Current through August 31, 2023
All insurance carriers, self-insured employers, and licensed
adjusters servicing Idaho worker's compensation claims shall comply with the
following requirements: (3-23-22)
01.
Idaho Office. (3-23-22)
a. All
insurance carriers, self-insured employers, and licensed adjusters servicing
Idaho worker's compensation claims shall maintain an office within the state of
Idaho. The offices shall be staffed by adequate personnel to conduct business.
(3-23-22)
b. The insurance carrier
or self-insured employer shall authorize and require a member of its in-state
staff or an Idaho licensed resident adjuster to service and make decisions
regarding claims pursuant to Section
72-305, Idaho Code.
(3-23-22)
c. As staffing changes
occur and, at least annually, the insurance carrier, self-insured employer, or
licensed adjuster shall submit to the Commission Secretary the names of those
authorized to make decisions regarding claims pursuant to Section
72-305, Idaho Code. Each
authorized insurance carrier shall designate only one (1) Claims Administrator
for each policy of worker's compensation insurance.
(3-23-22)
02.
Claim
Files. All Idaho worker's compensation claim files shall be maintained
within the state of Idaho in either hard copy or immediately accessible
electronic format. Claim files shall include, but are not limited to: (3-23-22)
a. FROI and Claim for Benefits;
(3-23-22)
b. Copies of bills for
medical care; (3-23-22)
c. Copy of
lost-time computations, if applicable; (3-23-22)
d. Correspondence reflecting reasons for any
delays in payments, the resolution of such delays, and acceptance or denial of
compensability; (3-23-22)
e.
Employer's return-to-work communications; and (3-23-22)
f. Medical reports.
(3-23-22)
03.
Correspondence. All original correspondence involving adjusting
decisions regarding Idaho worker's compensation claims shall be authorized from
and maintained at in-state offices. (3-23-22)
04.
Date Stamp. Each of the
documents listed in Subsections
305.02 and
305.03, above, shall be
date-stamped with the name of the receiving office on the day received, and by
each receiving agent or vendor acting on behalf of the claims office.
(3-23-22)
05.
Notice and
Claim. All First Reports of Injury, Claims for Benefits, notices of
occupational illnesses, and fatalities shall be sent directly to the in-state
adjuster for the insurance carrier or self-insured employer. The original copy
of the FROI, Claim for Benefits, and notices of occupational illness and
fatality shall be sent electronically to the Industrial Commission.
(3-23-22)
06.
Compensation
Payments - Generally. (3-23-22)
a. All
compensation, as defined by Section
72-102, Idaho Code, must be issued
from the in-state office. (3-23-22)
b. Except as ordered otherwise by the
Commission, the insurance carrier or self-insured employer may make
compensation payments by either: (3-23-22)
i.
Check or other readily negotiable instrument; (3-23-22)
ii. When requested by the Claimant,
electronic transfer payment to an account designated by the Claimant in
accordance with the requirements of Subsection
305.07; or (3-23-22)
iii. When requested by the Claimant,
electronic transfer payments made through an access card; if that option is
made available by the carrier or self-insured employer, in accordance with the
requirements of Subsection
305.08.
(3-23-22)
c. If the
Claimant is represented by an attorney who may have an attorney's lien for fees
due on such compensation payments, the attorney must agree to payment by
electronic transfer to Claimant's account or payment through an access card
before such compensation may be paid other than by a check made payable to the
Claimant and the attorney. (3-23-22)
07.
Electronic Transfer
Payments. (3-23-22)
a. A Claimant may
request that the insurance carrier or self-insured employer make compensation
payments by electronic transfer to a personal bank account by providing the
insurance carrier or self-insured employer in writing: the name and routing
transit number of the financial institution and the account number and type of
account to which the Claimant wants to have the compensation electronically
transferred. The insurance carrier or self-insured employer shall provide the
Claimant with a written form to fill out the required information by this
subsection within seven (7) days of receiving a request for electronic transfer
of payments from the Claimant unless the Claimant has already completed an
on-line electronic form provided by the carrier or employer.
