Current through 2024-38, September 18, 2024
A. Disability
Control
(1) Maximum medical improvement
(MMI): The servicing carrier shall take appropriate steps to establish and
document MMI in each case file for partial incapacity cases with dates of
injury before October 17, 1991.
(i) MMI shall
be established by decree, by formal agreement, by the payment of a permanent
impairment award, or by strong medical evidence.
(ii) If MMI has not been established for a
partial incapacity case, the case file shall contain a documented plan
including discussion of specific measures by which the servicing carrier
intends to establish MMI with the Workers' Compensation Board.
(2) The servicing carrier shall
establish disability control and track weeks of disability in accordance with
39 M.R.S.A. §§55-A or 55-B, and 39-A M.R.S.A. §§ 211 -214,
as appropriate.
(i) The case file shall
clearly indicate whether disability payments are being made under § 54-B,
total incapacity, or under § 55-B (or
39-A M.R.S.A.
§213) , partial incapacity.
(ii) If payments are being made under 39
M.R.S.A. § 55-B or 39-A M.R.S.A. § 213, the servicing carrier shall
track payments and/or weeks of disability against the statutory maximum
duration of 400 weeks after MMI for dates of injury before October 17, 1991;
520 weeks of compensation for dates of injury from October 17, 1991 through
December 31, 1992; 260 weeks of compensation for dates of injury on or after
January 1, 1993.
(iii) Every case
file shall be reviewed at least every 6 months.
B. Claimant Contact
(1) Continuing contact with the unrepresented
injured worker at least every 6 months, and with the physician at intervals
consistent with the injury and estimated length of disability and with
obtaining an estimated return to work date.
(2) Medical examinations under
39-A M.R.S.A. §§207 or
312
where questions of disability, causal relationships, and treatment exist or
where reports of treating physicians are not forthcoming
(3) Activity checks consistent with length of
disability and/or suspected fraud, at least every 6 months. Activity checks may
include but are not limited to phone calls to the claimant and/or his/her
employer, in-person contact, surveillance, or contact with a designated
representative.
(4) Availability of
return to modified or light work duties consistent with medical restrictions,
if return to regular job does not appear medically feasible or is
unavailable.
(5) Vocational
rehabilitation, in the form of alternative work, modified work, job placement,
on the job training, and/or schooling, ensuring strict compliance with
statutory standards.
C.
Coordination of benefits. The servicing carrier shall maintain an ongoing
review of open cases with regard to each of the following factors, as may be
appropriate in a particular case:
(1)
Employment Rehabilitation Fund possibilities;
(2) Social Security and unemployment
benefits;
(3) Third party
recovery;
(4) Progress of
claimant's medical condition toward maximum medical improvement;
(5) Potential propriety of vocational
rehabilitation.
Claimant activity and dependency checks shall be made at
least every 6 months.
D. Timely indemnity benefit payments. All
indemnity benefit payments will be made promptly, in accordance with statutory
provisions.
E. Medical Cost
Management
(1) Review all medical bills or
medical abstracts/documentation generated from the actual bills to verify
reasonableness of charges and necessity of services. Appropriate reference to
standards, scales, or schedules of appropriate charges adopted to the Workers'
Compensation Board pursuant to
39-A M.R.S.A.
§209 is required.
(2) Where no questions of liability or
reasonableness exist and physician reports have been received, pay all bills
within 30 calendar days.
(3) Where
questions of liability or reasonableness exist, promptly investigate and obtain
such further information as is necessary to resolve questions.
F. Settlements. Where appropriate,
carriers shall identify and pursue settlement opportunities. Any settlement
shall be based on sound claims judgment consistent with liability and medical
evidence developed, in accordance with the law and benefit structure.
G. Claim Reopenings. Carriers shall record
and document all reopenings of claims previously thought to be closed,
including reason for the reopening and action taken or plan of action required
to manage/close the case.
