Workers Compensation Current Business Process

Transcription

1 Current Business Process Initial Claims Reporting to TPA Injured employee reports injury to supervisor on duty. If First Aid/no formal medical treatment needed, agency completes Report Only section of FNOL in TPA web portal stopping at line 18a. If treatment is required, supervisor generates treatment Authorization form & goes with employee to authorized medical provider. Supervisor obtains copy of Work Note given to employee by authorized medical provider. Supervisor completes Form 19 or other agency Injury Report form and gives to agency. Agency completes entire FNOL Injury Report in TPA web portal for injury requiring formal medical treatment. Supervisor interviews employee and witnesses and gets their written statements. Supervisor completes Incident Investigation Report and gives package to agency within 48 hours of injury. Agency forwards Incident Investigation package to TPA and agency safety officer/ committee immediately upon receipt. TPA reviews claim report, assigns adjuster, conducts investigation, and recommends claim approval or denial. If employee removed from work, supervisor provides employee s job description to TPA. LEO Salary Continuation- Determine eligibility and do required letters, if applicable. TPA Third Party IC Industrial Commission OSHR Office of State Human Resources HR Human Resources LEO Law enforcement officer

2 Current Business Process Return To Work Supervisor reviews authorized treating physician s assigned work restrictions in Work Note to identify appropriate modified duty work in agency. If LE, obtain clearance from LE Medical Office, may need requalification. Supervisor discusses modified duty work with HR and agency. Supervisor meets with employee to discuss and sign modified duty work agreement. Process BEACON action for employee returning to work. Employee gives supervisor copy of new Work Note following each visit with authorized treating physician. Supervisor reassesses modified duty work assignment following receipt of each Work Note. Work restrictions accommodated for 90 days. Modified duty status reviewed at 90 day mark for projected duration. If employee reaches MMI and is assigned no permanent work restrictions, returns to pre-injury position. If employee reaches MMI and is assigned work restrictions, supervisor, agency, and HR review job description and work restrictions. Employee returns to preinjury job with accommodations, or other suitable employment within agency or state government. If suitable employment cannot be identified, vocational rehabilitation may be assigned, settlement may occur, or workers compensation benefits continue. Employee may be separated if unable to perform job functions. LE Law Enforcement MMI Maximum Medical Improvement HR Human Resources

3 Current Business Process Case Settlement Employee separated, has resigned, has been RIFed, has been terminated, salary continuation has ended, or permanent work restrictions cannot be accommodated. If eligible, employee should already be on STD running concurrently with WC. If employee is eligible for LTD, HR sends letter or contacts employee regarding eligibility. TPA prepares case settlement evaluation including MSA amount, if applicable, and submits to agency. Agency obtains settlement authorization from agency and notifies TPA of approved amount. If claim settlement less than $75,000, TPA/AG negotiates settlement and agreement reached. If claim settlement greater than $75,000, TPA must obtain authorization from AG s office before settlement negotiation. Case settled by parties or at mediation with agency represented by AG. TPA forwards settlement information to AG for clincher agreement preparation. AG sends clincher agreement to employee for signature. After employee signs, AG sends signed clincher agreement to agency for signature. AG forwards signed clincher agreement and required attachments to IC for approval with copy to TPA and agency. TPA sends large payment request, if applicable, to agency requesting funds transfer in advance to OSC while clincher is pending at IC. Upon receipt of approved clincher agreement, AG s office forwards copy of approval Order to TPA and agency for payment processing. TPA Third Party STD/ LTD Short-Term/Long-Term disability MSA Medicare Set Aside IC Industrial Commission AG Attorney General (NCDOJ - Section) HR Human Resources RIF Reduction-in-force MMI Maximum Medical Improvement

4 Current Business Process Nurse Case Management Agency or TPA may recommend NCM services in accordance with established protocols. Agency selects NCM vendor. TPA contacts selected NCM vendor and sends claim records to NCM vendor. NCM Vendor sends Form 25C to IC and TPA. NCM vendor begins providing services and sends progress reports to TPA and agency. TPA and agency monitor NCM services and discuss employee progress to determine if continued services are needed. NCM services are terminated by TPA upon receipt of agency s instructions to do so. IC Industrial Commission NCM Nurse Case Management TPA Third Party HR Human Resources

5 Current Business Process Vocational Rehabilitation Services Agency or TPA may recommend VR services in accordance with established protocols. Agency selects VR vendor. TPA contacts selected VR vendor and sends claim records to VR vendor. VR Vendor sends Form 25C to IC and TPA. VR vendor begins providing services and sends progress reports to TPA and agency. TPA and agency monitor VR services and discuss employee progress to determine if continued services are needed. VR services are terminated by TPA upon receipt of agency s instructions to do so. IC Industrial Commission VR Vocational Rehabilitation TPA Third Party HR Human Resources MMI Maximum Medical Improvement

6 Current Business Process Surveillance Authorization TPA and agency analyzes information received from any source regarding credibility of employee s claim. TPA seeks agency approval for surveillance. If agency initially disapproves surveillance, TPA may seek OSHR recommendation for surveillance. Agency makes final decision regarding need for surveillance. Agency selects approved surveillance vendor and sends OSHR surveillance referral information form to TPA adjuster. TPA contacts surveillance vendor and forwards completed information form TPA, agency, and surveillance vendor develop detailed surveillance plan based on all relevant information. Surveillance vendor performs services and sends investigative reports to TPA, agency, and OSHR. TPA confers with agency and OSHR if needed regarding surveillance report and takes appropriate action. TPA Third Party

