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Policy and Procedure Name:
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Temporary Total Compensation
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Policy #:
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CP-20-02
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Code/Rule Reference:
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O.A.C. 4123-3-09(B)(1)(b),
4123-3-32,
4123-5-18(C)
and (D), 4123-5-20,
4123-6-20(B)
R.C. 4123.511(H),
4123.53(B),
4123.55,
4123.56,
4123.61,
4123.651(C),
5101.141(C)(1)-(2a),
3119.01(C)(12)(f)
Industrial
Commission of Ohio (IC) Hearing Officer Memo C3
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Effective Date:
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9/23/22
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Approved:
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Patricia Harris, 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-20-02, effective 10/28/21
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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
Average Weekly Wage (AWW)
Disability Evaluators’ Panel (DEP)
Due Process
Extent of Disability (EOD) Exam
Full Weekly Wage (FWW)
Lost Time Claim
Maximum Medical Improvement (MMI)
Medical Only Claim
Net Pay
Paid Time Off (PTO)
Parties to the Claim
Profit Sharing
Wage Agreement
IV. POLICY
A. General Policy Statements
B. Considerations for
Determining if TT is Payable
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. The Request for
Temporary Total Compensation (TT)
C. Eligibility Factors
D. Evaluating the
Supporting Medical Evidence
E. Special Considerations
for Payment of TT
F. Initial Decision with
TT Included
G. Claim Certification
H. TT as a Subsequent
Decision (may be a new or subsequent period of TT)
I. TT Entitlement and TT
Restart Letters
J. IC Order Language
K. Managing Ongoing TT
L. Medical Exams and
Payment of TT
M. Terminating TT
N. Suspending TT
O. Reinstating TT
The purpose of this policy is to ensure that the Ohio Bureau
of Workers’ Compensation (BWC) evaluates and makes an accurate determination
regarding payment of temporary total compensation (TT) to an injured worker
(IW) who is unable to return to the former position of employment for eight
days or more due to a work-related injury or occupational disease.
This policy applies to claims services staff and BWC
attorneys.
Average
Weekly Wage (AWW): For purposes of this policy, the basis
upon which to compute benefit payments subsequent to the first twelve weeks of
temporary total disability.
Disability
Evaluators’ Panel (DEP): Qualified medical specialists hired
by BWC to provide quality, impartial medical evaluations and medical file
reviews to support claims management.
Due Process:
Legal principle that government may not deprive an individual of life, liberty,
or protected property rights without providing notice and an opportunity to be
heard.
Extent of
Disability (EOD) Exam: An evaluation of the condition(s)
allowed in the IW’s claim in regard to:
- The IW’s ability to return to the former position of
employment;
- Restrictions that prevent the IW’s return to the former
position of employment;
- The IW having reached maximum medical improvement (MMI);
- The feasibility of a referral for vocational
rehabilitation services; and
- The IW’s eligibility for continued TT.
Full Weekly
Wage (FWW): For purposes of this policy, the basis for
payment of compensation for the first 12 weeks of TT.
Lost Time
Claim: A claim with eight or more days of lost time directly
caused by a work-related injury, even if compensation or wages in lieu of
compensation have not been paid to the IW or in any claim in which BWC awards
compensation.
Maximum
Medical Improvement (MMI): A treatment plateau (static or
well-stabilized) at which no fundamental functional, physiological, or
psychological change can be expected within reasonable medical probability in
spite of continuing medical or rehabilitative procedures. An IW may need
supportive treatment to maintain this level of function.
Medical Only
Claim: A claim with seven or fewer days of lost time from
work directly caused by a work-related injury, for which the IW receives no
compensation for lost wages (e.g., TT, salary continuation) or is not awarded
any compensation for the life of the claim.
Net Pay:
Gross wages minus taxes.
Paid Time
Off (PTO): A pool of time offered by the employer that the IW
can call in at any time; can be used as sick time, vacation time, or holiday
pay.
Parties to
the Claim: The IW, IW representative, employer, and employer
representative. BWC is considered a party to the claim and may present
arguments when:
- The employer or employer representative does not appear at
a hearing; or
- The employer or employer representative does appear at a
hearing, as long as the arguments and/or evidence presented by BWC is not
cumulative or duplicative of what the employer has presented.
Profit
Sharing: Employees are paid a portion of the profits of a
business.
Wage
Agreement: An agreement between the IW and employer in which
the employer advances wages to the IW for a period of up to 12 weeks (except
under special circumstances) closely following the date of injury or disability
and with the understanding that BWC will forward the IW’s check(s) for TT to
the employer as reimbursement for the advancement when TT becomes payable to
the IW.
1. It is BWC’s
policy to:
a. Provide notification
of the request to the non-filing party when a new (initial or subsequent)
period of TT has been requested;
b. Compensate an IW
who is totally disabled from work for eight or more days due to a work-related
injury or occupational disease;
c. Create
payment of TT based upon the available return to work information;
d. Automatically
reassign a Medical Only claim to the appropriate claims office for
investigation and processing when an IW submits a Request for Temporary
Total Compensation (C-84) or equivalent form;
e. Issue a BWC
Order to grant TT or refer the request for payment of TT to the IC, unless the
IW withdraws the request;
f. Determine
if an IW is receiving Unemployment Compensation benefits from the Ohio
Department of Job and Family Services (ODJFS) prior to issuing payment of TT;
and
g. Prohibit payment
of TT when the IW:
i. Has
returned to work;
ii. Is
released without restrictions to return to the former position of employment by
the treating provider;
iii. Refuses a
written offer of work within their capabilities made by the employer of record
or another employer;
iv. Has reached MMI;
v. Is working
(full time or part time) for any employer during the disability period;
vi. Has returned to work
and is requesting TT for a doctor’s appointment and/or medical treatment or
services;
vii. Receives profit-sharing
benefits over the same period TT is requested, and the IW attended meetings and
other employment-related activities that would constitute working. However, BWC
may pay TT and profit-sharing benefits over the same period if the IW is not
performing any form of employment-related activity;
viii. Is receiving Department of
Administrative Services (DAS) Hostage Leave according to the collective
bargaining agreement;
ix. Is a volunteer and has
no lost earnings;
x. Is serving
as an elected political official and is attending meetings, whether frequent or
infrequent, or performing any other activity related to the political position;
xi. Is on active military
duty;
a) Generally,
active duty requires physical activities and pay that is inconsistent with the
receipt of TT.
b) Soldiers who
report for any drills, including weekend duty, are often paid for reporting for
duty and any payment received as a result of reporting for duty is also
inconsistent with the receipt of TT.
xii. Is working as a poll worker.
The poll worker is considered an employee of the Board of Elections for the day
worked at the polls; or
xiii. Elects to use PTO as sick leave.
2. Rate of Payment
a. It is BWC’s
policy to pay TT for the first 12 weeks at 72% of the IW’s FWW, subject to the
statewide maximum for the injury year and any applicable offsets.
i. If
the FWW is at or below 1/3 of the statewide average weekly wage (SAWW) for the
injury year, TT will be paid at the FWW.
ii. If the FWW
is above 1/3 of the SAWW for the injury year, but 72% of the FWW is at or below
1/3 of the SAWW for the injury year, TT will be paid at 1/3 of the SAWW for the
injury year.
iii. If 72% of the
FWW is above 1/3 of the SAWW for the injury year and at or below the statewide
maximum for the injury year, TT will be paid at 72% of the FWW.
iv. If 72% of the FWW is
above the statewide maximum for the injury year, TT will be paid at the
statewide maximum for the injury year.
b. It is BWC’s
policy to pay TT after the first 12 weeks at 66 2/3% of the IW’s AWW, subject
to the statewide maximum for the injury year and any applicable offsets.
i. If
the AWW is at or below 1/3 of the SAWW for the injury year, TT will be paid at
the AWW.
ii. If the AWW
is above 1/3 of the SAWW for the injury year, but 66 2/3% of the AWW is at or
below 1/3 of the SAWW for the injury year, TT will be paid at 1/3 of the SAWW
for the injury year.
iii. If 66 2/3% of
the AWW is above 1/3 of the SAWW for the injury year and at or below the
statewide maximum for the injury year, TT will be paid at 66 2/3% of the AWW.
iv. If 66 2/3% of the AWW
is above the statewide maximum for the injury year, TT will be paid at the
statewide maximum for the injury year.
1. BWC may pay TT
over the same period as the following:
a. Vacation pay;
b. Vacation pay in
lieu of sick leave;
c. Holiday
pay;
d. Compensatory
time;
e. Sick leave
benefits paid by the employer of record that are intended to supplement TT;
f. Jury
duty pay;
g. PTO used as any
leave time other than sick leave;
h. Supplemental
payments;
i. Benefits
of a non-occupational sick and accident program that is fully or partially
funded by the IW;
j. Public
Employees Retirement System (PERS) benefits;
k. Social
security disability benefits;
l. Severance
pay;
m. Statutory Permanent
Total Disability paid in a different claim;
n. Unused accrued
sick leave paid in a lump sum (e.g., employee cashing in sick leave or
receiving payment upon separation);
o. Unused accrued
vacation time; or
p. Federal
unemployment compensation paid by Ohio.
