How to Calculate 21-Day Compliance Using the Bureau's Formula
The information provided here is intended to help workers’ compensation insurers improve their accuracy and timeliness in 21-day reporting as well as to maintain and/or increase their compliance percentage rate.
Subsequent documents used to establish a workers’ compensation claim include a Notice of Compensation Payable (NCP), Notice of Temporary Compensation Payable (NTCP), Agreement for Compensation, and the Notice of Compensation Denial (NCD).
To begin the 21-Day count, insurers should compare the “Date Employer was Notified” and the “Date Disability Began” found on the First Report of Injury (FROI) against the subsequent document(s) filed, using the later of the two dates.
ISSUES THAT MAY INTERFERE WITH THE 21-DAY CALCULATION
FROI filing issues that interfere with the 21-Day calculation:
- When there is no FROI on file with the Bureau:
- Determine whether the FROI was filed after a full day, shift, or turn of work missed or prior to lost time, resulting in non-transmittal.
- Determine whether the FROI was appropriately filed following a delayed disability situation.
- Consider possible non-compliance.
- If FROI was appropriately filed:
- Make certain the dates entered in Date Employer Notified and Date Disability Began are correct.
- Look for typographical errors on the dates, which could account for excessive filing delays.
- Consider whether the FROI is being properly transmitted through electronic means.
- End 21-Day count with file date of subsequent document(s).
Subsequent Document Filing issues that may interfere with the 21-Day calculation:
- Date of Notice on the form does not establish the file date. Absent a U.S. Postal Service Postmark, the file date is equal to the date of receipt in the Bureau.
A U. S. Postal Service Postmark (legibly affixed to the outside of the envelope) will give you proper mailing credit that will override the receipt date. Office postage metered dates will not override Bureau receipt date. The postal service does not guarantee consistent mail delivery, and we encourage the regulated community to take advantage of the U.S. Postmark for time-sensitive documents.
If U.S. Post Mark is used for timely filing credit, it must be clear and legible, or credit cannot be applied. This may require you to stand at the postal counter and observe the hand-stamp. When presenting Bureau filings at the postal counter, request that the hand-stamp NOT be placed over the top of the stamps so that it will be legible. When stamped over top of stamps or office meter strips, the postmark often disappears or displays illegibly.
- Medical Only Filings should not be included in the Bureau’s 21-Day calculations. If a subsequent document intended as a Medical Only filing appears on the report, it will remain a late filing if the language on the form does not clearly indicate its use as a Medical Only filing. If the intent of the document is unclear, it will be registered as a lost-time claim.
- If an NTCP, NCP, or Agreement for Compensation appears to be issued late due to intermittent periods of disability, any notations to explain the circumstances, including the date that the waiting period is met, can be considered for timely filing if explained appropriately under Remarks. These remarks should be brought forward for reconsideration of timeliness. Credit will be given if properly noted.
- If the employee failed to report the injury to the employer within 120 days and the Denial is issued for that reason, the employer should note that late notice on the face of the Denial. If that late notice is noted on the face of the subsequent document, the insurer may submit for reconsideration of late filing.
21-DAY COMPLIANCE FORMULA
Bureau Compliance Formula Incorporates 3 Sections of the Act
Section 406.1 (a) and (c), Make Payment or Deny Within 21 days of Notice
Section 406.1 (a): The employer and insurer shall promptly investigate each injury reported or known to the employer and shall proceed promptly to commence the payment of compensation due either pursuant to an agreement upon the compensation payable or a notice of compensation payable as provided in section 407 or pursuant to a notice of temporary compensation payable as set forth in subsection (d), on forms prescribed by the department and furnished by the insurer. The first installment of compensation shall be paid not later than the twenty-first day after the employer has notice or knowledge of the employe’s disability. Interest shall accrue on all due and unpaid compensation at the rate of ten per centum per annum. Any payment of compensation prior or subsequent to an agreement or notice of compensation payable or a notice of temporary compensation payable or greater in amount than provided therein shall, to the extent of the amount of such payment or payments, discharge the liability of the employer with respect to such case.
Section 406.1 (c): If the insurer controverts the right to compensation it shall promptly notify the employe or his dependent, on a form prescribed by the department, stating the grounds upon which the right to compensation is controverted and shall forthwith furnish a copy or copies to the department.
Section 438, Proper Reporting of Injuries
Understand your responsibilities under Section 438. Only file the First Report of Injury if reportable. If an injured worker does not miss a full day, shift, or turn of work, a First Report should not be filed with the Bureau. Remember also to file the First Report in cases of delayed disability at the time the employee misses a full day, shift or turn of work.
The Bureau no longer accepts paper versions of this form. Effective Jan. 1, 2006, the process of electronically filing the First Report of Injury was made mandatory for all insurers and self-insured employers. Most companies have chosen Electronic Data Interchange (EDI) as the electronic means to transmit the First Report data and the remaining choose the Internet application made available by the Bureau.
Neither means of electronic submission will transmit if a full day, shift or turn is not indicated.
When filing a report, a date must be entered in the following fields of the First Report of Injury (FROI): Last Day Worked and Date Disability Began. Failure to enter the dates in these fields will render the injury non-reportable and will not be added to First Report of Injury database.
