No. 37622 (Amendment): Section R612-200-1. Acceptance / Denial of a Claim

(Amendment)

DAR File No.: 37622
Filed: 05/14/2013 10:19:02 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule change is to outline the workplace injury reporting process within the electronic reporting environment.

Summary of the rule or change:

This rule change requires employers to report workplace injuries to insurance carriers who then report to the Labor Commission electronically. Previously both employers and carriers reported paper forms to the Labor Commission.

State statutory or constitutional authorization for this rule:

• Section 34A-3-108
• Section 34A-2-407

This rule or change incorporates by reference the following material:

• Adds Claims EDI Implementation Guide, published by Labor Commission, 04/19/2013
• Adds Utah Claims R3 EDI Tables, published by Labor Commission, 04/19/2013

Anticipated cost or savings to:

the state budget:

The Commission anticipates some cost to set up and monitor, however in the long term this is offset by personnel savings (time spent manually entering paper forms).

local governments:

The Commission does not anticipate any cost or savings to local governments because they are already reporting claims to the Commission.

small businesses:

The Commission does not anticipate any cost to small businesses because they are already reporting claims to the Commission. There may be some savings because they will not be reporting claims to two entities.

persons other than small businesses, businesses, or local governmental entities:

The Commission anticipates insurance carriers may incur some costs to meet the electronic reporting requirements.

Compliance costs for affected persons:

Insurance carriers only operating in Utah would have initial development costs. Insurance carriers operating in other electronic reporting jurisdictions may incur costs to add Utah to their electronic distribution. Insurance carriers do incur costs associated with transmitting their reports through authorized EDI vendors and will be assessed noncompliance fines if they fail to follow reporting protocols.

Comments by the department head on the fiscal impact the rule may have on businesses:

There are no costs to small businesses, there may be a small savings to those who are currently filing reports to both the carrier and Commission.

Sherrie Hayashi, Commissioner

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Labor Commission
Industrial Accidents
HEBER M WELLS BLDG
160 E 300 S
SALT LAKE CITY, UT 84111-2316

Direct questions regarding this rule to:

• Ron Dressler at the above address, by phone at 801-530-6841, by FAX at 801-530-6804, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/01/2013

This rule may become effective on:

07/08/2013

Authorized by:

Sherrie Hayashi, Commissioner

RULE TEXT

R612. Labor Commission, Industrial Accidents.

R612-200. Workers' Compensation Rules - Filing and Paying Claims.

R612-200-1. [Acceptance/Denial of a Claim]Reporting and investigating injuries.

A. [Upon receiving a claim for workers' compensation benefits, the insurance carrier or self-insured employer shall promptly investigate the claim and begin payment of compensation within 21 days from the date of notification of a valid claim or the insurance carrier or self-insured employer shall send the claimant and the division written notice on a division form or letter containing similar information, within 21 days of notification, that further investigation is needed stating the reason(s) for further investigation. Each insurance carrier or self-insured employer shall complete its investigation within 45 days of receipt of the claim and shall commence the payment of benefits or notify the claimant and division in writing that the claim is denied and the reason(s) why the claim is being denied.]Employer's Obligation to Report Injury.

1. Time requirements. Within 7 days after first notice of a work-related injury, except an injury requiring only first aid treatment as defined in subsection B. of this rule, an employer must report the injury as follows:

a. Insured employer. An insured employer must report the injury to its workers' compensation insurance carrier.

b. Self-insured employer. A self-insured employer must report the injury to its claims administrator.

c. Uninsured employer. An uninsured employer must report the injury directly to the Division.

d. An employer is deemed to have notice of a workplace injury upon the earliest of the following:

i. Observation of the injury;

ii. Verbal or written notice of the injury from any source; or

iii. Receipt of any other information sufficient to warrant further inquiry by the employer.

2. Penalty for failure to properly report injury. The Division may impose a civil assessment of up to $500 against an employer for each occurrence in which the employer fails to report a work-related injury as required by this rule.

B. First Aid.

1. Injury Required Treatment Only by First Aid Need Not Be Reported. An employer is not required to report a work injury that requires only first aid treatment.

a. First aid treatment is limited to medical care provided on-site or at an employer-sponsored free clinic. It may include an initial visit and one subsequent follow-up visit within 7 days of the injury or, if provided by a licensed health professional in an employer-sponsored free clinic, then an initial visit and two subsequent visits within 14 days of the injury.

b. The Employer must maintain health records on site for first aid treatment. (This does not apply to reporting it on OSHA's 300 log).

2. Treatments That Constitute First Aid. First aid treatment is limited to the following types of medical care:

a. Non-prescription medications at non-prescription strength.

b. Tetanus immunizations;

c. Cleaning, flushing or soaking wounds on the skin surface;

d. Applying bandages, gauze pads, etc.;

e. Hot or cold therapy, limited to hot or cold packs, contrast baths and paraffin;

f. Use of any totally non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc.;

g. Use of temporary immobilization devised while transporting an accident victim (splints, slings, neck collars, or back boards);

h. Drilling a fingernail or toenail to relieve pressure, or draining fluids from blisters;

i. Eye patches, simple irrigation, or use of a cotton swab to remove foreign bodies not embedded in or adhered to the eye;

j. Use of irrigation, tweezers, cotton swab or other simple means to remove splinters or foreign material from areas other than the eye;

l. Use of finger guards;

m. Massages;

n. Drinking fluids to relieve heat stress.