2. BWC may pay TT
with an offset:
a. In claims with a
date of injury on or after 11/3/1989, when an IW is receiving social security
retirement benefits (the actual amount of the benefits is not a factor) and
where the TT rate is greater than 66 2/3% of the SAWW for the date of injury;
b. When an IW is
receiving unemployment compensation that was paid and funded by the ODJFS;
c. When an IW
is receiving benefits of a non-occupational sick and accident program that is
fully funded by the employer of record; or
d. When the IW has
received sick leave from the injury employer at less than 100% of the IW’s
earnings and the sick leave is not intended to supplement TT. If the sick leave
is paid from the injury employer at 100% of the IW’s earnings, and the sick
leave replaces earnings, BWC must not pay TT.
1. BWC staff must
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. Claims services
staff must contact and provide notification to the employer or employer’s
authorized representative upon receipt of a request for a new period of TT.
a. Claims services
staff’s initial attempt at contact and notification must be by phone, unless
the employer or employer’s representative has requested another form of contact.
Claims services staff must request any additional information to be submitted
within three business days of the date of the phone call.
b. Claims services
staff must send the “Insured Due Process Letter” if initial contact and
notification cannot be done by phone. Claims services staff must request any
additional information to be submitted within:
i. Three
business days from the date of the letter if it is sent by fax or e-mail; or
ii. Seven
calendar days (plus four additional days per the Mailbox
Rule policy) from the date of the letter if it is sent by mail.
2. Claims services
staff must create a new TT case for:
a. The first C-84
or equivalent form and continue updating the case until ongoing TT stops; and
b. Each new period
of TT.
3. Claims services
staff must verify that the C-84 or equivalent form includes at least the
following information for BWC to award TT:
a. The IW’s
signature on the completed form, unless the IW is completely incapacitated
(e.g., coma) and unable to sign the C-84 or equivalent form.
i. The
date of the IW’s signature must be generally close in time to the requested
period of disability the treating provider has certified. If the signature is
not close in time, BWC may further investigate.
ii. The IW’s
attorney cannot sign the C-84 or equivalent form on behalf of the IW.
b.
Verification of receipt (or lack of receipt) of any other benefits,
salary continuation, or earnings.
i. The
IW’s receipt of monetary government assistance has no impact on the payment of
TT unless the IW is working to receive the benefits.
ii. When
receipt of monetary government assistance is indicated, BWC must contact the IW
to determine if the IW is required to work in order to receive the benefits.
iii. If the IW claims
he or she has a waiver of the work requirements due to his or her disability,
BWC may consider the waiver by verifying it by phone with the applicable county
office of jobs and family services; however, the IW will need to submit written
verification as soon as possible.
c. Work
history over the requested period;
d. Light duty
availability;
e. Certification
that the IW understands he or she cannot work and collect TT.
4. TT can be paid
for an initial four-week period without a signed C-84 or medical proof in the
following circumstances:
a. A properly
completed and signed application is submitted;
b. The employer certifies
the claim; and
c. The
payment of benefits is non-controversial (i.e., TT may be considered when the
circumstances of the industrial accident will obviously preclude the IW from
returning to work and will result in a lost-time claim).
Example:
The IW is a truck driver involved in a motor vehicle accident during work. The
IW has broken both his legs and is currently hospitalized. The employer
certifies the claim. Medical evidence has not yet been submitted to BWC, but it
is clear that the IW will be disabled from working for an extended period. In
these circumstances, BWC would not need a C-84 or medical proof to support and
pay TT benefits for up to 4 weeks.
5. When there is a
delay between the date of injury and the date the IW is able to get an
appointment with the treating physician, claims services staff may pay TT for a
period up to four weeks from the date of injury as long as the treating
provider has certified TT. For periods of TT longer than four weeks, claims
services staff must consult with an IMS and MSS to determine the reasonableness
of the medical evidence.
6. If the IW is
over age 62, claims services staff must verify via crossmatch if the IW is
receiving Social Security Retirement (SSR) benefits.
7. If an IW
indicates he or she is receiving social security disability benefits, claims
services staff must contact the IW and request medical evidence regarding the
basis for the social security disability benefits.
8. If the IW
indicates he or she is receiving retirement benefits, claims services staff may
ask the IW or the employer of record if the IW has retired completely, removing
him or herself from the workforce, and if the retirement is related to the
allowed condition(s) in the claim.
9. Claims services
staff may pay TT without a signed C-84 or equivalent form when the IW is
completely incapacitated (e.g., coma) and unable to sign a C-84 or equivalent
form. If an IW cannot physically sign the C-84 or equivalent form, but is
lucid, they may:
a. Have another
person sign the IW’s name, noting beside the signature that the IW is
physically unable to sign; or
b. Place an “X” or
other mark that is intended to reflect the IW’s acknowledgement in place of the
IW’s signature.
10. When a request is submitted
for a back period of TT in excess of two years prior to the date of filing of
the application (e.g., request for TT from 6/1/2017-12/31/2017 is filed on
3/5/2020), claims services staff must:
a. Deny TT at the
time of initial claim determination; or
b. Refer to the IC
for a request subsequent to the initial claim determination.
11. Claims services staff must
notify the IW of the requirements for payment of TT compensation if a period of
disability greater than seven days is indicated in the evidence in the claim
and a C-84 or equivalent form and/or MEDCO-14 or equivalent form has not been
filed.
12. If a C-84 or equivalent form
and a MEDCO-14 or equivalent form indicating seven days or less of lost time or
restrictions have been filed, claims services staff must not consider the
request for TT.
13. Claims services staff must
not request a C-84 or equivalent form when a MEDCO-14 or equivalent form
indicating seven days or less of lost time or restrictions is filed with no
C-84 or equivalent form.
1. When they exist
in the claim, claims services staff must consider the following factors (list
not all-inclusive) when determining if the IW is eligible for TT:
a. Concurrent
Payments
i.
Claims services staff may pay the following compensation types concurrently
with TT when substantiated by supporting medical evidence:
a) Scheduled Loss;
b) Temporary
Partial (TP) only if in a different claim involving different body parts and
conditions;
c) Facial
Disfigurement (FD);
d) Violation of
Specific Safety Requirement (VSSR);
e) Statutory
Permanent Total Disability (PTD) only if the IW returned to work and had a new
injury resulting in a new claim. TT can be paid in the new injury claim
concurrently with the Statutory PTD in the original claim. The TT for the new
injury is not payable in the original claim;
f) Percentage
Permanent Partial (%PP) only when the %PP was paid first and the IW later
requests TT over the same period in the same claim; or
g) TT in another
claim, but only if paid as a split (i.e. one payment of TT is issued, but split
between claims).
ii. Claims
services staff must not pay the following compensation types
concurrently with TT in the same claim or in a different claim:
a) Wage Loss (WL);
b) Living
Maintenance (LM);
c) Living
Maintenance Wage Loss (LMWL);
d) Change of
Occupation; or
e) Permanent Total
Disability (PTD), except Statutory PTD as noted above.
b. Inability to
work as the direct result of something other than the allowed injury or
occupational disease (formerly called voluntary abandonment)
i. When
the reason for the IW’s loss of wages is in question, claims services staff may
complete the Entitlement to TT Worksheet (formerly called Voluntary Abandonment
Worksheet) and review the information gathered with the local BWC attorney.
a) Claims services
staff may deny TT via a BWC Order if it is determined during the initial determination
investigation that the IW’s loss of wages is not a direct result of reasons
related to the injury or occupational disease.
b) The local BWC
attorney must assist in determining that the appropriate fact pattern is cited
and the language on the BWC Order is appropriate.
ii. If TT has
been allowed in a claim, and then the local BWC attorney determines the IW is
no longer suffering a loss of wages due to the allowed injury or occupational
disease, the local BWC attorney may prepare a Motion (C-86), which
claims services staff must refer to the IC via a Notice of Referral (NOR). Claims
services staff must generate the NOR from the TT case with BWC as the filing
party.
c. Time
Period of TT Eligibility
i. The
First Seven Days
a) Claims services
staff must pay TT beginning on day eight when the IW is disabled for more than
seven days, but less than 14 consecutive days, due to a work-related injury.
b) Claims services
staff must pay TT for the first seven days of disability once the IW has been
disabled for more than 14 consecutive days due to a work-related injury,
whenever that occurs in the life of the claim.
c) Example:
i) The
IW’s date of injury and last date worked are 04/01/2020.
ii) The IW’s
period of disability is seven days, 04/02-04/08/2020.
iii) The IW returns to work
on 04/09/2020.
iv) The IW has a
subsequent period of disability from 05/01-05/31/2020. The IW returns to work
on 06/01/2020.
v) The IW is paid
TT for 04/02-04/08/2020 in addition to 05/01-05/31/2020 because they have 14 or
more consecutive days of disability due to a work-related injury.
ii. Claims
services staff must consider the following payments as wages in lieu of TT and
count them toward the first 12 weeks of TT when they are paid:
a) Living
Maintenance;
b) Salary Continuation;
c) Full sick leave;
d) Non-occupational
sickness and accident benefits fully funded by the employer of record; and
e) Occupational
Injury Leave (OIL).
iii. Claims services
staff must pay TT to an eligible IW whose treating provider has released the IW
to return to work with restrictions, but the employer fails to accommodate
those restrictions. As long as the restrictions are preventing the IW from
performing the job the IW held at the time of the injury, claims services staff
must continue payments to an eligible IW.
