Workers Disability Compensation Claims Procedures Issued: January 1, 1994 Revised: March 29, 2012

Transcription

1 State f Michigan Administrative Guide t State Gvernment Wrkers Disability Cmpensatin Claims Prcedures Issued: January 1, 1994 Revised: March 29, 2012 SUBJECT: APPLICATION: PURPOSE: CONTACT AGENCY: Wrkers Disability Cmpensatin Claims Prcedures. Executive Branch Departments and Sub-units. T prvide directin n frms, prcedures and respnsibilities fr state emplyee wrkers disability cmpensatin claims reprting and prcessing. Department f Technlgy, Management and Budget (DTMB) Office f the State Emplyer (OSE) Emplyee Health Management (EHM) Divisin TELEPHONE: FAX: SUMMARY: This wrkers cmpensatin claim prcedure identifies frms and prcedures fr claims reprting and prcessing; defines respnsibilities f the emplyee r emplyee representative, the emplyer, and the third party administratr; and utlines the steps f the rejected claims appeals prcess. APPLICABLE FORMS: Emplyee/Emplyee Representative: Wrkers Cmpensatin Claim OSE/EHM Frm Rev. April 2008 Emplyer: DTMB-0923 First Wrkers Cmpensatin Check Release CS-701 Ntice f Cmmencement f Cmpensatin Payments PROCEDURES: Purpse: Regulatry Agency: WC-701 Ntice f Cmpensatin Payment WC-107 Ntice f Dispute T describe the frms and prcedures required t ensure prper emplyee Wrkers Disability Cmpensatin Claims reprting and prcessing. T define the respnsibilities f the emplyee r emplyee representative, emplyer, and the state s Third Party Claims Administratr (TPA) in Wrkers Cmpensatin claims prcessing. T utline the steps f the rejected claim appeals prcess. Applicatin: All departments, bards, cmmissins, ffices, agencies, authrities r ther units f the Executive Branch f state f Michigan gvernment. 1 f 5

2 References: P.A. 431 f Executive Order Explanatin f Abbreviatins: DTMB Department f Technlgy, Management and Budget HRMN Human Resurces Management Netwrk LTD Lng Term Disability MIOSHA Michigan Occupatinal Safety and Health Act TPA Third Party Claims Administratr WCA Wrkers Cmpensatin Agency WDCA Wrkers Disability Cmpensatin Act Intrductin and Operating Philsphy: Under Michigan s Wrkers Disability Cmpensatin Act (WDCA), agencies must prvide state emplyees wh receive a persnal injury arising ut f and in the curse f their emplyment: Reasnable medical, surgical, hspital services and medicines r ther attendance r treatment recgnized by the laws f this state as legal, when they are needed. Cmpensatin if the injury r illness keeps the emplyee incapacitated frm earning full wages fr mre than seven cnsecutive days; and Vcatinal rehabilitatin services, including retraining and jb placement, as may be reasnably necessary t restre him r her t useful emplyment. Rles and Respnsibilities: Emplyee: Ntify the emplyer as sn as a wrk related injury r illness ccurs. Participate in necessary medical/psychlgical/vcatinal rehabilitatin evaluatin and treatment, which may include an independent medical exam as rdered by the Wrkers Cmpensatin Agency (WCA). Prvide the emplyer with infrmatin necessary fr prcessing the claim. If the injury r illness causes an interruptin in emplyment, this includes keeping emplyer infrmed as t prgnsis, prgress tward returning t prductive wrk, and pssible need fr reasnable accmmdatins. Return t prductive wrk as sn as pssible, with reasnable accmmdatin, if apprpriate. Emplyer: Althugh the emplyer may cntract with an insurance carrier r a TPA t assist in managing claims fr benefits, the emplyer is ultimately respnsible fr cmpliance with the WDCA. Ensure emplyee seeks/receives immediate and apprpriate medical treatment and evaluatin. Ntify the state s wrkers cmpensatin TPA when an emplyee has an injury r illness that may be wrk related. Ensure a timely determinatin f cmpensability by prviding all necessary data t the TPA in a reasnable time frame. Ensure that the emplyee is receiving all entitled benefits, including special legislated supplements, supplements under Civil Service Rules and Regulatins, and any bargained benefits, and the emplyee is aware f any discretinary benefits. Administrative Guide t State Gvernment Prcedure: Revised: 3/29/ f 5

