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Policy and Procedure Name:
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Federal Black Lung Claims (aka Coal Miner’s
Pneumoconiosis)
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Policy #:
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CP-06-05
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Code/Rule Reference:
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R.C. 4131.01
to R.C.
4131.06; O.A.C.
4123-21-08; 30 US C.801
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Industrial Commission (IC) Resolution/Memo
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N/A
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Effective Date:
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04/04/2025
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Approved:
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Shawn Crosby, Chief Operating Officer
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Origin:
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Operational Policy and Support
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Supersedes:
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Policy # CP-06-05, effective 07/22/2019
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History:
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Previous versions of this policy are available upon
request
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Table of
Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
B-Reader
Coal Workers’ Pneumoconiosis Fund
Federal Black Lung Benefits Program
IV. POLICY
A. BWC Management of
Federal Black Lung Claims
B. Questions
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. General Provisions
C. DOL Inquiry and Notice
of Claim
D. DOL Schedule for
Submission of Additional Evidence
E. DOL Proposed Decision
and Order
F. Paying Compensation and
Medical Benefits
G. Death Claims
H. Disputes
This policy ensures that BWC properly administers benefits
to coal miners (or their dependents) employed by coal mine operators that have
black lung coverage through BWC, as required by the U.S. Department of Labor
(DOL).
This policy applies to BWC staff involved in the processing
of black lung claims.
B-Reader:
A physician certified by the National Institute for Occupational Safety and
Health (NIOSH) as demonstrating proficiency in classifying radiographs of
pneumonoconiosis.
Coal Workers’ Pneumoconiosis
Fund: A separate state of Ohio compensation fund
created pursuant to R.C. 4131.01 to 4131.06, for the payment of compensation
and benefits under the Federal Black Lung Benefits Program.
Federal Black Lung Benefits
Program: A federal program administered by the DOL
that provides monthly payments and medical benefits to coal miners totally
disabled from black lung disease arising from employment in or around the
nation's coal mines and to a coal miner's dependent survivors when the coal
miner dies due to black lung disease.
1. It
is BWC’s policy to respond to:
a. Requests
from the DOL for workers’ compensation information on a coal miner; and
b. Notifications
of Federal Black Lung claims from the DOL.
2. When
the DOL finds BWC to be the insurer for the responsible operator on a Federal
Black Lung claim and orders compensation:
a. BWC
will disburse payments to the coal miner or the dependents from the Coal
Workers’ Pneumoconiosis Fund as the order directs; and
b. Manage
the claim in compliance with DOL requirements.
3. BWC
may:
a. Represent
the interest of the Coal Workers’ Pneumoconiosis Fund in all proceedings
pertinent to a contested (controverted) claim; and
b. Charge
all administrative costs associated with administering the claim to the Coal
Workers’ Pneumoconiosis Fund, including the representation expenses the claim
incurs.
4. Federal
Black Lung claims are not subject to:
a. Deduction
for family support orders;
b. The
provisions for the Disabled Workers’ Relief Fund; and
c. Deduction
for the purposes of recoupment of overpayment in a BWC state-fund claim.
5. All
coal miners’ black lung disease claims that are submitted as state-fund claims
are processed in accordance with the Occupational
Disease policy and procedures.
1. Questions
concerning Federal Black Lung claims must be directed to the DOL, Ohio Black
Lung District Office at 1-800-347-3771; or
2. BWC’s
Special Claims Department at 614-466-9903.
1. BWC
staff will refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Must
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. This
procedure provides direction on BWC-specific procedures and general guidance on
the federal procedures and requirements for claims qualifying under the Federal
Black Lung Benefits Program.
2. Black
Lung Team
a. The
Black Lung Team consists of:
i.
Claims service specialist (CSS);
ii. Injury
management supervisor (IMS);
iii. Medical service specialist
(MSS); and
iv. Attorneys
from BWC Legal.
b. The
BWC Special Claims Department will handle Federal Black Lung claims and
inquiries unless otherwise assigned by Operations management.
3. The
Special Claims CSS will consult with BWC Legal, as needed, regarding the
handling of a Federal Black Lung claim.
4. Federal
Forms
a. Special
Claims staff may locate most Federal Black Lung forms on the DOL Division of
Coal Mine Workers' Compensation (DCMWC) website.
b. If a
particular Federal Black Lung form is not available on the DOL DCMWC website,
Special Claims staff must contact the DOL and obtain
the form.
c. Special
Claims staff must always follow the DOL’s direction when any of the Federal
Black Lung forms or requirements change.
1. Notice
of Claim from the DOL
a. When
a “Notice of Claim” for black lung is received from the DOL, the Special Claims
CSS will:
i.
