Procedures for Payment of Reimbursement Benefits by the Fund
(1) In order to establish payment for reimbursement benefits from the Subsequent Injury Trust Fund,
(a)an agreement setting forth-factual information establishing the employer’s right to reimbursement must be accomplished by the use of Subsequent Injury Trust Fund Form “B”, referred to as “Reimbursement Agreement.” This Agreement will be initiated by the Subsequent Injury Trust Fund and forwarded to the employer or insurer for signature. The Agreement must be approved by the State Board of Workers’ Compensation.
(b)The employer will be required to submit an itemized statement of weekly income benefits paid to the injured employee. In addition, an itemized statement of medical benefits paid on behalf of the claimant must be submitted to the Subsequent Injury Trust Fund, along with providers’ charges or a fee schedule audit. An employer or insurer who can provide a certified counterpart of its electronically generated or computer-generated pay document which identifies payment date, provider service, treatment (CPT) codes, and the amount paid may be relieved from the requirement of providing the Subsequent Injury Trust Fund with copies of providers’ charges. The Subsequent Injury Trust Fund may require narrative reports when deemed reasonably necessary by the Subsequent Injury Trust Fund. However, where the reimbursement request is based on documented, future medical and rehabilitation expenses which have been paid by the self-insured employer or insurer in accordance with a settlement agreement which provides that said funds will be set aside in a trust or similar funding mechanism consistent with federal laws and/or regulations; and, that said funds will be used solely for medical and rehabilitation expenses, the Subsequent Injury Trust Fund is authorized to reimburse such funds set aside in accordance with the usual and customary charges of the anticipated medical and rehabilitation expenses.
(c)Weekly income benefits and medical benefits reimbursement requests will be outlined on Subsequent Injury Trust Fund Form “C”, referred to as “Reimbursement Request Form.” No reimbursement will be made unless a Reimbursement Request form is completed and signed by the claiming party. The employer or his insurer is required to attest to their efforts to assure that the injured employee is entitled to receive, or to continue to receive workers’ compensation benefits. Failure to comply with this regulation may subject the claim to a denial of reimbursement benefits. After the initial fund payment, reimbursement requests may be made in 13-week intervals.
(2) In the event the employer and the Fund fail to reach an agreement, the claiming party may make application to the State Board of Workers’ Compensation for a hearing in regard to the matters at issue through the use of Form WC-14, Notice of Claim/ Request for Hearing. The Form WC-14 shall be directed to the State Board of Workers’ Compensation with a copy forwarded to the Subsequent Injury Trust Fund.
(3) When the Subsequent Injury Trust Fund denies a reimbursement claim submitted by an employer, the employer may move for reconsideration of the denial by submitting to the administrator of the Trust Fund such additional information which was impossible for the employer to obtain prior to the Trust Fund’s denial no later than 15 calendar days before the initially-scheduled hearing date. The parties should make every attempt to resolve their differences prior to the hearing, but if neither the Trust Fund nor the aggrieved party can reach an agreement, the matter may, upon request of either party, be referred to the Mediation Unit of the State Board of Workers’ Compensation.
This provision shall in no way enlarge the time period in which the employer/insurer must request a hearing to challenge the Trust Fund’s denial before the State Board of Workers’ Compensation.
(Rule 622-1-.06 amended April 2002 and December 2002)