Claim denied as This is a work-related injury (or) illness and thus the liability of the Worker’s Compensation Carrier

Work-Related Injury Claim Denied? Here’s How to Handle Worker’s Compensation Denial (Call Flow Guide)

When a claim is denied with the message:

“This is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier”

it means the insurance payer is saying the claim should be billed to Worker’s Compensation (WC) instead of commercial insurance.

This blog explains the On-Call scenario and step-by-step questions that should be asked to resolve the denial quickly and correctly.

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What Does This Denial Mean?

If the patient’s injury or illness happened at work, then Worker’s Compensation insurance becomes the primary payer.

So the commercial insurance will deny the claim because it is not responsible for work-related claims.

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On-Call Scenario: Worker’s Compensation Liability Denial

Step 1: Ask for the Denial Date

Start the call with:

✅ “May I get the denial date?”

This helps document when the denial was issued and supports timely reprocessing.

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Step 2: Request WC Details

Next question:

✅ “Could you please provide the Worker’s Compensation details?”

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Step 3: Does the Representative Have WC Details?

At this point, identify if the representative has Worker’s Comp information.

✅ If YES — Rep Has WC Details

Ask for these details:

✅ “What is the name, policy ID, payer ID, and mailing address of Worker’s Comp?”

Then confirm:

✅ “May I have the claim number and call reference number?”

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❌ If NO — Rep Does NOT Have WC Details

Then collect call tracking info:

✅ “May I have the claim number and call reference number?”

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Important Note: What to Do If WC Details Are Not Available

If the representative cannot provide WC details, follow these steps:

1) Check in the system for WC insurance

Look for:

• WC insurance available in the patient’s profile OR
• Patient payment history showing WC as primary insurance

If WC insurance exists, then:

✅ Check eligibility for that WC insurance
✅ Resubmit the claim to the WC payer

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2) Check payer web portal (if access available)

If you have portal access, you can:

✅ Search and retrieve Worker’s Compensation insurance details from the payer portal.

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3) If no WC information exists

If you cannot find WC insurance in system or portal:

✅ Release the claim to the patient (patient responsibility)

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Updating Insurance Correctly (Very Important)

If the representative provides full Worker’s Comp details:

✅ Update WC as Primary Insurance
✅ Resubmit claim to WC insurance

Do NOT keep Commercial Insurance as Secondary

❌ Commercial insurance should not remain as secondary once WC is primary.

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Special Case: Medicare as Secondary (Allowed)

Medicare can be kept as secondary ONLY if:

• WC processes the claim first
• WC leaves balance as patient responsibility

Then:

✅ Update MSP code correctly
✅ Bill remaining balance to Medicare

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Quick Summary (Simple Workflow)

1. Claim denied due to WC liability
2. Ask denial date
3. Ask for WC details
4. If rep has details → collect WC info + claim # + call ref #
5. If rep doesn’t have details → collect claim # + call ref # and check system/portal
6. If WC found → update primary + resubmit
7. If no WC → release to patient
8. Medicare can be secondary if MSP updated