2. Claims services
staff must refer to Section V.E. (Special Considerations for Payment of TT) for
information including, but not limited to, various employment types and other
employer compensation payments.
1. Claims services
staff must require the following supporting medical evidence in order to pay TT,
except as noted in V.B.4 above:
a. A MEDCO-14; or
b. Equivalent form
to the MEDCO-14.
2. Claims services
staff must evaluate the supporting medical evidence for the following:
a. If supporting
medical evidence is submitted, but a C-84/equivalent form is not, claims
services staff must follow the “Medical Supporting Period of Disability
Received without C-84 from IW” workflow found on COR.
b. Claims services
staff must verify that the supporting medical documentation (including the
MEDCO-14):
i. Supports
the period of disability the IW is requesting; and
ii. Confirms
the IW’s disability is independently caused by a condition(s) allowed in the
claim.
c.
When supporting medical documentation (including the MEDCO-14) lists a
non-allowed condition(s) or a disallowed condition(s) as causing temporary
total disability, it is not valid and claims services staff must not accept it.
Claims services staff must contact the MCO with a request to obtain medical
evidence that supports temporary total disability due to a condition(s) allowed
in the claim. The MCO has up to three full business days to contact the
treating provider regarding obtaining the medical evidence If the MCO does not
respond to claims services staff or is unable to obtain the medical evidence,
claims services staff may attempt to contact the provider.
i. If
claims services staff does not receive medical evidence that supports temporary
total disability due to a condition(s) allowed in the claim, they must staff
the issue with a BWC attorney to determine next steps based on the
circumstances of the claim.
ii. If the IW
is currently receiving TT, claims services staff must not continue payment of
TT until valid supporting medical documentation is obtained. When valid
documentation is obtained, claims services staff may begin payment of TT back
to when it was previously put on hold.
d. Claims services
staff must review the MEDCO-14 or equivalent form and ensure the following
required information has been provided by the treating provider. This
information may also be included in the claim file:
i. The
date of the MEDCO-14 or equivalent form;
ii. The date
of the last examination;
iii. The
International Classification of Diseases (ICD) diagnosis code(s) recognized in
the claim for all conditions and all parts of the body being treated that are
affecting the length of disability, including a primary diagnosis code, with a
narrative description identifying the condition(s) and specific area(s) of the
body being treated;
iv. Any reason why
recovery has been delayed;
v. The date
temporary total disability began;
vi. The current physical
capabilities of the claimant;
vii. An estimated or actual
return to work date;
viii. An indication of need for
vocational rehabilitation;
ix. Objective findings;
and
x. Clinical
findings supporting the above information.
e.
When the MEDCO-14 or equivalent form is incomplete and does not comply
with V.D.2.d.(i-x) above, claims services staff must review the claim file to
determine if the missing information can be found in other medical evidence on
file. If the missing information is contained in the claim file, it is
considered as a supplement to the form; therefore, the form and the claim file
information are sufficient to support the payment of TT. If the missing
information is not on file, claims services staff must contact the MCO to
obtain any medical information that is missing or needed to make a decision
regarding the payment of TT. The MCO has up to three full business days to contact
the appropriate provider regarding obtaining the necessary information. If the
MCO does not respond to claims services staff or is unable to obtain the
necessary information, claims services staff may attempt to obtain the information.
f. When
claims services staff requests supporting medical documentation, but does not
receive it, claims services staff must notify the IW to give the IW an
opportunity to attempt to obtain supporting medical documentation from the
treating provider. Ultimately, the IW is responsible for providing supporting
medical documentation to receive payment of TT.
g. Claims services
staff must review the information in the electronic claim file to determine if
evidence relating to the IW’s position of employment at the time of injury is
already on file or included in a previous MEDCO-14 or equivalent form. If such
information is on file, staff must not require the treating provider to
complete the section of the MEDCO-14 or equivalent form that relates to the
IW’s job duties and responsibilities.
h. Claims services
staff must verify that the MEDCO-14 or equivalent form is signed by a provider
authorized to support a period of disability (see Provider Signature on Medical
Evidence Grid or MEDCO-14 Job Aid on COR) or their authorized designee. If the
MEDCO-14 or equivalent form is signed by a provider who is not authorized to
support a period of disability or their authorized designee, claims services
staff must contact the MCO, and the MCO must contact the treating provider’s
office to discuss who has the authority to support a period of disability or
sign the MEDCO-14 or equivalent form on behalf of the treating provider. The
MCO has up to three full business days to contact the treating provider
regarding obtaining supporting evidence that is appropriately signed. If the
MCO does not respond to claims services staff or is unable to obtain
appropriately signed supporting evidence, claims services staff may attempt to
obtain the evidence.
i. Claims
services staff must not suspend or deny payment of TT because the treating
provider is not BWC certified. It is not a requirement for the treating
provider to be BWC certified to complete and sign a MEDCO-14 or equivalent
form.
4. When the
treating provider supports a period of disability prior to the first time the
IW saw the provider, claims services staff must review the supporting
documentation and the request for TT with a supervisor to determine if the
period of disability is appropriate.
1. Accrued Sick
Leave or Vacation Time Payout: When an employer pays the IW for unused
accrued sick leave or vacation time, claims services staff may pay TT or LM
over the same period when supporting documentation is submitted.
2. Assault Leave
a. When assault
leave is paid to an IW, claims services staff may pay TT concurrently, if
allowed under the applicable collective bargaining agreement.
b. Claims services
staff must obtain a copy of the IW’s collective bargaining agreement and must review
and discuss the issues in the claim with the local BWC attorney prior to making
payment. The BWC attorney may assist in determining the nature of the assault
leave and whether or not the leave is intended to replace workers’ compensation
benefits.
3. Elected
Political Position
a. Claims services
staff may pay TT to an elected political official when they:
i. Have
been disabled for eight or more days; and
ii. Have
submitted a request for TT and supporting medical documentation.
b. Claims services
staff must not pay TT to an elected political official when they are working,
including attending frequent or infrequent meetings or other activity related
to the position. Please refer to the Wage Loss Compensation policy
and/or procedure to determine if the IW is entitled to wage loss compensation.
c. Claims
services staff must review the issue with a BWC attorney when the elected
official is receiving wages and it appears that they are performing no work.
4. Foster Care
a. Claims services
staff must determine if foster care maintenance payments to cover costs for
items such as food, clothing, travel, or liability insurance or foster care
maintenance payments for child support purposes are being paid prior to
deciding how TT or LM payments are affected.
b. Note: Foster
care payments may represent payment for the care of an elderly or disabled
person, which may conflict with payment of TT or LM. Claims services staff must
consult with a BWC attorney in these instances.
5. Hostage Leave
a. Hostage leave is
paid according to the collective bargaining agreement under which the IW is
employed.
b. Claims services
staff must obtain a copy of the IW’s collective bargaining agreement and must review
and discuss the issues in the claim with the local BWC attorney prior to making
payment. The BWC attorney may assist in determining the nature of the hostage
leave and whether or not the leave is intended to replace workers’ compensation
benefits.
6. Living
Maintenance (LM)
a. When claims
services staff discovers that TT was paid for a period in which LM should have
been paid, or LM was paid for a period in which TT should have been paid,
claims services staff must:
i. Replace
the compensation paid with the appropriate compensation type; and
ii. Deduct the
originally paid compensation from the compensation that should have been paid. This
is referred to as an even adjustment.
a) If the TT and LM
rates are the same, claims services staff must:
i) Pay
no money paid to the IW; and
ii) Create no
overpayment;
b) If one rate is
higher than the other, the result of the adjustment will be:
i) An
additional payment to the IW; or
ii) An
overpayment for the IW.
b. When an IW is
changing from LM to TT without a break in payment, claims services staff must
send a “TT Restart Letter.”
7. Military Duty
a. Claims services
staff must not pay TT when the IW is on active military duty.
b. Active duty
generally requires physical activity and pay that is inconsistent with the
receipt of TT.
c. Soldiers
who report for any drills, including weekend duty, are often paid for reporting
for duty and any payment received as a result of reporting for duty is also
inconsistent with the receipt of TT.