7 Current Business Process Separation from State Employment Employee s date of injury at least 12 months prior to current date, or permanent work restrictions cannot be accommodated. HR determines eligibility for Long- Term Disability benefits and sends package to employee; employee may file application. Agency issues employee Pre Separation Letter giving employee 15 calendar days to respond. If employee does not respond to Pre Separation letter, agency sends Letter of Separation with separation date no sooner than 20 days after Pre Separation letter is sent, notice of benefits termination, and grievance rights. If employee responds to Pre Separation Letter proposing alternative method of return to work, agency approves or denies proposal. Agency personnel perform necessary actions in BEACON for separation or return to work. If employee is separated, benefits continue as administered by TPA. WC HR Human Resources

8 Current Business Processes BEACON Instructions Employee on WC LOA, not salary continuation eligible Supervisor submits leave request to HR timekeeper and gives copy to agency. Agency sends letter/memo to work location verifying and authorizing Leave of Absence- (LOA- WC). Work location submits PAR form to HR timekeeper for entry of action and supplemental leave. Refer to BEACON Checklist and Job Aids available. Start Workflow: Use only the following options: a. #13 LOA with TTD supplement b. #14 LOA-TTD Effective date must be first date out of work after date of injury per Authorized Treating Physician. Maintain Text: Create notes indicating action details: a. PCR# and date of action, b. Per NCGS , c. Date of injury, d. Current vacation, sick & bonus leave hours, e. anticipated return to work dates (if known), f. Where medical notes are located supporting action. Follow BEACON instructions accordingly as it applies to Workflow options listed. Perform follow-up BEACON action(s), wherever applicable. WC LOA Leave of Absence HR Human Resources PAR Personnel Action Request TTD Temporary Total Disability

9 Current Business Processes BEACON Instructions Employee on WC LOA, salary continuation eligible per NCGS TPA reviews injury report for salary continuation eligibility and recommends approval or denial; OSHR and agency concurs. Supervisor submits leave request to HR timekeeper. enters salary continuation leave information in TPA claims management system. Supervisor submits PAR Form to HR timekeeper for entry of action and time. Refer to BEACON Checklist and Job Aids available. TPA drafts salary continuation eligibility letter and sends to. verifies content of salary continuation eligibility letter, puts on letterhead, gets agency head signature, and sends back to TPA. TPA sends salary continuation eligibility letter with filing of Form 60 or 63 to IC and sends copy to employee. HR Timekeeper starts workflow using the #15 WC LEO Continuation Pay option. Effective date must be first date out of work after date of injury per authorized treating physician. HR Timekeeper enters salary information and starts Workflow. Maintain Text: Create notes indicating action details: a. PCR# and date of action, b. Per NCGS , c. Date of injury, d. Current vacation, sick & bonus leave hours, e. anticipated return to work dates (if known), f. Where medical notes are located supporting action. To complete this Action: a. Pull/Copy/Save notes from Initial action b. Change employee Work Plan, if applicable c. Maintain Text: Paste copied notes d. Check & Save reviewing action until workflow is complete. Process weekly 2001 (Time Entry), if applicable, to assure monthly payments. TPA Third Party WC HR Human Resources PAR Personnel Action Request LEO Law Enforcement Officer IC Industrial Commission OSHR Office of State Human Resources

10 Current Business Process NCIC Form 26A (PPD) Payment Process Authorized treating physician determines employee at MMI and issues PPD rating in medical note or on Form 25R. Employee returns to full duty work at preinjury or another job. Employee or agency may request second opinion on PPD rating from physician of choice at employer s expense. Employee, TPA, and agency agree on PPD rating to be paid and notify TPA. TPA prepares Form 26A and sends with medical records to agency or employee for signature. Employee returns signed Form 26A to agency or TPA (whichever entity sent it to employee). Agency reviews Form 26A, signs, and sends to TPA. TPA sends signed Form 26A and medical records to IC for approval. IC approves Form 26A and sends approval notice to TPA. TPA notifies agency of Form 26A approval. TPA issues periodic or lump sum PPD payment check(s) to employee/attorney. TPA completes Form 28B within 16 days of last payment of medical or disability compensation and sends to IC and employee. TPA Third Party IC Industrial Commission MMI Maximum Medical Improvement PPD Permanent Partial Disability

11 NC Office of State Human Resources WORKERS COMPENSATION CLAIM PROCESS Employee reports injury to supervisor. Supervisor administers First Aid or directs employee to initial medical treatment. Supervisor reports injury to Agency. Agency electronically reports injury to TPA. Supervisor completes Incident Investigation Report and gives to agency. Agency forwards Incident Investigation Report to TPA and agency safety officer/committee. TPA performs investigation and recommends accept/deny/pay claim without prejudice. Agency makes final decision to accept/ deny/pay claim without prejudice. TPA coordinates employee s ongoing medical treatment until claim is closed. Agency coordinates light duty job with injured employee s supervisor. Agency reports suspicious activity/ potential fraud to TPA & OSHR. Agency may select surveillance vendor and works with TPA to direct surveillance activities. Agency may approve NCM and VR in accordance with established protocols. TPA files all required forms with Industrial Commission. Employee returns to work with or without permanent restrictions, or employee is separated. If employee at MMI returns to work with permanent partial disability rating, rating paid & claim closed. If motion filed/hearing requested on disputed issue, AG represents agency. If claim needs final settlement, TPA prepares settlement evaluation, agency sets authority and directs process with AG advice and representation. TPA Third Party AG Attorney General OSHR Office of State Human Resources MMI Maximum Medical Improvement HR Human Resources