3 Crdinate the apprpriate return t wrk f an emplyee whse injury r illness causes an interruptin in emplyment, including prvisin f reasnable accmmdatin, if apprpriate, and/r placement assistance if necessary. Recrd accidents and illnesses with MIOSHA and take indicated actins necessary t avid similar injuries r illnesses in the future. Apprval f claims fr special legislated supplements (i.e., P.A. 293 f 1975 fr Department f Crrectins; P.A. 414 f 1976 fr Department f Cmmunity Health; P.A. 131 f 1978 fr Department f Human Services; P.A. 452 f 178 fr Department f State; and P.A. 368 f 1978 fr Department f Military and Veterans Affairs) are made by the appinting authrity. Wrkers Cmpensatin Claims Management Services (TPA): The TPA is delegated respnsibility by the emplyer t d claims management frm the time a claim fr benefits is received until the claim is frmally clsed. The TPA is respnsible fr: Ntifying the WCA when an emplyee has an injury r illness that may be wrk related. Ensuring a timely determinatin f cmpensability by requesting frm affected parties any infrmatin relative t the claim. Ensuring apprpriate wage replacement and related benefits are prvided in a timely manner. Crdinating prvisin and payment fr necessary medical/psychlgical/ rehabilitatin treatment. Facilitating apprpriate return t wrk. Ntifying the emplyee, emplyer, and the WCA immediately when the status f a claim changes. Internal Ntificatin (Emplyer/Supervisr): State law currently allws the emplyer t direct the emplyee s treatment fr the first 28 days fllwing a wrk related injury r illness. Even if the reprt is nt in writing, the supervisr shuld prmptly respnd t the ntificatin f a wrk related injury r illness. Sme departments r facilities have a cntract with a lcal medical clinic r prvider and thus initially require treatment frm that surce. Departments may als delegate certain steps t a manager ther than the emplyee s immediate supervisr. Supervisrs shuld check with their Human Resurces Office t determine if their department has a separate set f written prcedures t be used. Ntificatin t the Wrkers Cmpensatin TPA (Emplyer/Human Resurces Office): When the Human Resurces Office is ntified f an emplyee injury r illness that may be wrk related, the TPA must be frmally ntified and prvided with the basic infrmatin necessary t determine cmpensability, prcess medical payments, and cmpute any entitled benefits. These TPA functins are knwn as claims management and are the TPA s respnsibilities. Overall case management, including the distributin and flw f necessary infrmatin and frms, is the n-ging respnsibility f the Human Resurces ffice, part f which includes assuring that the claims management prcess ccurs in a crdinated and timely manner. Determinatin f Cmpensability: The TPA is respnsible fr basic claims management, which includes determining cmpensability f individual claims, cmputing benefits due under the state WDCA, and assuring benefits are prvided as required by the Act. The TPA is nt respnsible fr administering benefits that may supplement wrkers cmpensatin, nr is it respnsible fr case management issues beynd thse mandated by the WDCA, r by the PTA s cntract with the state. Administrative Guide t State Gvernment Prcedure: Revised: 3/29/ f 5