8. Multiple
Employers: If an employee worked for multiple employers during the same
period of time and is injured at one of the jobs:
a. Claims services
staff may pay TT if the IW cannot work at any job.
b. Claims services
staff must not pay TT if the IW continues to work full or part time at any job.
9. Non-occupational
Sick and Accident Insurance (short or long term disability)
a. Claims services
staff must offset payment of TT by the gross amount received from the benefits
of a non-occupational sick and accident insurance program that is fully funded
by the employer of record when the benefits are paid over the same period as TT.
i. Claims
services staff must enter the gross amount received from the non-occupational
sick and accident insurance program in the claims management system as a rate
offset to the TT that is payable.
ii. On the
adjustments tab, choose “Add Adjustment” in the adjustments drop down. Select
“Offset” as the type, “Disability” as the category and “Employer Fully Funded”
as the adjustment type.
iii. For example:
a) The FWW rate is
$165.00 and the date of injury is 03/31/2009.
b) The IW receives
benefits from an employer paid non-occupational sick and accident insurance
policy from 04/01/2009 to 05/01/2009 at the rate of $150.00/week.
c) The IW is
entitled to the difference of $15.00/week in TT from 04/01/2009 to 05/01/2009.
b. Claims services
staff must pay the full TT amount with no offset when the IW pays all or part
of the insurance premium for a non-occupational sick and accident program, and
the benefits of the sick and accident insurance are paid over the same period
as TT. For example:
i. The
FWW rate is $165.00. The date of injury is 03/31/2009.
ii. The IW
receives benefits from 4/1/2009 to 05/01/2009 at $150.00/week from a
non-occupational sick and accident insurance policy that the IW paid for. The
IW must also receive $165.00/week in TT from 04/01/2009 to 05/01/2009.
c. Claims
services staff must pay the full TT amount with no offset when the IW is
receiving benefits of a non-occupational sick and accident program that is
fully funded by an employer other than the employer of record, and the benefits
are paid over the same period as TT. For example:
i. The
FWW rate is $165.00. The date of injury is 03/31/2009.
ii. The
employer of record is Joe’s Restaurant. The IW receives benefits from
04/01/2009 to 05/01/2009 at $150.00/week from a non-occupational sick and
accident insurance policy that is fully funded by Jane’s Hair Salon.
iii. The IW must also
receive $165.00/week in TT from 04/01/2009 to 05/01/2009.
10. Occupational
Injury Leave (OIL)
a. For OIL offered
by the state agencies listed below, claims services staff must:
i. Make
no payments of TT the IW may be entitled to over the same period that benefits
from the OIL program are received;
ii. Request a Calendar
of Wages Paid (ADM-4741) form from the employing agency for periods of lost
time not paid under the OIL program;
iii. Consider the
weeks paid in the OIL program as part of the first 12 weeks of TT;
iv. Ensure that the
participating agency or third party administrator (TPA) provides a notice of
approval or extension for those employees participating in the OIL program.
b. Only employees
of the following state agencies are eligible for this program:
i. Department
of Rehabilitation and Corrections;
ii. Department
of Youth Services;
iii. The Ohio State
Troopers’ Association;
iv. Ohio Department of
Mental Health;
v. Department
of Developmental Disabilities;
vi. Department of
Veterans’ Services;
vii. School for the Deaf; and
viii. School for the Blind.
c. Claims
services staff must follow V.E.10.a.i,iii, and iv. above when OIL is offered by
other government entities.
11. ODJFS
a. Claims services
staff:
i. May
offset payment of TT and/or reimburse ODJFS for unemployment compensation that
was paid and funded only by the ODJFS.
ii. May pay TT
over the same period that unemployment benefits have been paid when
unemployment benefits are paid by a state other than Ohio or the federal
government.
b. Refer to the ODJFS
Reimbursement and Claim Adjustment policy and procedure on COR for more
information.
12. Passive Income:
Claims services staff may pay TT if the IW is receiving passive income from
sources such as rental properties or investments without performing work for
that business.
13. Paid Time Off
(PTO): If the specific type of leave time used as PTO (e.g., sick time,
holiday pay, vacation leave) is not noted, claims services staff must contact
the employer to verify how the PTO was used by the IW. If the PTO is not
designated as any type of leave time, BWC considers it to be vacation time.
14. Poll workers: When an
IW is receiving TT and has worked at the polls over the same time period,
claims services staff must issue a BWC Order to omit the one day worked at the
polls, and then payment of TT will start up again.
15. Profit Sharing
a. Claims services
staff must review issues involving profit sharing with the supervisor, and then
with the local BWC attorney, if necessary, to determine if payment is
appropriate.
b. Claims services
staff must not pay TT when the IW has received profit-sharing benefits and has
attended meetings or other employment-related activities that constitute
working.
c. Claims
services staff may pay TT when the IW has received profit-sharing benefits, but
has not performed any form of employment-related activities.
16. Public Employees
Retirement System (PERS) Benefits and Social Security Disability
a. Claims services
staff must pay TT with no offset when an IW is receiving PERS benefits or
social security disability benefits.
b. When the IW’s
social security disability/widow’s benefits change to social security
retirement, claims services staff must not pay a weekly TT benefit amount that
exceeds 66 2/3 % of the SAWW. See Section V.E.21 below.
c. When the
IW reaches age 62 and their TT rate exceeds 66 2/3% of the SAWW, claims
services staff must contact their supervisor to request a social security cross
match to determine if the IW is receiving social security benefits and the type
of benefits the IW is receiving.
i. The
assigned PTD CSS may assist in reviewing the information provided from the
cross match to determine if the benefits paid to the IW are either disability
or retirement benefits.
ii. If the IW
is not receiving social security retirement benefits, claims services staff must
set a work item as a reminder that the IW is over age 62 and that a cross match
must be requested each time TT is extended.
iii. If claims
services staff discovers, after TT or LM have been paid, that the IW was on
social security retirement and TT or LM should have been offset, claims
services staff must issue a BWC Order to set the IW up overpaid.
17. Seasonal Employees
a. Claims services
staff may continue to pay TT to an injured worker who was engaged in seasonal
employment (e.g., construction, landscaping, farming) once his/her seasonal
employment ends.
b. Claims services
staff must request documentation to support the seasonal employee’s search for
employment once seasonal employment ended.
c. Issues
regarding continued entitlement to TT for seasonal employees must be considered
on a case by case basis.
18. Severance Pay: When
an IW is receiving TT compensation and receives severance pay from an employer,
claims services staff must pay TT with no offset for the severance pay.
19. Sick Leave: When
the IW receives sick leave benefits from an employer, including an employer who
is not the employer of record, claims services staff must determine if the sick
leave is intended to replace earnings, or supplement or offset TT. Claims
services staff may need to refer to V.E.20 below for information regarding a
sick leave buy back/wage agreement.
a. Replacement
i. If
sick leave is paid at 100% of the IW’s earnings and replaces earnings, claims
services staff must not pay TT.
ii. Claims
services staff must build the salary continuation benefit plan in the claims
management system.
b. Supplement
i. Claims
services staff must pay TT when sick leave is paid as a supplement to TT.
ii. Payment of
sick leave and TT allows the IW to return to up to 100% of their earnings. This
may occur when the IW has a large FWW/AWW and is already receiving the maximum
TT rate, but is receiving less than their full earnings.
iii. Example:
a) IW’s DOI is
5-10-2017
b) FWW/AWW are
$1,500.00
c) TT will be paid
at the maximum rate for 2017 ($902.00) because 72% of the FWW and 66-2/3% of
AWW are above $902.00. However, $902.00/wk. is below the amount of IWs usual
paycheck so the employer is allowing the IW to take sick leave to bring payment
(TT and sick leave) to the IW up to 100% of the IW’s usual paycheck.
c. Offset
i. If
sick leave is paid at less than 100% of the IW’s earnings and is not intended
to supplement TT, claims services staff must pay TT less the amount of sick
leave received.
ii. The sick
leave amount must be entered in the claims management system. On the
adjustments tab, choose “Add Adjustment” in the adjustments drop down. Select
“Offset” as the type, “Disability” as the category and “Partial Sick Leave” as
the adjustment type.
iii. Example:
a) IW’s DOI is
3-28-2017
b) FWW/AWW is
$1,200.00
c) FWW rate =
$864.00
d) AWW rate =
$800.00
e) Employer’s sick
leave payment is $600/wk.
f) The IW’s
actual TT payment is $264.00/wk ($864-$600) for the first 12 weeks (FWW) and
$200/wk ($800-$600) after the first 12 weeks (AWW).
g) $600 (The
partial sick leave amount) will be entered in the claims management system
(Indemnity Payments-Adjustments-Add Adjustment-Offset). Disability is the
category and partial sick leave is the adjustment type.