If you enter a date in Last Day Worked but nothing at Return to Work Date, you will be communicating (possibly inadvertently) that the employee is still out as of filing date of the FROI. It will be counted as lost time, and the electronic application will accept it as such.
To assure accurate documentation of the injury, be certain to report the correct four-digit Bureau Code
for insurance carriers and self-insured employers.
Section 438 (a): An employer shall report all injuries received by employes in the course of or resulting from their employment immediately to the employer’s insurer. If the employer is self-insured such injuries shall be reported to the person responsible for management of the employer’s compensation program.
Section 438 (b): An employer shall report such injuries to the Department of Labor and Industry by filing directly with the department on the form it prescribes a report of injury within forty-eight hours for every injury resulting in death, and mailing within seven days after the date of injury for all other injuries except those resulting in disability continuing less than the day, shift, or turn in which the injury was received. A copy of this report to the department shall be mailed to the employer’s insurer forthwith.
Section 407, Simultaneous Notice
Section 407: On or after the seventh day after any injury shall have occurred, the employer or insurer and employe or his dependents may agree upon the compensation payable to the employe or his dependents under this act; but any agreement made prior to the seventh day after the injury shall have occurred, or permitting a commutation of payments contrary to the provisions of this act, or varying the amount to be paid or the period during which compensation shall be payable as provided in this act, shall be wholly null and void. It shall be unlawful for any employer to accept a receipt showing the payment of compensation when in fact no such payment has been made.
Where payment of compensation is commenced without an agreement, the employer or insurer shall simultaneously give notice of compensation payable to the employe or his dependent, on a form prescribed by the department, identifying such payments as compensation under this act and shall forthwith furnish a copy or copies to the department as required by rules and regulations. It shall be the duty of the department to examine the notice to determine whether it conforms to the provisions of this act and rules and regulations hereunder.
All agreements made in accordance with the provisions of this section shall be on a form prescribed by the department, signed by all parties in interest, and a copy or copies thereof forwarded to the department as required by rules and regulations. It shall be the duty of the department to examine the agreement to determine whether it conforms to the provisions of this act and rules and regulations hereunder.
All notices of compensation payable and agreements for compensation and all supplemental agreements for the modification, suspension, reinstatement, or termination thereof, and all receipts executed by any injured employe of whatever age, or by any dependent to whom compensation is payable under section three hundred and seven, and who has attained the age of sixteen years, shall be valid and binding unless modified or set aside as hereinafter provided.
SUGGESTIONS FOR FILING SUBSEQUENT DOCUMENTS TIMELY
Control your File Date by using a U.S. Postmark
Care should be taken to obtain a clear and legible postmark. Where there is evidence that a postmark was attempted, even if it is not legible, Bureau procedure dictates that the envelope be entered in the official file as it may become useful in litigation.
DO NOT Ignore Bureau notices that warn of scanning difficulties
When a form is returned from the Bureau stamped Form Not Scanned, it is critical that you make contact IMMEDIATELY with the Bureau to have your forms tested and approved for compatibility with the Bureau’s scanning operation. It is the responsibility of the filing party to ensure that forms meet Bureau specifications. Do not compromise filing dates due to technological problems. Promptly contact the Bureau’s Helpline (800-482-2383) for information on how to resolve any identified spacing issues on forms.
NOTE: It is recommended that each filing entity contact the Bureau prior to the mandatory use date of new or revised Bureau forms so that testing can be completed prior to changeover. Do not assume that your company’s system is properly reading the form specifications simply because your software vendor has received Bureau approval on new/revised forms. Often incompatibility is caused by your system’s inability to read and print as encoded.
Notice of Temporary Compensation Payable
The NTCP can be used if the filing party is unsure of job-relatedness, liability, extent of injury, etc. The investigation period may be extended up to 90 days from the first payment. Wages may also be estimated if uncertain and can be corrected by filling additional NTCPs.
Estimated Wages on a Notice of Compensation Payable
Wages can be marked “estimated” on an NCP; however, if the final wages are lower than the estimated amount, an agreement is necessary to make the correction (if wages are higher or the same, agreement is not necessary).
Use Remarks Section on NCP, NTCP and Agreement for Compensation
Make use of Remarks to document timeliness as in cases such as intermittent periods of disability, broken periods of time to fulfill seven-day waiting period, or modified duty situations where no full days were missed.
Notice of Workers’ Compensation Denial
The Notice of Workers’ Compensation Denial was revised in 2007 with a mandated use date of April 16, 2007. The form now provides an area for documenting “Date employer received notice or knew of alleged injury or date of employee’s claimed disability.”
Do not explain or document late notice through the use of a cover letter. Late notice by employer to insurer is not an acceptable reason for missing the filing requirement.
Get Credit for Timely Issuance of Agreements for Compensation
The Bureau will accept Agreements for Compensation bearing only the adjuster’s signature to preserve the 21-day filing credit. However, the Agreement will not establish compensation until it is signed by both the adjuster -and- the injured worker.
Medical Only Filings SHOULD NOT appear on your 21-Day Report
If you choose to file a Bureau document to establish a Medical Only claim, it must clearly be marked as such, or it will be counted as a lost-time claim. Speak with your legal representative about whether to file a Medical Only document, whether another document should be filed, and the phrase(s) to use to clearly express the intention that only medical will be paid for the injury.