(3-23-22)
b. The insurance carrier
or self-insured employer may make compensation payments to the Claimant by
electronic transfer to an account designated by the Claimant if the Claimant:
(3-23-22)
i. Requests in writing that payment
be made by electronic transfer; (3-23-22)
ii. Provides the information required by
Paragraph 305.07.a. above; and (3-23-22)
iii. Is reasonably expected to be entitled to
receive compensation payments for a period of eight (8) weeks or more from the
point that Subparagraphs 305.07.b.i. and 07.b.ii. are satisfied.
(3-23-22)
c. The
insurance carrier or self-insured employer shall initiate payment by electronic
transfer starting with the first benefit payment due on or after the twenty
first day after the requirements of Paragraph 305.07.b., above are met, but
shall continue to make timely payments by check until the insurance carrier or
self-insured employer initiates benefit payment delivery by electronic
transfer. (3-23-22)
d. If the
Claimant has previously been receiving benefit payments by electronic transfer
and wants to receive benefits by check, the insurance carrier or self-insured
employer shall initiate benefit payment delivery by check starting with the
first benefit payment due to the Claimant on or after the seventh day after
receiving a written request for such payments. (3-23-22)
08.
Access Card Payments.
(3-23-22)
a. Access card means any card or
other payment method that may be used by a Claimant to initiate electronic fund
transfer from an insurance carrier's or a self-insured employer's bank account.
The term "access card" does not include stored value cards or prepaid cards
that store funds directly on the card and that are not linked to an insurance
carrier's or a self-insured employer's bank account. (3-23-22)
b. An insurance carrier or a self-insured
employer may pay compensation through an access card to a Claimant if there is
written mutual agreement signed by the insurance carrier or self-insured
employer and the Claimant. The insurance carrier or self-insured employer shall
maintain accurate records of the mutual agreement for, at a minimum, four
hundred and one (401) weeks from the date of injury. The written agreement
shall contain an acknowledgment that the Claimant received and agreed to the
written disclosure required by Paragraph 305.08.d. (3-23-22)
c. An insurance carrier or a self-insured
employer providing compensation payments to a Claimant through an access card
shall: (3-23-22)
i. Permit the Claimant to
withdraw the entire amount of the balance of an access card in one transaction;
(3-23-22)
ii. Not reduce
compensation payments paid to a Claimant through an access card for the
following fees, surcharges, and adjustments: (3-23-22)
(1) Overdraft services under which a
financial institution pays a transaction (including a check or other item) when
the Claimant has insufficient or unavailable funds in the account;
(3-23-22)
(2) ATM withdrawal or
point of sale purchase for more than the card holds and the transaction is
denied; (3-23-22)
(3) ATM balance
inquiries; (3-23-22)
(4)
Withdrawing money from network ATMs; (3-23-22)
(5) Withdrawing money from a teller;
(3-23-22)
(6) Customer service
calls; (3-23-22)
(7) Activating the
card; (3-23-22)
(8) Fees for card
inactivity; (3-23-22)
(9) Closing
account; (3-23-22)
(10) Access card
replacement through standard mail; (3-23-22)
(11) Withdrawing the entire payment in one
transaction; (3-23-22)
(12) Point
of sale purchases, or (3-23-22)
(13) Any other fees or charges that are not
authorized under Subparagraph 305.08.c.iii., and (3-23-22)
iii. Only permit a Claimant to be charged for
the following: (3-23-22)
(1) Fees for access
card replacement through an expedited mail service; (3-23-22)
(2) International transaction fees, and
(3-23-22)
(3) Out-of-network ATM
fees. (3-23-22)
d. Insurance carriers or self-insured
employers shall provide a written disclosure to the Claimant contemporaneously
with the written mutual agreement required under Paragraph 305.08.b. that
includes: (3-23-22)
i. A summary of the
Claimant's liability for unauthorized electronic fund transfers;
(3-23-22)
ii. The telephone number
and address of the person or office to be notified when the Claimant believes
that an unauthorized electronic fund transfer has been or may be made;
(3-23-22)
iii. The type of
electronic fund transfers that the Claimant may make and any limitations on the
frequency of transfers; (3-23-22)
iv. Any fees imposed for electronic fund
transfers or for the right to make transfers, including a statement that fees
may be imposed by an ATM operator that is out-of-network; (3-23-22)
v. Fees for expedited card replacement or
international transaction fees will be removed from the balance maintained in
the bank account linked to the access card; (3-23-22)
vi. A summary of the Claimant's right to
receipts and periodic statements; (3-23-22)
vii. All bank locations and network ATMs in
the United States where the Claimant may access his or her funds at no cost;
(3-23-22)
viii. A statement
informing the Claimant that they have a right to receive payments directly into
their personal bank account through direct deposit or by check.