20. Sick
Leave Buy Back/Wage Agreements
a. Claims services
staff must receive written notice of the sick leave buy back/wage agreement
between the employer and IW.
b. When claims
services staff are considering honoring a sick leave buy back/wage agreement,
staff must ensure that:
i. Written
notice of the agreement is signed by the employer and IW and submitted to BWC
within 30 calendar days of the beginning date of payment(s) of wages, sick
leave, or advancement. For example:
a) The employer
paid wages from 4/17-4/30/2015 on 5/8/2015.
b) Written notice
of the agreement must be submitted to BWC within 30 calendar days of 5/8/2015,
the beginning date of payment.
c) If continuous,
ongoing payments are made by the employer, additional notices of the beginning
of payment are not required. For example:
i) The
employer paid wages from 4/17-4/30/2015 on 5/8/2015, from 5/1-5/14/2015 on
5/22/2015, and from 5/15-5/28/2015 on 6/5/2015.
ii) One notice
is required to be submitted within 30 days of 5/8/2015, the beginning date of
payment.
iii) Additional notices are
not required 30 calendar days from 5/22/2015 and 6/5/2015.
d) However, an
additional notice(s) is required if there is a break in the employer’s payment,
and then payment resumes. For example:
i) The
employer paid wages from 4/17-4/30/2015 on 5/8/2015.
ii) The IW
returned to their former position of employment on 5/1/2015, but worked for
only two weeks, and then was unable to work again due to their injury.
iii) The employer paid
another period of wages from 5/15-5/28/2015 on 6/5/2015.
iv) Written notice of the
agreement must be submitted to BWC within 30 calendar days of 5/8/2015, the
beginning date of payment for the first period.
v) A second notice
must be submitted to BWC within 30 calendar days of 6/5/215, the beginning date
of payment for the second period.
ii. Within 30
calendar days of the end date of payment of wages, sick leave, or advancement,
the employer or IW has submitted written notice that payment has ended. For
example:
a) The employer’s
final payment of wages to the IW was for the period 12/4-12/17-2015, and was
made on 12/25/2015.
b) Within 30
calendar days of 12/25/2015, the end date of payment, the employer or IW must
submit written notice to BWC that payment has ended.
c) If continuous,
ongoing payments are made by the employer, additional notices that payment has
ended are not required. For example:
i) The
employer paid wages from 4/17-4/30/2015 on 5/8/2015, from 5/1-5/14/2015 on
5/22/2015, and from 5/15-5/28/2015 on 6/5/2015.
ii) One notice
is required to be submitted to BWC within 30 days of 6/5/2015, the end date of
payment.
iii) Additional notices are
not required 30 calendar days from 5/8/2015 and 5/22/2015.
d) However, an
additional notice(s) is required if there is a break in the employer’s payment,
and then payment resumes. For example:
i) The
employer paid wages from 4/17-4/30/2015 on 5/8/2015.
ii) The IW
returned to his/her former position of employment on 5/1/2015, but worked for
only two weeks, and then was unable to work again due to his/her injury.
iii) The employer paid
another period of wages from 5/15-5/28/2015 on 6/5/2015.
iv) Written notice of the
agreement must be submitted to BWC within 30 calendar days of 5/8/2015, the end
date of payment for the first period.
v) A second notice
must be submitted to BWC within 30 calendar days of 6/5/2015, the end date of
payment for the second period.
c. If the
sick leave buy back/wage agreement extends beyond the period of time originally
submitted, but claims services staff does not receive written notice of the
change, claims services staff must not send the IW’s payment(s) of TT
compensation in care of the employer.
d. It is possible
that claims services staff may not receive a request for TT when staff
receives:
i. Written
notice of the agreement between the employer and IW; or
ii. Written
notice of the beginning or end date of payment of wages, sick leave, or
advancement.
iii. However, claims
services staff must receive a request for TT within two (2) years of the date
of payment of wages, sick leave, or advancement in order to pay TT over the
period covered by the employer and IW’s agreement.
e. Claims services
staff must pay TT to the IW when claims services staff has determined TT is
payable based on this procedure and related policy. Claims services staff must
not pay TT strictly based on the agreement between the employer and IW.
f. Claims
services staff must enter in the claims management system the full amount of
the weekly sick leave buy back/wage agreement monies paid.
g. Claims services
staff must mail warrants in care of the employer, but made out to the IW, with
instructions that the warrant(s) must be personally signed by the IW.
h. Claims services
staff must pay TT to the IW for a period not to exceed 12 weeks closely
following the date of injury or beginning of disability, except in special
circumstances. Examples of special circumstances include, but are not limited
to the following:
i. A
clearly defined human resources (HR) policy/employee handbook policy; or
ii. A
bargaining unit contract.
i. When
determining if special circumstances apply and extension of a sick leave buy
back/wage agreement beyond 12 weeks is appropriate, claims services staff must
review the circumstances with their supervisor, and then with the local BWC
attorney, if necessary.
i. When
a clearly defined HR policy/employee handbook policy or a bargaining unit
contract is submitted as proof of special circumstances, claims services staff must
review the policy or contract with their IMS to determine if special
circumstances apply.
ii. When proof
other than a clearly defined HR policy/employee handbook policy or a bargaining
unit contract is submitted as proof of special circumstances, claims services
staff must review the proof with a BWC field attorney to determine if special
circumstances apply.
21. Social Security
Retirement (SSR)
a. In claims with
dates of injury on or after 11/03/1989, claims services staff must pay a weekly
TT or LM benefit amount that does not exceed 66 2/3% of the SAWW for the date
of injury when an IW is receiving SSR benefits (the actual amount of the SSR
benefits is not a factor). This includes payments of TT at the FWW rate or the
AWW rate.
b. Example:
i. The
date of injury is 03/05/2009 and the IW’s AWW is $1,095.00.
ii. The
maximum SAWW for 2009 is $767.00.
iii. The IW is
receiving social security retirement; therefore, they are not entitled to the
full maximum weekly amount of $767.00.
iv. The IW is entitled to
66 2/3 of $767.00, which is $511.33.
c. Additional
information can be found on the TT and Social Security Retirement Job Aid on
COR.
22. Student Injured Workers
a. Claims services
staff may pay TT to a student IW in the following situations:
i. When
the injury prevents the IW from returning to the former position of employment,
but does not prevent the IW from attending school; or
ii. When the
injury prevents the IW from returning to the former position of employment and
from attending school.
b. Claims services
staff may pay TT to the student IW if they can show that they would have
remained in the work force and did not voluntarily remove him/herself from the
work force due to returning to school.
c. Claims
services staff must review and discuss claims pertaining to payment of TT to
student injured workers with their local BWC attorney and supervisor.
23. Teachers and Other
School Employees
a. Claims services
staff must determine issues involving a teacher or other school employee’s
eligibility for TT on a case by case basis and may review the claim with their
supervisor and a BWC attorney, if necessary.
b. When claims
services staff is determining an issue involving a school employee’s
eligibility for TT over the summer months, claims services staff must review
and discuss the issue with the local BWC attorney prior to issuing a decision.
Prior to the staffing with the BWC attorney, claims services staff must
consider the following questions:
i. Was
the school employee injured during the school year;
ii. Is the
school employee receiving their regular wages (salary continuation);
iii. Is the school
employee currently receiving TT; and
iv. Is the school employee
still under contract with the school for the period in which TT is requested?
c. When a
teacher or other school employee is receiving their wages during the summer
months and those wages were earned during a prior period, claims services staff
may pay TT with no offset over the same period that the IW is receiving their
wages. Claims services staff must not preclude the IW from receiving TT simply
because the IW is receiving wages for a prior work period.
d. Claims services
staff must not pay TT to a teacher or other school employee who is receiving their
wages during the summer months and who is not scheduled to work over the summer
months unless the teacher or other school employee shows intent to work during
those months. The following information documents proof of their intent to work
during the summer months:
i. A
job offer for the summer that they are temporarily and totally disabled;
ii. A history
of working at another job during the summer months; or
iii. A job search for
summer employment performed prior to the injury.
e. Claims services
staff must refer the issue to the IC when the IW indicates an intention to work
during the summer months, but has no evidence of such intent.
f. Once
BWC has determined that a teacher or other school employee is entitled to TT,
payments may continue as long as the teacher or other school employee is unable
to return to work at one of their former places of employment.
g. If a teacher or
other school employee has been receiving continuous TT and is unable to work
during the previous 9-month academic year as a result of the industrial injury,
the teacher or other school employee is entitled to continue to receive TT
during the summer months as long as the teacher or other school employee is not
receiving payment of any wages.
h. Example 1
(corresponds to 23d. directly above – not eligible for TT): A teacher gets
injured in May and is off work until August (a new school year begins in
September). The teacher continues to be paid wages over a pro-rated 12-month
period and has never worked over the summer months. The teacher is able to
return to the teaching job once school resumes. TT is not payable to the
teacher during their period of disability (May-August) because they did not
show intent to work over the summer months and there was no loss in earnings.
i. Example
2 (corresponds to 23d. directly above – eligible for TT): Same facts as example
1, but the IW has worked every summer for the last three years. TT is payable
to the teacher during their period of disability because they had a loss in
earnings over the summer.
j. Example
3 (corresponds to 23g. directly above): A teacher gets injured in November, is
not paid anything under the teaching contract during the period of disability,
and has received TT during the remainder of the school year. The teacher is now
applying for TT for the summer months. TT is payable to the teacher for the
summer months because they were unable to earn any wages during the school year
and will not receive their regular pro-rated wages.