Notify the Black Lung Team of the receipt of the notice of claim.
ii. Search
the claims management system for any existing Federal Black Lung claim.
a) If
no claim currently exists, the Special Claims CSS must obtain a claim number
via the Application Processing Unit, utilizing the following information:
i)
Name;
ii) Social
Security number;
iii) Date of birth;
iv) Address;
v) Date
of filing (equals date of injury);
vi) Employer name,
and
vii) Employer policy number.
iii. If a Federal
Black Lung claim number does exist, the Special Claims CSS will use the
existing claim number.
b. The Special
Claims CSS must complete an Operator Response to Notice of Claim
(CM-2970a) and return it to the DOL within 30 days of receipt.
i.
The Special Claims CSS must make a liability determination on the part
of BWC (referred to as the “operator” by the DOL).
ii. Other
parties to the claim are not copied on this response.
c. BWC
Legal may file a motion with the DOL to dismiss the claim if it is determined
BWC is not the appropriate carrier or for any other legal reason.
2. DOL
Inquiry
a. BWC
receives black lung claim inquiries from the DOL – Division of Coal Mine
Workers’ Compensation via a Request for State or Federal Workers’
compensation Information” (CM-905) form.
b. Upon
receipt of the CM-905, Special Claims CSS must:
i.
Search the claims management system for the information requested using
the coal miner’s name and Social Security number; and
ii. Provide
the requested information to the DOL in a timely manner.
1. Upon
receipt from the DOL of a Schedule for
Submission of Additional Evidence (SSAE), the Special Claims CSS,
under the direction of BWC Legal, will:
a.
Notify the Black Lung Team of the SSAE;
b. Prepare an Operator Response to Schedule for
Submission of Additional Evidence (CM-2970) when:
i.
Disagreeing with the designation of BWC as the
responsible operator liable for the claim; and
ii. Contesting the claimant’s entitlement to benefits.
c. Return the CM-2970 to the DOL and send a copy to the
claimant and/or claimant’s authorized representative; and
d. Refer the claim to the MSS for review.
2. The
MSS will:
a. Determine
if an independent medical examination (IME), including a review by a B-reader, or High-Resolution Computed Tomography is needed;
b. Consider
all relevant evidence and supportive medical materials; and
c. Staff
their recommendation with the Black Lung Team.
3. IME
a. If
an IME is needed, Special Claims CSS will:
i.
Create a case in the claims management system;
ii. Prepare
and send a letter to the physician inserting the appropriate ad hoc questions;
and
iii. Prepare and send
notice of examination to the:
a) Coal
miner (and their representative, if applicable);
b) DOL; and
c) Employer
(and their representative, if applicable).
b. If
the coal miner does not show up for the exam, the Special
Claims CSS must work with the coal miner and the physician to reschedule it. The
Special Claims CSS will not suspend the claim for failing to appear for an
examination.
c. The Special Claims CSS must staff a coal miner’s failure to
appear with Legal. BWC Legal may file a motion to show cause (as to why the
coal miner failed to appear for an examination) with either the DOL or the
Office of Administrative Law Judges, as may be appropriate.
d. When an examination needs to be rescheduled or there is the
possibility that the Special Claims CSS will not obtain the exam report within
the time provided by the DOL, the Special Claims CSS may request additional
time from the DOL to submit evidence in response to the SSAE.
e. Upon receipt of the IME report and the Service Invoice
(C-19), the Special Claims CSS will:
i.
Send a copy of the IME report to the:
a) Coal miner (and their representative, if applicable);
b) DOL;
c) Employer (and their representative, if applicable);
ii. Email a copy of the IME report to the BWC attorneys on the
Black Lung Team;
iii. Send the C-19 or equivalent document for payment to the
Medical Billing and Adjustments (MB&A) Department.
f.
The Special Claims CSS will:
i.
Reimburse the coal miner’s travel expenses as
directed by the DOL;
ii.
Consult with the DOL on any unusual
travel expenses or travel reimbursement questions;
iii. Use the DOL rates for travel reimbursement; and
iv. Follow the Travel
Reimbursement policy and procedure for general
processing steps.
4. Interpreter and Translation Services
a. The Special Claims CSS will refer to the Interpreter
and Translation Services policy and procedure when the coal miner requests or
demonstrates a need for an interpreter for BWC-scheduled exams.
b. Otherwise, interpreter services must be provided at the
direction and in the manner directed by the DOL.
1. Withdrawal
of a Claim: If the Special Claims CSS receives notice
from the DOL that the coal miner/claimant has withdrawn their claim, the
Special Claims CSS will:
a. Dismiss the claim in the claims management system; and
b. Enter a note in the claims management system reflecting the
notification of the withdrawal.
2. Denial
of Benefits: If the Special Claims CSS receives a
“Proposed Decision and Order” (PDO) from the DOL that the claim is denied, they
will:
a. Deny the claim in the claims management system;
b. Enter a note in the claims management system reflecting the
notification of denial of the claim;
c. Set a work item in the claims management system to contact
the DOL to determine if the coal miner has submitted an appeal/request for
hearing six weeks later; and
d. If the coal miner has submitted an appeal/request for
hearing, notify BWC Legal.
