(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.
O.C.G.A. Sec.
34-9-354.