24. TT Split among Multiple
Claims
a. When requests
are received in separate claims asking BWC to pay TT over the same period and
claims services staff has confirmed that split TT is the intent of the IW,
claims services staff must refer all claims involved in the request to the IC
at the same time:
i. Seeking
a determination of TT; and
ii. A decision
regarding payment of TT in one claim or split among claims.
b. In the referral,
claims services staff must:
i. Ask
the IC to set the claims as a “heard with” and not as reference claims to
ensure that the IC publishes one order addressing the request for TT; and
ii. Include
the “heard with” in the based on add text section.
c. If TT is
being paid in one of the claims referred to the IC, claims services staff must
note this information on the referral and continue to pay TT in that claim,
with supporting evidence, until the IC issues a decision.
d. Claims services
staff must review issues involving TT split among multiple claims with an IMS
and/or local BWC attorney.
25. Volunteers
a. A volunteer IW
with no other employment is not entitled to TT as no loss of wages has occurred
due to a work-related injury.
b. BWC may pay TT
when a volunteer IW has multiple jobs, one as a volunteer with no earnings and
the other as an employee with earnings.
Example: A volunteer firefighter
also works as a mechanic at a local garage. He/she suffers an injury and cannot
work at either job. TT may be payable.
1. Claims services
staff may allow or deny a request for TT on the BWC Order when they are issuing
a decision for an initial award of TT at the same time as the initial claim
allowance.
a. Claims services
staff must not deny TT on the BWC Initial Allowance Order solely due to the
absence of a completed and signed C-84 or equivalent form from the IW; however,
they may include the appropriate order insert regarding consideration of the TT
request.
b. When the claim
is changed over to lost time and the allowance order from Medical Claims is
still within the appeal period with no appeal filed:
i. Claims
services staff must vacate the allowance order and issue a new order to allow
the claim and payment of TT (when TT is medically supported).
ii. If the
claim is certified, claims services staff must release TT upon issuance of the
re-issued initial allowance order.
2. If a party to
the claim appeals the BWC Order for initial allowance after the appeal period
has expired, claims services staff must:
a. Refer the claim
to the IC for hearing;
b. Keep the claim
in the status as determined by the BWC Order for initial allowance; and
c. Continue
paying TT in the claim while the IC adjudicates the appeal when a valid request
for TT and supporting documentation have been submitted.
3. Claims services
staff must issue a decision to allow a claim and grant TT once the wages are
set, supporting medical evidence is received, and the compensable period and
amount of the TT payment are determined. Staff must refer to the Orders,
Waivers, Appeals, and Hearings policy and procedure for further guidance on
issuing the order and the Wages policy and procedure for more
information regarding setting wages.
1. When the claim
is certified:
a. The employer
retains the right to appeal to the BWC order.
b. Claims services
staff must release TT immediately when the BWC Order has been issued for
initial decisions only. If a timely appeal is filed to the order, claims
services staff must place the claim in “Hearing” status and stop compensation
until a District Hearing Officer (DHO) decision is made.
c. Claims
services staff must not hold payment of TT for receipt of a waiver or
expiration of the appeal period.
d. But the initial
allowance order has not been issued and the claim was changed over from medical
only to lost time, claims services staff must issue the initial allowance order
and release TT without waiting for expiration of the appeal period of the
order.
e. After the
initial allowance order is issued and no appeal has been filed, claims services
staff must release TT when the certification is received.
2. When the
employer does not respond regarding claim certification, or the claim is
rejected, and the claim is being allowed after the initial investigation is
complete, claims services staff may release TT once the appeal period has
expired and no appeal was filed, or a signed Waiver of Appeal Period
(C-108) is submitted by the IW and employer. Claims services staff is not
required to obtain a C-108 from the employer when the employer is out of
business or their policy number is in a final cancelled status.
1. Claims services
staff must:
a. Not consider a
request for TT until a final decision is reached on any previously filed
request for an additional condition(s) when the requested condition(s) is the
sole basis for the period of disability covered by the TT; and
b. Send the
“Application/Request Pending Letter” to notify the parties to the claim that
the request for TT is suspended.
2. If there is no
dispute or conflict with the requested TT and evidence has been received to
support the payment, claims services staff must generate a BWC Order outlining
the TT award being granted when:
a. The initial allowance
decision in the claim is final; or
b. BWC
is paying TT after an interruption in payment, or an omitted or extended period
between TT payments, regardless of the period of time. See H.6
below.
3. Claims services
staff must refer the issue of payment of TT to the IC if a conflict or dispute
exists.
a. When a conflict
or dispute created by a party to the claim, including BWC, is supported by
objective evidence, claims services staff must refer the issue to the IC for
hearing.
b. If a party to
the claim, including BWC, objects to the payment of TT, but does not support
the objection with evidence, the objection does not create a conflict;
therefore, claims services staff must process the request for TT as though the
party did not object.
4. Claims services
staff must release TT when a BWC Order is issued granting TT (including when
the claim is changed over from medical only to lost time) and:
a. the appeal
period for the order has expired with no appeal filed, even if the claim was
certified; or
b. a signed C-108 is
submitted by the appropriate parties.
i. Claims
services staff is not required to obtain a signed C-108 from the employer when
the employer is out of business or their policy number is in a final cancelled
status.
ii. Claims
services staff is not required to obtain a C-108 from the IW if the only issue
addressed in the order is payment of TT.
5. Claims services
staff must contact the IW or IW’s attorney and request a completed and signed
C-84 or equivalent form when a C-86 requesting payment of TT is filed by the IW
or IW’s attorney, but a completed and signed C-84 or equivalent form has not
been submitted.
a. Claims services
staff must dismiss the C-86 if the completed and signed C-84 or equivalent form
is not received and payment of TT was the only issue requested on the C-86.
b. If there are
multiple issues on the C-86, claims services staff must refer the C-86 to the
IC and include the evidence for the other issue(s).
i. Claims
services staff must ask the IC to deny TT based on the lack of a signed C-84 or
equivalent form from the injured worker.
ii. If claims
services staff requests denial of TT for a medically-related reason, claims
services staff must obtain a physician file review to support the denial prior
to referring the C-86 to the IC.
6.
When there is a break in payment of TT, regardless of the length of the
break in payment (see H.2.b above), and a need for
clarification of information or to obtain additional information, claims
services staff must contact the injured worker, employer, and/or MCO to
investigate and verify the following:
a. Reason for the
lapse in payment of TT (What happened?);
b. Status of the
disabling condition(s) as of last exam/treatment;
c. Return to
work dates, including light/modified duty;
d. Receipt of any
other benefits during the period of disability; and
e. Any deductions
or offsets to TT.
7. When salary
continuation has been paid previously, and TT is now payable, claims services
staff must issue an order granting payment of TT.
a. If there is a
conflict or dispute with the requested TT, claims services staff must refer the
issue to the IC.
b. When the appeal
period expires with no appeal filed, claims services staff must release TT.
c. Claims
services staff must release TT immediately upon receipt of a written waiver
from the appropriate parties prior to the expiration of the appeal period.
1. The claims
management system automatically sends the “TT Entitlement Letter” when the
initial TT award is entered into the claims management system, regardless of
when the award is granted in the life of the claim.
2. Claims services
staff must manually generate the “TT Entitlement Letter” when a subsequent
period of TT is granted.
3. Claims services
staff is not required to send the “TT Entitlement Letter” for ongoing TT awards.
4. When an IW is
changing from payment of LM to TT, claims services staff must send the “TT
Restart Letter.”
1. Claims services
staff must pay TT according to the IC Order when the order states that TT must be
paid upon submission of supporting medical evidence and the evidence is
received.
d. Claims services
staff must have a completed and signed C-84/equivalent form from the IW.
e. Claims services
staff must not issue a separate BWC Order awarding TT compensation.
2. Claims services
staff must issue a BWC Order granting TT or must refer the request to the IC
when the IC orders that payment of TT must be considered upon submission
of supporting medical evidence and the evidence is received.
3. Claims services
staff must pay TT as directed in the IC Order when an IC Order is received
ordering TT paid, but the IW’s signature is absent from the C-84 or equivalent
form.
