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Within 48 hours of the employer's acceptance of a catastrophic injury as compensable, simultaneously with the Form WC-1, naming a catastrophic supplier;
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Within 15 days of notification that rehabilitation is required to request a rehabilitation supplier;
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When the employer/insurer requests a supplier for cases with dates of injury prior to July 1, 1992;
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When the employer/insurer requests a change of supplier;
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To request reopening of rehabilitation; or
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Upon request of the Board.
The employee or employee's attorney shall file a Form WC-R1 to request appointment of a supplier for cases with dates of injury prior to July 1, 1992, for change of supplier or reopening of rehabilitation.
Form WC-R1CATEE. Employee Request for Catastrophic Designation. The employee or employee's attorney shall file:
A case party shall file a Form WC-R1 when a stipulated settlement provides for rehabilitation and rehabilitation is not already on the case. A case party may file a Form WC-R1 to request an extension of vocational rehabilitation services for cases with dates of injury prior to July 1, 1992.
All required information shall be supplied and shall be legible. The certificate of service must be completed and the date mailed must be indicated.
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If the employer/insurer fail to timely designate the claim catastrophic and the employee believes the case to qualify for catastrophic designation;
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With supporting documentation;
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Presentinga choice for a Board Certified catastrophic rehabilitation supplier.
Form WC-R2. Rehabilitation Transmittal Report.
The principal rehabilitation supplier shall file:
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To accompany updated narrative progress reports on catastrophic cases every 90 days;
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To request a rehabilitation conference or prepare for a rehabilitation conference;
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With all progress reports as required by the Board not submitted with a Form WC-R2A and when a stipulation request has been submitted;
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Upon request of the Board;
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To report medical care coordination services for non-catastrophic cases with dates of injury prior to July 1, 1992.
Form WC-R2A. Individualized Rehabilitation Plan. The principal rehabilitation supplier shall file within 60 calendar days from the date of appointment; not later than 30 calendar days prior to the end of the current rehabilitation period to request extension of services, or to amend an approved plan 30 calendar days prior to the date of plan expiration.
Form WC-R3. Request for Rehabilitation Closure. The principal rehabilitation supplier shall file this form, accompanied by a closure report and any necessary documentation:
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Following 60 days of return to work status;
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When further services are not needed or feasible;
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When a stipulated settlement has been approved by the Board that does not include further rehabilitation services; or
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When the Board has closed the case.
Any party may file to request closure of rehabilitation accompanied by documentation supporting the request.
Filing with the Board:
A pro-se party must file correspondence, documents or forms in paper with any Board office.A document may be filed via facsimile transmission.Any filing by facsimile transmission must be clearly labeled with the name of the claimant, claim number, and Board division or employee to whom the facsimile transmission is directed.
No party or attorney shall use the ICMS doc-type "Misc" when requesting any action by the Board. This doc-type shall only be used when no action is being requested.
All forms, documents, or other correspondence should be filed electronically through ICMS web submission or EDI, if available.
Service upon a party or attorney of any form, document, or other correspondence shall be by electronic mail.Whenever electronic mail is not available, service shall be by U.S. Mail.
When electronically filing any form with the Board, and when required by Statute, Rule, or form to serve a copy on an opposing attorney or party, a copy of the form or the ICMS equivalent of the form filed may be used for service.
Any party or attorney filing a form with the Board shall use the most current version of the form.In addition, no party or attorney shall submit any form that has been discontinued or altered.A violation of this rule may result in the rejection of the filing with the Board, and/or the imposition of a civil penalty under O.C.G.A. §34-9-18.
Form WC-Subpoena. Use this form for hearings. Do not file subpoenas with the Board.Subpoenas shall be produced at the hearing or attached to a motion only when enforcement or a postponement is at issue.
Form WC-Bill of Rights.Bill of Rights. Use and post with the panel of physicians (Form WC-P1, Form WC-P2, or WC-Form P3).See O.C.G.A. §34-9-81.1 & Board Rule 81.1.
Form WC-P3. WC/MCO Panel. To be utilized only by employers/insurers contracted with a Board Certified Managed Care Organization. See Board Rule 201
Form WC-P1. Panel of Physicians.See Board Rule 201.