(3-23-22)
e. An insurance
carrier or a self-insured employer shall provide the written disclosure and any
notice of term or condition changes required under Paragraph 305.08.d. that:
(3-23-22)
i. Are printed in not less than
twelve (12) point font; (3-23-22)
ii. Include the full text to communicate all
terms and conditions; (3-23-22)
iii. Are written in a clear and coherent
manner and wherever practical, words with common and everyday meaning shall be
used to facilitate readability; and (3-23-22)
iv. Are appropriately divided and captioned
in a meaningful sequence such that each section contains an underlined,
boldfaced, or otherwise conspicuous title or caption at the beginning of the
section that indicates the nature of the subject matter included in or covered
by the section. (3-23-22)
f. An access card issued to a Claimant under
this Subsection 305.08
shall: (3-23-22)
i. Not bear any information
that could reasonably identify the Claimant as a participant in the worker's
compensation system; and (3-23-22)
ii. Include on the front or back of the
access card a toll-free customer service number and website address. Customer
service personnel shall be available by phone Monday through Friday during
normal business hours (9 a.m. to 6 p.m. Mountain Time).
(3-23-22)
g. The
insurance carrier or self-insured employer shall provide a written notice to
the Claimant at least twenty one (21) days before the effective date of any
change in a term or condition of the mutual agreement or disclosure, including
terminating the access card program, increased fees, or liability for
unauthorized electronic fund transfers. Any terms or conditions that violate
the requirements of this Subsection
305.08 are null and void and may
result in administrative action against the carrier or employer. An insurance
carrier or employer shall provide a written notice of term or condition changes
that: (3-23-22)
i. Provides a comparison of
the current terms and the changes; and (3-23-22)
ii. References the Claimant's ability to
request a change in method of payment to electronic fund transfer to his or her
personal bank account in accordance with Subsection
305.07 or to payment by check.
(3-23-22)
h. An insurance
carrier or a self-insured employer may close the access card account by issuing
a check to the Claimant with the remaining balance of the access card if the
account has been inactive for twelve (12) months or longer. (3-23-22)
i. The insurance carrier or self-insured
employer shall not remove money from the Claimant's account or access card
except to remove permitted fees under Subparagraph 305.08.c.iii. or to close
the account for inactivity of a period of twelve (12) months or more. An
insurance carrier or a self-insured employer seeking to recoup overpayments
shall follow the requirements of section
72-316, Idaho Code.
(3-23-22)
j. An insurance carrier
or a self-insured employer is considered to have made a compensation payment
the date the payment is available on the Claimant's access card.
(3-23-22)
09.
Checks and Drafts. Checks must be signed and issued within the state of
Idaho; drafts are prohibited. (3-23-22)
a. The
Commission may, upon receipt of a written Application for Waiver, grant a
waiver from the provisions of Subsections
305.06 and
305.09 of this rule to permit an
insurance carrier or a self-insured employer to sign and issue checks outside
the state of Idaho. (3-23-22)
b. An
Application for Waiver must be accompanied by an affidavit signed by an officer
or principal of the insurance carrier or self-insured employer, attesting to
the fact that the insurance carrier or self-insured employer is prepared to
comply with all statutes and rules pertaining to prompt payments of
compensation. (3-23-22)
c. All
waivers shall be effective from the date the Commission issues the order
granting the waiver. A waiver shall remain in effect until revoked by the
Industrial Commission. At least annually, staff of the Industrial Commission
may review the performance of any insurance carrier or self-insured employer
for which a waiver under this rule has been granted to assure that the
insurance carrier or self-insured employer is complying with all statutes and
rules pertaining to prompt payments of compensation. (3-23-22)
d. If at any time after the Commission has
granted a waiver, the Commission receives information permitting the inference
that the insurance carrier or self-insured employer has failed to provide
timely benefits to any Claimant, the Commission may issue an order to show
cause why the Commission should not revoke the waiver; and, after affording the
insurance carrier or self-insured employer an opportunity to be heard, may
revoke the waiver and order the insurance carrier or self-insured employer to
comply with the requirements of Subsections
305.06 and
305.09 of this rule.