4. The IC may
consider the IW’s presence at a hearing sufficient to meet the requirement of
an IW requesting TT.
5. When a
subsequent C-84 or equivalent form is submitted, claims services staff must:
a. Pay on-going TT
when the IW has signed the C-84 or equivalent form; or
b. Follow up with
the IW to obtain a signature when necessary.
6. When the IC
orders BWC to pay TT and the IW has also received salary continuation, claims
services staff must pay TT as ordered by the IC (usually the difference between
the TT rate and the IW’s net pay).
1. When medical
evidence and a completed and signed C-84 or equivalent form are submitted to
support continued or ongoing payments of TT, claims services staff is not
required to:
a. Provide notification
to the employer of record every time TT is extended; or
b. Issue a BWC
Order.
2. Claims services
staff may discuss an extension of TT with the employer of record in an effort
to manage the IW’s continued disability. If the employer verbally objects to
the ongoing payment of TT, claims services staff must explain to the employer
that:
a. A verbal
objection will not stop payment of TT; and
b. The employer
must file a C-86, with supporting evidence, for the issue to be addressed.
3. When a conflict
or dispute exists with ongoing payment of TT, claims services staff must
continue to pay TT and refer the issue to the IC for a hearing.
a. Claims services
staff does not have authority to discontinue payment or terminate TT when a
conflict or dispute exists with ongoing payment.
b. Claims services
staff must attempt to resolve any conflicts to avoid a referral to the IC.
c. If the
employer submits a C-86 objecting to ongoing payment of TT with supporting
evidence, claims services staff must continue to pay TT and refer the issue to
the IC.
4. BWC may create a
conflict or dispute by objecting to the continued payment of TT. The dispute
must be:
a. Supported by
objective evidence (e.g., physician file review or exam); and
b. Be clearly
outlined in the Notice of Referral to the IC.
5. If the IW is not
expected to return to work, claims services staff must send a C-84 to the IW
and set a work item to follow up with the IW if he or she does not return the
C-84 or equivalent form.
6. If the IW is
expected to return to work on the estimated date, claims services staff must
set a work item for the estimated return to work date to remind him or her to
follow up and obtain an actual return to work date if the IW returned to work
on that date. Claims services staff must update disability tracking in the
claims management system with the actual return to work date.
7. Claims services
staff must continue payment of TT when the IW is receiving TT and the IW files
an Application for Compensation for Permanent Total Disability (IC-2).
a. Claims services
staff must not terminate TT based upon the filing of the IC-2.
b. Payment of TT
may continue until there is an MMI finding or the IC makes a determination on
the IC-2.
c. Claims
services staff must terminate TT as ordered by the IC when the IC-2 is allowed.
d. When the IC is
processing an IC-2 and BWC subsequently receives medical evidence from the
treating provider indicating that the IW has reached MMI, claims services staff
must terminate TT as of the MMI date. Claims services staff is not required to
wait on a decision on the IC-2.
e. If the IC is
processing an IC-2 and evidence is received from a provider other than the
treating provider indicating the IW has reached MMI, claims services staff may
send the MMI issue to the IC while the IC-2 is still under consideration.
f. When
the IW has filed an IC-2 after BWC has made an MMI referral to the IC, the
process to terminate TT due to a finding of MMI may continue.
g. Claims services
staff may schedule the IW for an extent of disability exam if an IC-2 has been
filed.
h. If the IC-2 is
dismissed or the IC finds the IW is not permanently and totally disabled,
claims services staff must review the issue with the local BWC attorney to
determine if any of the evidence from the IC-2 or IC exam for permanent total
disability could be used as a basis for an IC referral on the issue of MMI.
i. Refer
to the Permanent
Total Disability (PTD) and Disabled Workers’ Relief Fund (DWRF) policy
and procedure for more information.
1. Claims services
staff may schedule an exam to evaluate the treatment and extent of disability
early in the life of the claim to facilitate the earliest possible safe return
to work and to ensure appropriate and timely medical treatment.
2. Claims services
staff may schedule the IW for
a. An extent of
disability exam anytime, if appropriate; or
b. A 200-week
exam.
3. Claims services
staff must schedule a 90-day exam as required by law.
4. Claims services
staff must refer to the Independent
Medical Examinations and Physician File Reviews policy and procedure
for information regarding medical exams.
1. Claims services
staff must terminate TT without a hearing for any of the following reasons when
no conflict or dispute exists:
a. The IW returns
to work;
b. The IW’s
treating provider has made a written statement that the IW is capable of
returning to the former position of employment.
c. The IW’s
treating provider indicates the IW has reached maximum medical improvement
(MMI); or
d. The IW’s
employer or another employer makes work available within the IW’s physical
capabilities.
i. The
job offer must be in writing.
ii. The IW’s
treating provider must be in agreement with the job offer.
2. Return to Work
(RTW) – Claims services staff must pay TT up to, but not including, the day the
IW returns to work.
Example:
The IW’s estimated or actual RTW date is 05/31/2020. TT is paid up to and
including 05/30/2020.
a. Claims services
staff may need to contact the IW, employer, their respective authorized
representative, or the treating provider to obtain or verify the correct RTW
date.
b. Claims services
staff must update disability tracking in the claims management system with the
actual RTW date.
c. Claims
services staff must send the “TT Terminated Letter” to notify all parties to
the claim of the following:
i. Ongoing
TT is being terminated due to RTW;
ii. No
overpayment exists because payment of TT ended prior to the RTW date; and
iii. The IW is no
longer eligible for TT.
a) Claims services
staff must send the letter rather than an order as there is no issue to appeal.
b) Claims services
staff must not send the letter when TT is ordered paid for a closed period in
the past.
d. Claims services
staff must send a BWC Order to terminate TT when the IW receives TT beyond the
RTW date. Once a decision on the TT termination issue is final, claims services
staff must address the IW’s overpayment in a separate BWC order. Refer to the Overpayment
of Compensation policy and/or procedure for more information regarding
overpayments.
3. Treating
Provider Releases the IW without Restrictions – claims services staff must pay
TT up through and including the day before the treating provider released the
IW to return to their former position of employment.
a. Claims services
staff must send a BWC Order when the IW has not returned to work.
b. Claims services
staff must send an order rather than a letter because their decision to
terminate TT based on the treating physician’s opinion to release the IW
without restrictions may be appealed by the IW or employer.
4. Treating
Provider Releases the IW with Restrictions
a. Claims services
staff must gather the following evidence to determine if termination of TT is
appropriate:
i. A
written job offer that is within the medical restrictions set forth by the
treating provider and agreed to by the treating physician; and
ii. A job
description.
b. Claims services
staff may continue to pay TT when the IW refuses a job offer that would require
them to work a shift or at a location that is different than the former
position of employment.
c. Claims
services staff may review such issues with the local BWC attorney to determine
if payment of TT must continue or if the issue must be referred to the IC for
hearing.
5. Maximum Medical
Improvement (MMI)
a. Claims services
staff must refer the issue to the IC when:
i. A
conflict or dispute exists regarding MMI; or
ii. The IW is
receiving or requesting TT at the time a party to the claim (including BWC)
files a request to find the IW has reached MMI.
b. If claims
services staff receives an exam report that finds the IW MMI on some, but not
all, allowed conditions, staff:
i. Must
review the issue with a BWC attorney to determine if IC referral is
appropriate;
ii. May refer
the matter to the IC on a NOR;
iii. Must not
enter MMI in disability tracking unless TT is being terminated due to MMI;
iv. May refer to the:
a) TT job aids on
COR; and
b) Notice
of Referral to the IC policy and procedure for further guidance.
c. Treating
Provider Finds MMI
i. Claims
services staff must issue a BWC Order to terminate TT when the treating
physician:
a) States the IW
has reached MMI and TT is being requested or paid in the claim; or
b) Concurs with a
finding of MMI and TT is being requested or paid in the claim.
ii. When the
treating provider submits a MEDCO-14 or equivalent form and indicates the IW
has reached MMI, claims services staff must terminate TT effective on the date
of the last examination, unless the treating provider specifies an MMI
effective date.
Example:
·
The treating provider performs an exam on 10/02/2020.
·
The treating provider’s medical report dated 10/05/2020 states
the IW is MMI, but an effective date is not given.
·
The effective date of the termination is 10/02/2020, the date of
the treating provider’s medical exam.
·
TT is paid through 10/01/2020.
iii. Claims services
staff must terminate TT as of the date listed on the MEDCO-14 or equivalent
form when the treating provider indicates the IW has reached MMI and must pay
TT through the day before the MMI effective date.
Example:
·
The treating provider indicates on the MEDCO-14 or equivalent
form that the IW has reached MMI on 10/2/2020.
·
The MMI effective date entered in the MMI section of the MEDCO-14
is the termination date.
