Newer is Not Always Better:

New Indiana Worker's Compensation Board Forms

 

The Indiana Worker's Compensation Board (Board) has revised two familiar forms and published a new form.  These forms are available on the Board's Web site, but they are not available in electronic version.  Paper versions must still be printed and submitted to the Board. 

 

Notice of Denial of Benefits – State Form 53914

 

The Board has introduced a new form called the Notice of Denial of Benefits.  As one would guess, you should use this form when denying a claim.  The new form asks for some additional information related to the adjuster or case manager. 

 

Although there is a new form, there is no change to the procedure for notifying the Board and the employee that a claim is denied.  The decision about compensability should be made and notice given to the Board and the employee within 30 days of notice of the injury, unless an extension of time has been requested.  We believe this form will be beneficial because it does not give an employee the perception that he or she can respond to the denial or request additional action as the prior Form 38911 did. 

 

Report of Claim Status – State Form 38911

 

The Form 38911 continues to be an important "jack of all forms" when terminating or reducing temporary total disability (TTD), but you no longer use the 38911 to deny a claim.  There are several other changes made to the new 38911.

 

·          Send Notice in Advance

The top part of the form now requests information related to the adjuster or case manager.  Like the previous Form 38911, the new 38911 notifies the employee and the Board that TTD benefits are being terminated based on statutory requirements which mirror statutory language.  The statute also says that if TTD is being terminated for any other reason, an employer must notify the employee of its "intent" to terminate TTD.  The new 38911 explicitly says that the notice needs to be sent at least four days in advance of the TTD termination date when the treating physician releases the employee to return to work or determines that the employee has reached maximum medical improvement (MMI).  You will need to continue to communicate closely with the treating physician's office so that you can send the required notice in advance of the termination date. 

 

·          Attach Medical Documentation

The new 38911 form reflects the Board's requirement that you attach medical documentation if you are reducing or terminating TTD benefits because an employee has been released to return to work (full or part-time) and/or has reached MMI.  The medical documentation could be a slip from the physician noting that the employee has reached MMI on a certain date.  You should still obtain a more detailed report addressing why the employee is at MMI and what, if any, permanent partial impairment (PPI) rating is assigned. 

 

·          Record Dates and Amounts of Compensation

This form continues to serve as notice to the Board of the total compensation payments made and the dates of payment.  The lower portion of the new 38911 needs to be filled out to report payment of certain benefits.  Unfortunately, there is no longer space to record an end date for the payments and very little space to include an explanation for the calculation.  It is important to continue to document this information on the form in order to determine when the statutory limitations period begins to run.  These dates are also important for determining ongoing responsibility for medical (ORM) under Medicare's new mandatory reporting requirements.

 

·          Request IME and Additional Medical Care

The new 38911 gives the employee an opportunity to dispute the termination or reduction of benefits, to ask for further medical care, and to request an independent medical examination (IME).  The wording on the new form may give an employee the impression that he or she will be entitled to receive an IME or further medical care simply by checking the box.  It will be important to continue to monitor employee requests for IMEs and to contact the Case Coordinator to discuss whether the employee is entitled to an IME and, if so, to agree on a physician to perform the IME. 

 

Application for Adjustment of Claim for Provider Fee – State Form 18487                                  

 

Form 18487 is used by medical providers who believe that their unpaid and partially-paid services constitute statutory medical expenses under the Act.  The revised form looks similar to its predecessor but requests some additional information related to insurance carriers, adjusters and bill reviewers.

 

At the bottom of the form, the provider must include the latest date of service, rather than date of service, and include information reflecting that there has been some effort made by the provider to resolve this claim prior to filing the application.  This new requirement, along with an increased filing fee, may decrease the number of Provider Fee Applications being filed.  Once an Application for Provider Fee has been filed, the Board will not allow the case to be dismissed or resolved without addressing the provider's claim. 

 

Conclusion

 

It is important to stay familiar with Board procedures and to use the forms appropriately.  The Board has previously said that it will begin to penalize employers, TPAs or insurance carriers for not filing the appropriate forms in a timely manner.  If you have any questions about how and when to use these forms, please contact Ann Stewart.

 

This publication is intended for general information purposes only and does not and is not intended to constitute legal advice.  The reader must consult with legal counsel to determine how laws or decisions discussed herein apply to the reader's specific circumstances.