(3-23-22)
10.
Copies of Checks. Copies of checks and/or electronically
reproducible copies of the information contained on the checks must be
maintained in the in-state files for Industrial Commission audit purposes. A
copy of the first income benefit check shall be sent to the Industrial
Commission electronically on the same day of issuance. (3-23-22)
11.
Prompt Claim Servicing.
Prompt claim servicing includes, but is not limited to: (3-23-22)
a. Making an initial decision to accept or
deny a Claim for an injury or occupational disease within thirty (30) days of
the date the Claims Administrator receives knowledge of the same. The worker
shall be given notice of that initial decision in accordance with Section
72-806, Idaho Code. Nothing in
this rule shall be construed as amending the requirement to start payment of
income benefits no later than four (4) weeks or twenty-eight (28) days from the
date of disability under the provisions of Section
72-402, Idaho Code.
(3-23-22)
b. Payment of medical
bills in accordance with the provisions of Section
803 of these rules.
(3-23-22)
c. Payment of income
benefits on a weekly basis, unless otherwise approved by the Commission.
(3-23-22)
i. The first payment of income
benefits under Section
72-408, Idaho Code, shall
constitute application by the insurance carrier or self-insured employer for a
waiver to pay Temporary Total Disability (TTD) benefits on a bi-weekly basis,
Temporary Partial Disability (TPD) benefits on other than a weekly basis,
Permanent Partial Disability (PPD) benefits based on permanent impairment and
Permanent Total Disability (PTD) benefits every twenty-eight (28) days, rather
than on a weekly basis. (3-23-22)
ii. Such waiver application shall be granted
upon receipt and remain in effect unless revoked by the Industrial Commission
in accordance with Subparagraph 305.11.c.iii. (3-23-22)
iii. If at any time after a waiver has been
granted pursuant to this section the Commission receives information permitting
the inference that the insurance carrier or self-insured employer has failed to
service claims in accordance with Idaho law, or that such waiver has created an
undue hardship on a Claimant, the Commission may issue an order to show cause
why the Commission should not revoke that waiver, and after affording the
insurance carrier or employer an opportunity to be heard, may revoke the waiver
with respect to all or certain Claimants and order the insurance carrier or
self-insured employer to comply with the requirements of Subsection
305.11.c. of this rule.
(3-23-22)
d. Payment of
the first Permanent Partial Disability (PPD) benefit based on permanent
impairment no later than fourteen (14) days after receipt of the Medical Report
providing the impairment rating. The first payment shall include payment of
benefits retroactive to the date of medical stability. (3-23-22)
e. Temporary Partial Disability (TPD)
payments shall be calculated using the employee's pay period, whether weekly,
bi-weekly, or semi-monthly. For employees paid pursuant to any other schedule,
TPD benefits shall be calculated semi-monthly. TPD payments owed for a
particular pay period shall issue no later than seven (7) days following the
date on which employee is ordinarily paid for that pay period.
(3-23-22)
12.
Audits. The Industrial Commission will perform periodic audits to
ensure compliance with the above requirements. (3-23-22)
13.
Non-Compliance.
Non-compliance with the above requirements may result in the revocation of the
authority of an insurance carrier to write worker's compensation insurance or
self-insured employer to self-insure its worker's compensation insurance
obligations in the state of Idaho, or such lesser sanctions as the Industrial
Commission may impose. (3-23-22)