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 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 (New and Subsequent Periods 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 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 BWC 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 regarding:
- 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 despite 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 (SC)) 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 of record (EOR), and EOR. BWC is considered
a party to the claim and may present arguments when:
- The EOR or EOR representative does not appear at a
hearing; or
- The EOR or EOR 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 EOR 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 (RTW) 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 EOR 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 EOR 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 (PTD) 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 (SSR) 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 EOR; 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 will not pay TT.
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. 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, SC, 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
they have a waiver of the work requirements due to their 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 they 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).
d. Example:
i.
The IW is a truck driver involved in a motor vehicle accident during
work.
ii. The
IW has broken both his legs and is currently hospitalized. The employer
certifies the claim.
iii. Medical evidence
has not yet been submitted to BWC, but the IW will be disabled from working for
an extended period.
iv. In these
circumstances, BWC would not need a C-84 or medical proof to support and pay TT
benefits for up to four weeks.
5. When
there is a delay between the date of injury and the date the IW can 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 if the treating provider has
certified TT. For periods of TT longer than four weeks, claims services staff
must consult with an injury management supervisor (IMS) and medical service
specialist (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 SSR benefits.
7. If
an IW indicates they are 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 they are receiving retirement benefits, claims services staff
may ask the IW or the EOR if the IW has retired completely, removing themselves
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. Factors
claims services staff must consider when determining if the IW is eligible for
TT include, but are not limited to:
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 (SL);
b) Temporary partial
(TP), only if in a different claim involving different body parts and
conditions;
c) Facial
disfigurement (FD);
d) Violation
of a specific safety requirement (VSSR);
e) Statutory
PTD only if the IW returned to work and had a new injury resulting in a new
claim.
i)
TT can be paid in the new injury claim concurrently with the statutory
PTD in the original claim.
ii) The
TT for the new injury is not payable in the original claim;
f)
Percentage of permanent partial disability (%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) 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” and review the
information gathered with BWC Legal.
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) BWC Legal
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 BWC Legal determines the IW is no
longer suffering a loss of wages due to the allowed injury or occupational
disease:
a) BWC
Legal may prepare a Motion (C-86).
b) 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) LM;
b) SC;
c) Full
sick leave;
d) Non-occupational
sickness and accident benefits fully funded by the EOR; 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 RTW with restrictions, but the employer fails to accommodate those
restrictions. If 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) of this procedure 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 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 or a disallowed condition as causing temporary total disability, it
is not valid and claims services staff must not accept it.
i.
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.
ii. The
MCO has up to three full business days to contact the treating provider
regarding obtaining the medical evidence.
iii. 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.
a) 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 BWC Legal to determine next steps based on the circumstances of
the claim.
b) 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 IW;
vii. An estimated or actual
RTW 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.
i.
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.
ii. 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.
a) The
MCO has up to three full business days to contact the appropriate provider
regarding obtaining the necessary information.
b) 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 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 or their authorized designee to support a period of
disability (see “Provider Signature on Medical Evidence Grid” or MEDCO-14 job
aid on COR).
i.
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.
ii. 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.
a) The
MCO has up to three full business days to contact the treating provider
regarding obtaining supporting evidence that is appropriately signed.
b) 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.
3. 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 BWC Legal prior to
making payment. BWC Legal may assist in determining the nature of the assault
leave and whether 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 procedure to determine if the IW is
entitled to WL.
c. Claims
services staff must review the issue with BWC Legal 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. 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 BWC Legal 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 BWC Legal prior to
making payment. BWC Legal may assist in determining the nature of the hostage
leave and whether the leave is intended to replace workers’ compensation
benefits.
6. 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 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
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 EOR 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.
iii. 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 EOR, 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
EOR 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 may:
i.
Offset payment of TT and/or reimburse ODJFS for unemployment
compensation that was paid and funded only by the ODJFS.
ii. 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 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. PTO
a. 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.
b. 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 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 BWC Legal, 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 claims service specialist (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 IW who was engaged in seasonal
employment (e.g., construction, landscaping, farming) once their 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
a. When
the IW receives sick leave benefits from an employer, including an employer who
is not the EOR, claims services staff must determine if the sick leave is
intended to replace earnings, or supplement or offset TT.
b. Claims
services staff may need to refer to V.E.20 below for information regarding a
sick leave buy back/wage agreement.
c. 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 SC benefit plan in the claims management system.
d. 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.
d) However,
$902.00/week 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.
e. 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/week.
f)
The IW’s actual TT payment is $264.00/week ($864-$600) for the first 12
weeks (FWW) and $200/week ($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 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 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 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 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 BWC
Legal, 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. 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”
22. Student IWs
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 themselves 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 IWs 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 (SC);
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 RTW 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 V.E.23.d above – not eligible for TT):
i.
A teacher gets injured in May and is off work until August (a new school
year begins in September).
ii. The
teacher continues to be paid wages over a pro-rated 12-month period and has
never worked over the summer months.
iii. The teacher can
return to the teaching job once school resumes.
iv. 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 VE.23.d above – eligible for TT):
i.
Same facts as Example 1, but the IW has worked every summer for the last
three years.
ii. 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 V.E.23.g above):
i.
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.
ii. The
teacher is now applying for TT for the summer months.
iii. 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.
c. Example:
i.
