows employer confirmation that a member has not returned to work.
Pre-Check Register Review This function produces a list of all members that are scheduled to receive a Disability or Supplemental Income check for the selected date period. The Pre-Check Register Review acts as a work sheet allowing the Fund staff to review and release all Disability or Supplemental Income claims that meet the criteria for payment.
Additionally, the system compares those members to current work history and flags those members for supervisory review and release.
Pre-Check Register This report can be generated by user-defined "period ending" dates for payment purposes. It identifies, by employer, each member to be paid, nature of disability, gross amount to be paid, FICA and taxes withheld and net amounts. It also provides grand totals of each category.
Extract and Check Writing This Extract function prints a list of members scheduled to receive checks, and Check Writing is for the actual printing of the weekly checks and explanations of benefits. Taxes are automatically deducted. Posting of checks issued to history is a separate automatic function.
Manual Check Writing and Voiding This function allows the ability to enter and make adjustments to payments made manually (Voids, replacement checks, additional payments, etc.)
Check Register This function prints a register of checks issued for the period payment is being made. If the Fund utilizes the Positive Pay Process, a file would be generated automatically for transmission to the bank.
Claim History A Claims History Summary screen displays a member’s complete history of Disability, Supplemental Income, or Death claims, allowing the user to select a specific claim to review. Claims are displayed with most recent payment on top.
The information shown is a complete copy of the Disability, Supplemental Income, or Death Claim format, but also displays the following:
  • Check number
  • Check date
  • Check amount
  • FICA and other tax deductions


Reports
The DBL System has a number of standard reports, each with extensive flexibility as to what period of time, or for which employers or groups of employers, or in what sequence a report appears. In addition, other SQL reporting tools, e.g., Microsoft Access or Crystal Reports can be utilized to generate ad-hoc reports.
FICA and Other Tax Deduction Report This report prints, by employer, the amount paid to a member, including and FICA and all other tax deductions. This report can be produced for any period of time, as defined by the user.
W2 Reporting This function prints W2's at the end of the year and SSI is a common filer with the IRS and will submit the data to the IRS electronically.
Change Log The system creates a comprehensive change log that records the ‘before and after’ image of the data that has been changed. It will also indicate who made the change and when it was made. Supervisory staff can review or audit, either selected changes or all changes made to the database. One can display all changes made to a particular member, or create a report by user, or department, for any date range. The analysis can be performed on selected files or tables, allowing a focus on a particularly critical or troublesome area.