·
TT is paid through 10/01/2020.
iv. Claims services staff must
enter the MMI effective date in the claims management system.
v. When an IW
is in a rehabilitation plan and the treating provider submits a MEDCO-14 or equivalent
form indicating the IW has reached MMI, compensation is not affected. If the IW
subsequently requests TT, the MMI finding may be sufficient for a referral to
the IC if no new and changed circumstances exist.
d.
Employer IME Finds MMI
i. If
TT is being requested or paid at the time the employer of record submits an IME
with an MMI finding and a request for a finding of MMI, claims services staff must
complete a NOR based on the employer’s C-86 or request for a finding of MMI.
ii. If no C-86
or request for a finding of MMI is submitted with the IME that concludes the IW
has reached MMI, claims services staff must contact the employer and ask if the
employer is seeking an MMI finding. If yes, claims services staff must ask the
employer to submit a C-86 or request for MMI finding.
a) When the C-86 or
request is received, claims services staff must refer the issue to the IC based
on the employer’s request.
b) Claims services
staff must not refer the issue without a C-86 or request from the employer.
iii. If TT is not
being requested or paid or the IW is receiving salary continuation at the time
the employer submits an IME with a finding of MMI and a request for a finding
of MMI, claims services staff must complete a NOR based on the employer’s C-86
or request for a finding of MMI. Claims services staff must recommend the C-86
or request be dismissed as TT is not being requested or paid.
e. BWC IME Finds
MMI
i. When
claims services staff receives a report from the DEP physician with a finding
of MMI, claims services staff must review the claim to determine if the IW is
still requesting or receiving TT and/or a new request for medical treatment has
been received. If the IW is requesting or receiving TT, claims services staff must
send to the treating provider:
a) The Physician
Letter – IME Received with MMI Finding; and
b) A copy of the
IME report, unless the provider has indicated they will review the report
online.
c) Before
proceeding with the MMI issue, claims services staff must wait the following
number of days to receive a response from the treating provider:
i) Seven
business days if the letter and report are sent by fax or e-mail (may set a
work item for eight days); or
ii) 11 days (7
+ 4 days per the Mailbox
Rule policy) if they are sent by mail (may set a work item for 12 days).
ii. Before
referring the request to terminate TT based on MMI, claims services staff must:
a) Review the claim
for any recent Physician’s Request for Medical Service or Recommendation for
Additional Conditions for Industrial Injury or Occupational Disease (C-9)
approving treatment that could potentially affect the IME findings; and
b) Review the claim
to determine whether the DEP physician was aware of the treatment being sought.
i) If
there is treatment being sought that is not mentioned in the BWC exam report,
claims services staff may obtain an addendum from the DEP physician.
ii) If the
treatment being sought affected the IME findings, claims services staff may
obtain an addendum from the DEP physician to address whether the treatment
being sought would impact the ultimate conclusion in the exam report.
iii) Claims services staff must
review the issue with the local BWC attorney to determine if it is appropriate
to move forward with the MMI referral.
iv) Claims services staff must
notify the MCO if a MMI referral is made to the IC so the MCO is aware in case
any new treatment requests come in after the referral.
iii. The effective
date of the TT termination is:
a) The MMI date
indicated by the treating provider when they give a specific MMI date in their
statement of concurrence with the IME results; or
b) The date of the
IME with treating provider concurrence. Claims services staff must pay TT up to
and including the day before the MMI effective date.
Example:
An IME is
performed on 10/02/2020.
The IME report
dated 10/05/2020 states the IW has reached MMI.
The treating
provider’s statement dated 10/15/2020 concurs with the MMI finding and provides
an effective date of 10/16/2020.
The effective
date of the termination is 10/16/2020, the date provided by the treating
provider.
Claims services
staff must enter 10/16/2020 as the MMI date in the claims management system to
pay TT up to and including the day before.
Example:
An IME is
performed on 10/02/2020.
The IME report
dated 10/05/202 states the IW has reached MMI.
The treating
provider’s statement dated 10/15/2020 concurs that the IW has reached MMI, but
an effective date is not given.
The effective
date of the termination is 10/02/2020, the date the IME was performed.
Claims services
staff must enter 10/02/2020 as the MMI date in the claims management system to
pay TT up to and including 10/01/2020.
iv. If TT is not being
requested or paid (e.g., IW was receiving TT, but no new C-84 or MEDCO-14 has
been submitted) or the IW is receiving salary continuation at the time of a
finding of MMI, claims services staff must document the finding in claim notes
for future reference in the event the IW becomes eligible for TT.
a) Claims services
staff must not enter a MMI date in the claims management system.
b) Claims services
staff must not issue a BWC Order or refer the matter to the IC, unless a
subsequent request for TT is received.
c) If a subsequent
request for TT is received, claims services staff must refer the issue to the
IC for a decision regarding TT entitlement, not MMI.
f. IC
Finds MMI
i. Claims
services staff must pay TT up to and including the TT termination date, which
is the date of the IC hearing that determined the IW had reached MMI; however,
the IC may determine an effective date of termination that is more appropriate
(e.g., IC affirms BWC Order terminating TT when the treating provider states an
MMI date).
ii. Claims
services staff must stop payment of TT compensation upon receipt of an IC Order
finding the IW has reached MMI.
g. Permanency
i. Medical
evidence that has determined a condition(s) is permanent may be sufficient to
terminate TT if the IW has reached MMI.
ii. When the
treating provider indicates that the IW’s medical condition(s) is not improving
further, no other treatment options are feasible, and the condition(s) has
reached a level of permanency, this may be evidence that the IW has reached MMI
and TT termination may be appropriate. The treating provider’s report must
strongly conclude that the IW has reached MMI in order for the report to
support TT termination. However, if the treating provider indicates that the
IW’s condition(s) is permanent, but is still responding to medical treatment
and is improving, this is not evidence that the IW has reached MMI. TT
termination is not appropriate.
Example:
·
Right knee sprain is allowed in an IW’s claim.
·
The IW is receiving treatment for the condition; however, a
progress report recently submitted by the treating provider states that the IW
is no longer benefitting from treatment, no other treatment options are viable,
and the condition has become permanent.
·
The IW may have reached MMI and TT termination may be appropriate.
Example:
·
An IW has an amputation and permanent loss of the leg, but the
IW’s condition is still improving with medical treatment.
·
The IW’s condition is permanent, but has not reached a maximum
level of medical recovery.
·
The IW has not reached MMI and TT termination is not appropriate.
6. Incarceration –
Refer to the Incarceration
policy and procedure for information regarding termination of TT due to
incarceration.
1.
Claims services staff must suspend TT when:
a. Without good
cause, an IW refuses to submit to any examination scheduled pursuant to RC
4123.651 or refuses to release or execute a release for any medical
information, record, or report that is required to be released pursuant to RC
4123.651 and involves an issue pertinent to the condition(s) alleged in the
claim, and the IC Hearing Administrator issues a compliance letter; or
b. An IW refuses to
submit to any medical examination or vocational evaluation scheduled pursuant
to RC 4123.53 or obstructs the same, or refuses to complete and submit to BWC
or the IC a vocational questionnaire within 30 days after BWC or the IC mails
the request to complete and submit the questionnaire.
2. For more
information, refer to the Independent
Medical Examinations and Physician File Reviews policy
and procedure.
1. Reinstating
Terminated TT
a. The termination
of TT, whether by BWC Order, IC Order, or court order, does not preclude the
commencement of TT at another point in time if the IW becomes temporarily and
totally disabled, unless TT is forever barred.
b. If the IW
becomes eligible to receive TT after termination and it is requested, claims
services staff must investigate the request as a new, subsequent request (see
V.H. above).
c. If TT was
previously terminated by the IC, BWC may reinstate payment of TT. An IC
Referral is not required.
d. Claims services
staff may issue an order when:
i. Following
staffing with a BWC attorney, the attorney agrees that the request for payment
of TT is supported by medical evidence of new and changed circumstances (e.g.,
surgery or newly allowed condition[s]) and no conflict or dispute exists; or
ii. TT has
been terminated by BWC due to a previous finding of MMI for the condition(s)
allowed in the claim and a request is submitted for TT for a newly allowed
condition(s) that renders the IW temporarily and totally disabled.
e. If TT was
terminated due to an IW’s incarceration, claims services staff may begin
payment of TT on the date the IW was first seen by his or her treating
physician, not the date the IW was released from confinement, unless it is the
same date the IW was first seen by his or her treating physician.
i. Claims
services staff must obtain supporting documentation; and
ii. May refer
to the Incarceration
policy and procedure for more information.
2. Reinstating
Suspended TT – Claims services staff must:
a. Reinstate TT
when the IW has remedied the reason for suspension.
b. Pay TT beginning
from the date of last payment if the IW has submitted supporting evidence; and
c. Notify all
parties to the claim that TT is being reinstated via the “TT Reinstatement
Letter.”