3. Award
of Benefits: If the Special Claims CSS receives a PDO from the DOL that the
coal miner/claimant is entitled to benefits, they will:
a. Notify
BWC Legal of the decision (BWC Legal may contest the award by requesting a
formal hearing before an administrative law judge);
b. Allow
the claim in the claims management system;
c. Enter a note in the claims management system reflecting the
DOL has awarded benefits;
d. Prepare the first payment of benefits as directed by the
DOL and consistent with section V.F.1 below;
e. Electronically sign, date, and return to the DOL the
Agreement to Pay Benefits (CM-941) and Certificate of First Payment of
Benefits (CM-906); and
f.
Send a medical benefits letter to the coal
miner, which advises the coal miner that:
i.
Their application has been approved for
Federal Black Lung benefits;
ii. BWC is the carrier for the Federal Black Lung claim and is responsible
for authorizing and paying medical benefits; and
iii. The coal miner needs to advise all Federal Black Lung
health-care and servicing providers of where and how invoices need to be
submitted to BWC.
1. Compensation
a. The Special
Claims CSS must convert the monthly rate provided by the DOL to a weekly rate
by multiplying the monthly rate by 12 months, then dividing by 52 weeks.
b. The Special
Claims CSS will then pay compensation bi-weekly.
c. The
Special Claims CSS will not:
i.
Apply family support deduction orders;
ii. Apply
provisions for the Disabled Workers’ Relief Fund; or
iii. Recoup an
overpayment of a BWC state-fund claim from a Federal Black Lung claim.
d. Every
January, the Special Claims CSS must:
i.
Check the DOL DCMWC website
for the current benefit rate;
ii. Manually convert the increase to the DOL monthly rate to a
weekly rate that is paid through the claims management system;
iii. Send the coal miner/claimant and the DOL notice of the wage
adjustment; and
iv. Send an annual contact letter to the coal miner/claimant.
2. Medical
Benefits
a. Medical
Bills
i.
The Special Claims CSS must review any medical
service invoices received for the coal miner to ensure:
a) The invoice includes Healthcare Common Procedure Coding
System (HCPCS), Current Procedural Terminology (CPT), and International
Classification of Diseases (ICD) codes; and
b) The provider is an enrolled and active BWC provider, and
the provider number is included.
i)
If the provider is not enrolled, the Special
Claims CSS will pend approval of the medical service invoice; and
ii) Send the provider the Application for Provider
Enrollment and Certification (MEDCO-13A).
ii. If
the medical service invoice is approved, the Special Claims CSS must:
a) Place
the date, initials, and their “A” number on the
invoice;
b) Indicate if the invoice is approved or denied and if
denied, the reason for the denial; and
c) Send it to Medical Billing and Adjustments (MB&A).
iii. If the medical service invoice is not approved, MB&A
will send notice and the reason it was not approved to the provider and parties
to the claim.
b. The Special Claims CSS will refer a Request for Medical
Service Reimbursement or Recommendation for Additional Conditions for
Industrial Injury or Occupational Disease (C-9) or equivalent to the
MSS for review.
c. Based upon the review by the MSS, the Special Claims CSS
will:
i.
Approve or deny the C-9 or equivalent request or
recommendation;
ii. Fax
the decision to the medical provider’s office; and
iii. Notify the coal miner by letter of the decision.
3. Reimbursement to the DOL
a. If the Special Claims CSS receives a “Request for
Reimbursement” from the DOL, they must process reimbursement at the full amount
as instructed by the DOL within 10 days.
b. The Special Claims CSS must follow BWC procedures for
generating such payment.
1. When
the Special Claims CSS receives notice that a coal
miner with an existing Federal Black Lung claim has died, they must:
a. Stop compensation; and
b. Use the Notice of Termination, Suspension, Reduction, or
Increase in Benefits Payments (C-908) to notify the DOL that benefit
payments have been terminated and the reason for the termination.
2. The Special Claims CSS will take no further action until a
PDO is received from the DOL.
3. If the DOL orders the continuation of compensation to a
spouse, ex-spouse, minor child, full-time student/child, or unmarried disabled
adult child, the Special Claims CSS must pay compensation consistent with
section V.F.1. of this procedure.
1. Disputes in a Federal Black Lung claim (e.g., a medical
service invoice is not approved, or a claimant disagrees with a compensation
rate):
a.
Must be staffed with BWC Legal; and
b.
Will not be referred to the Ohio Industrial
Commission or to the alternative dispute resolution process.
2. The Special Claims CSS must refer claimant inquiries
regarding their appeal rights under the Federal Black Lung Program to the
Office of Workers’ Compensation Programs website for national and/or regional
Federal Black Lung Program office phone numbers.