4 Respnse t Determinatin f Cmpensability (Emplyer/Human Resurces Office): Any questins abut the status f a wrkers cmpensatin claim shuld be directed t the claims examiner at the TPA. Frmal dispsitin f the claim will be reprted simultaneusly t the Human Resurces Office and the emplyee. The first receipt f a Ntice f Cmpensatin Payments (WC-701) indicates the TPA has determined that a claim is cmpensable. The Human Resurces Office will receive a check cvering the amunt f cmpensatin due frm the date f injury thrugh the date the determinatin was made. If the emplyee is represented by an attrney, the first check will be sent t the attrney, requiring Human Resurces t recver necessary re-payments directly frm the emplyee r the emplyee s attrney. All future cmpensatin checks will be sent directly t the emplyee. When benefits are t be terminated r mdified in any way, bth the emplyee and the Human Resurces Office will be s ntified within 24 hurs via a new WC-701 frm the TPA, r a Ntice f Dispute (WC-107). Cmpute the amunt f any Civil Service 2/3 supplement the emplyee is entitled t receive. The Human Resurces Office will receive authrizatin fr this supplement fr up t 50 weeks; this time perid may be extended under special circumstances (see Civil Service Regulatin 5.13). Re-credit the emplyee fr 2/3 f any leave credits used during the perid f cmpensability. - OR - If applicable, cmpute the amunt the emplyee is due under any legislated special supplements (reference P.A. 293 f 1975 fr Department f Crrectins; P.A. 414 f 1976 fr Department f Cmmunity Health; P.A. 131 f 1978 fr Department f Human Services; P.A. 452 f 1978 fr Department f State; and P.A. 368 f 1978 fr Department f Military and Veterans Affairs). Re-credit the emplyee fr 100% f any leave credits used during the perid f cmpensability. Emplyees receiving legislated special supplements are t be paid their nrmal net wage at time f injury. They receive benefits the same as emplyees using 1/3 leave credits. Nte: Emplyees wh receive LTD benefits during the perid f cmpensability are required t use their wrkers cmpensatin and supplemental payments t repay LTD. Re-cmpute the emplyee s tax liabilities fr the cmpensable perid. Determine the amunt due t the emplyee fr the cmpensable perid cvered by the first cmpensatin check and frward that amunt t the emplyee (r recver frm the emplyee if there is an amunt due the state because f verpayment), with an explanatin f the adjustments made, within 10 wrking days f receipt f the first benefit payment. The balance is receipted in n a payrll refund receipts vucher. Nte: If n adjustments are necessary, frward the first cmpensatin check t the emplyee within 5 wrking days f receipt f the first ntice f benefit payment. Prepare the HRMN system t pay any supplement due t the emplyee. Receipt f a WC-107 by the emplyee and the Human Resurces Office indicates the TPA has denied the claim, unless the Reasn fr Dispute (item 23) specifically indicates therwise. If additinal infrmatin r investigatin is given as the basis f the dispute, the Human Resurces Office shuld treat the claim as if it is still pending and shuld review its files t determine if there is available infrmatin that may facilitate reslutin f the dispute. Such infrmatin shuld be frwarded t the TPA immediately. Administrative Guide t State Gvernment Prcedure: Revised: 3/29/ f 5

5 If the TPA disputes either the need fr medical treatment r the wrk relatedness f the injury, the Human Resurces Office shuld: Manage the emplyee s situatin as it wuld any ther emplyee with a nn-wrk related disability. If the emplyee cntinues t be disabled and has nt yet applied fr LTD benefits, they shuld be encuraged t d s at this time. Ntify the emplyee that any future related medical bills shuld be submitted t the emplyee s health insurance carrier and include any bills in the Human Resurces Office s pssessin that have nt yet been sent t the TPA). The TPA will als send any medical bills they have n file, which are nt therwise payable as part f the determinatin prcess, t the emplyee r t the emplyee s health insurance carrier, if knwn. Claims Management f Cmpensable Claims (TPA): Once a claim has been determined t be cmpensable, the claim requires n-ging versight until the emplyee has returned t wrk (r the claim is therwise clsed). This includes maintain cntact with the emplyee and department t facilitate a return t wrk and t mnitr changes in disability r emplyment status. Case Management f Cmpensable Claims (Emplyer/Human Resurces Office): Part f the claims prcess is managing the emplyee/emplyer relatinship t minimize the lng term financial and human csts assciated with disability by facilitating as early a return t apprpriate prductive wrk as pssible. Appeals (Emplyee/Emplyer): The emplyee has a right t appeal a determinatin made by the TPA regarding the cmpensability f a claim. Nte: Because the TPA is n cntract with the state, disagreements between a state department made by the TPA are handled internally, with the Emplyee Health Management (EHM) Divisin f the Office f the State Emplyer (OSE) serving as the mediatr whenever necessary. *** Administrative Guide t State Gvernment Prcedure: Revised: 3/29/ f 5