3. Treatments That Are Not Considered First Aid. First aid does not include treatment of any injury that has resulted in a loss of consciousness, inability to work, work restriction, or transfer to another job.

C. Insurer and Self-Insured Employer's Duty to File First Report of Injury.

1. Purpose of First Report of Injury. The First Report of Injury is used to provide notice of work injuries to the Division as required by Section 34A-2-407 of the Utah Workers' Compensation Act and Section 34A-3-108 of the Utah Occupational Disease Act.

2. Incorporation by Reference of Technical Standards Governing First Reports of Injury. The Labor Commission hereby adopts and incorporates by reference the Industrial Accidents Division Claims EDI Implementation Guide ("EDI Implementation Guide") and the Utah Claims R3 EDI Tables ("EDI Tables"). (Date/version, etc.)

3. Compliance with EDI Implementation Guide and EDI Tables.

a. Each First Report of Injury must comply with the formatting standards and content requirements of the EDI Implementation Guide and EDI Tables and must contain the following minimum information:

i. Date of Injury;

ii. Type of loss (injury or occupational disease);

iii. Basic injury information, including a) nature of Injury (strain, puncture etc); b) part of body affected (hand, foot etc); and cause of injury (burn, fall, exposure etc);

iv. Description of event or conditions leading to injury or disease;

v. Injured worker's first and last name;

vi. Injured worker's date of birth;

vii. Injured worker's social security number, Green Card number, Employment Visa number, or Passport number. If none of these identification numbers are available, the entity preparing the First Report of Injury must contact the Division to obtain a substitute identification number;

viii. Injured worker's mailing address;

ix. Injured worker's employment status (part or full time);

x. Date employer had notice of the injury;

xi. Employer's name;

xii. Employer's federal employer identification number or federal tax identification number;

xiii. Employer's unemployment insurance number; and

xiv. Employer's physical business address.

b. The claim administrator shall report the appropriate First Report of Injury (FROI) based on the EDI standard, which includes the ability to communicate immediate denial and under investigation. In the event of denial or under investigation, the claim administrator must provide the claimant written notice of determination and reasons for it.

4. Time requirement for filing First Report of Injury. Within 7 days of receiving notice of a work injury, an insurance carrier or self-insured employer must submit a First Report of Injury for the injury to the Division.

a. An insurance carrier or self-insured employer is deemed to have notice of a workplace injury or disease upon receipt of verbal or written notice of the injury that includes the names of the employer and employee and the date of injury.

b. An employer that is not self-insured and does not have workers' compensation insurance must report any work injury directly to the Division.

c. The Division may impose a civil assessment of up to $500 against an insurance carrier or self-insured employer for each occurrence or failure to properly report a work injury as required by this rule. The penalty shall be applied only to the improperly filed report as a whole and not applied to each required date element required by section 3.a.

D. Investigation of Claims. An insurance carrier, claim administrator or uninsured employer shall promptly investigate the claim and either accept or deny the claim within 21 days of the date of notice. IF, with exercise of reasonable diligence, the insurance carrier, claim administrator or uninsured employer cannot complete its investigation within the initial 21-day period, it shall within that initial 21-day period submit to the Division a "First Report of Injury - Under Investigation" and provide a similar written notice to the subject employee. The insurance carrier, claim administrator or uninsured employer shall then be allowed 24 days in addition to the initial 21-day period to complete its investigation.

1. The Division may impose a civil assessment of up to $500 against an insurance carrier or self-insured employer for each occurrence of failure to properly report its compensability determination by the conclusion of the additional 24-day period provided by this subsection. The penalty shall be applied only to the improperly filed report as a whole and not applied to each required data element required by section 3.a.

[B]E. The payment of compensation shall be considered overdue if not paid within 21 days of a valid claim or within the 45 days of investigation unless denied.

[C]F. Failure to make payment or to deny a claim within the 45 day time period without good cause shall result in a referral of the insurance company to the Insurance Department for appropriate disciplinary action and may be cause for revocation of the self-insurance certification for a self-insured employer. Good cause is defined as:

1. Failure by an employee claiming benefits to sign requested medical releases;

2. Injury or occupational disease did not occur within the scope of employment;

3. Medical information does not support the claim;

4. Claim was not filed within the statute of limitations;

5. Claimant is not an employee of the employer he/she is making a claim against;

6. Claimant has failed to cooperate in the investigation of the claim;

7. A pre-existing condition is the sole cause of the medical problem and not the claimed work-related injury or occupational disease;

8. Tested positive for drugs or alcohol; or

9. Other - a very specific reason must be given.

[D]G. If an insurance carrier or self-insured employer begins payment of benefits on an investigation basis so as to process the claim in a timely fashion, a later denial of benefits based on newly discovered information may be allowed.

 

KEY: workers' compensation, filing, time, administrative proceedings

Date of Enactment or Last Substantive Amendment: [February 25, ]2013

Authorizing, and Implemented or Interpreted Law: 34A-2-101 et seq.; 34A-3-101 et seq.; 34A-1-104

 

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