A volunteer firefighter also works as a mechanic at a local garage.
ii. They
suffer an injury and cannot work at either job.
iii. 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:
a. Orders,
Waivers, Appeals, and Hearings policy
and procedure for further guidance on issuing the order; and
b. Wages
policy and procedure for more information about setting wages.
1. When
the claim is certified:
a. The EOR
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. If 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 EOR 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:
a. Once
the appeal period has expired and no appeal was filed; or
b. Upon
receipt of the signed Waiver of Appeal Period (C-108) submitted by the
IW and EOR. 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. 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 IW.
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 Section V.H.2.b above), and a need for clarification of
information or to obtain additional information, claims services staff must
contact the IW, 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. RTW
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
SC 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.
a. Claims
services staff must have a completed and signed C-84 or equivalent form from
the IW.
b. 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
ongoing 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 SC, 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 EOR every time TT is extended; or
b. Issue
a BWC order.
2. Claims
services staff may discuss an extension of TT with the EOR 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 EOR
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 EOR 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. Clearly
outlined in the Notice of Referral to the IC.
5. If
the IW is not expected to RTW, claims services staff must send a C-84 to the IW
and set a work item to follow up with the IW if they do not return the C-84 or
equivalent form.
6. If
the IW is expected to RTW on the estimated date, claims services staff must:
a. Set
a work item for the estimated RTW date to remind them to follow up and obtain
an actual RTW date if the IW returned to work on that date; and
b. Update
disability tracking in the claims management system with the actual RTW 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:
i.
Claims services staff must terminate TT as of the MMI date.
ii. 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 EOD 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 BWC Legal 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 policy and
procedure for more information.
1. Claims
services staff may schedule an exam to evaluate the treatment and EOD early in
the life of the claim to facilitate the earliest possible safe RTW and to
ensure appropriate and timely medical treatment.
2. Claims
services staff may schedule the IW for
a. An EOD
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 can return 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 agree with the job offer.
2. RTW
a. Claims
services staff must pay TT up to, but not including the day the IW returns to
work (e.g., the IW’s estimated or actual RTW date is 05/31/2020. TT is paid up
to and including 05/30/2020).
b. 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.
c. Claims
services staff must update disability tracking in the claims management system
with the actual RTW date.
d. 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.
e. Claims
services staff must send a BWC order to terminate TT when the IW receives TT
beyond the RTW date.
i.
Once a decision on the TT termination issue is final, claims services
staff must address the IW’s overpayment in a separate BWC order.
ii. Refer
to the Overpayment
of Compensation policy and procedure for more information regarding
overpayments.
3. Treating
Provider Releases the IW without Restrictions
a. 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.
b. Claims
services staff must send a BWC order when the IW has not returned to work.
c. 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 BWC Legal to determine if payment of
TT must continue or if the issue must be referred to the IC for hearing.
5. 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, they:
i.
Must review the issue with BWC Legal 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:
a) TT
job aids; and
b) Notice
of Referral to the Industrial Commission 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. For example:
a) The
treating provider performs an exam on 10/02/2020.
b) The
treating provider’s medical report dated 10/05/2020 states the IW is MMI, but
an effective date is not given.
c) The
effective date of the termination is 10/02/2020, the date of the treating
provider’s medical exam.
d) 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
when the treating provider indicates the IW has reached MMI and must pay TT
through the day before the MMI effective date. For example:
a) The
treating provider indicates on the MEDCO-14 or equivalent form that the IW has
reached MMI on 10/2/2020.
b) The MMI
effective date entered in the MMI section of the MEDCO-14 is the termination
date.
c) 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 EOR 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 SC 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.
ii. Before
proceeding with the MMI issue, claims services staff must wait the following
number of days to receive a response from the treating provider:
a) Seven
business days if the letter and report are sent by fax or e-mail (may set a
work item for eight days); or
b) 11 days (seven
plus four days per the Mailbox
Rule policy) if they are sent by mail (staff may set a work item for 12
days).
iii. 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 BWC Legal 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.
iv. 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.
c) Example:
i)
An IME is performed on 10/02/2020.
ii) The
IME report dated 10/05/2020 states the IW has reached MMI.
iii) The treating
provider’s statement dated 10/15/2020 concurs with the MMI finding and provides
an effective date of 10/16/2020.
iv) The effective
date of the termination is 10/16/2020, the date provided by the treating
provider.
v) 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.
d) Example:
i)
An IME is performed on 10/02/2020.
ii) The
IME report dated 10/05/202 states the IW has reached MMI.
iii) The treating
provider’s statement dated 10/15/2020 concurs that the IW has reached MMI, but
an effective date is not given.
iv) The effective
date of the termination is 10/02/2020, the date the IME was performed.
v) 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.
v. 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 SC 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.
a) The
treating provider’s report must strongly conclude that the IW has reached MMI for
the report to support TT termination.
b) 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.
iii. Example:
a) Right
knee sprain is allowed in an IW’s claim.
b) 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.
c) The
IW may have reached MMI and TT termination may be appropriate.
iv. Example:
a) An
IW has an amputation and permanent loss of the leg, but the IW’s condition is
still improving with medical treatment.
b) The IW’s
condition is permanent but has not reached a maximum level of medical recovery.
c) 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 BWC Legal, Legal 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 their treating physician,
not the date the IW was released from confinement, unless it is the same date
the IW was first seen by their 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.”