Form Rehab Obj.Any party who has an objection to any issue related to rehabilitation services must timely file this form with supporting documentation attached.Timely filing is within 20 days of the certificate of service of a WC-R1; WC-R1CATEE; WC-R2; WC-R2A; or WC-R3.
Form WC-Catastrophic Rehab Release.
Form WC-Rehabilitation Registration Application Renewal. Application to renew certification for a licensed rehabilitation supplier. File this form annually with the Board to renew certified rehabilitation supplier status in the state of Georgia.
Form WC-Rehabilitation Registration Application.Application to be a licensed rehabilitation supplier. File this form with the Board to be a certified rehabilitation supplier in the state of Georgia.
Form WC-R5.Request for Rehabilitation Conference. Any party or principal rehabilitation supplier may file to request a rehabilitation conference.
If an insurer, self-insurer, group self-insurer or designated claims office (TPA) adds, replaces, or terminates the services of a claims office, the trading partner agreement shall be immediately amended and updated.
If an insurer, self-insurer, group self-insurer, or designated claims office (TPA), files Form WC-1, WC-2, WC2a, WC-3, or WC-4 via EDI, then all subsequent FROIs (First Report of Injury) and SROIs (Subsequent Report of Injury) shall be filed via EDI. Failure to do so may subject the filing party to a penalty.
Upon request, or on its own, the Board, in its discretion, may grant exceptions to this rule.
The premium to be reported to the Board for the purpose of assessment shall be the "direct net earned premium". The minimum assessment based upon the administrative cost necessary to provide licensure support and basic computer management reports shall be $100 annually for each insurer and self-insurer.
The employer shall post the summary of rights, benefits, and obligations which is required by O.C.G.A. §34-9-81.1 and is provided by the Board in the same location as the panel of physicians which is required by O.C.G.A. §34-9-201.
No party to a claim or any party's attorney shall assist, secure, create, or execute any loan or assignment with a third party creditor which requires repayment out of any recovery, settlement, or payment of benefits from any claim filed under this chapter.
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Prior to filing in EDI, insurers, self-insurers, group self-insurers, and designated claims offices (TPAs) shall be certified to file via EDI by the Board.
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Insurers, self-insurers, group self-insurers, or designated claims offices (TPAs) shall file Forms WC-1, WC-2, WC-2a, WC-3 and WC-4 via EDI in form of FROIs (First Report of Injury) and SROIs (Subsequent Report of Injury).
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Any Form WC-1, WC-2, WC-2a, WC-3, or WC-4 that is filed in paper, by an insurer may be rejected by the Board and may subject the filing party to a penalty.
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When suspending benefits via EDI and an attachment to a filing or submission is required such as a medical report, or WC-240, the employer, insurer, shall mail to, or electronically file with the Board the required attachment prior to or simultaneously with the filing of the appropriate EDI transaction.
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Pleadings, forms, documents, or other filings shall be filed with the Board electronically through ICMS or EDI, unless otherwise authorized in these Rules. However, in the event of an outage preventing an electronic submission and the time for filing is at issue, the document may be filed in paper or by facsimile with any Board office. Any filing by facsimile transmission must be clearly labeled with the name of the claimant, claim number, and Board division or employee to whom the facsimile transmission is directed. The certificate of service, showing concurrent service upon the opposing party electronically or by facsimile transmission shall be a part of any electronic or facsimile transmission. Failure to include a certificate of service shall invalidate the filing. All facsimile transmissions must be identical to the originals and must be legible. The Board, within its discretion, may transmit documents by facsimile or electronic transmission.
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Any defense as to the time of filing a claim is waived unless it is made no later than the first hearing.
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A party filing a claim should file Form WC-14 with the Board and serve a copy on all other parties.
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A claim shall be filed electronically through ICMS.However, in the event of an outage preventing an electronic submission and the time for filing a claim is at issue, a claim may be filed in paper or by facsimile with any Board office. Any filing by facsimile transmission must be clearly labeled with the name of the claimant, claim number, and Board division or employee to whom the facsimile transmission is directed.
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An Alternative Dispute Resolution Division is established to resolve disputes without the necessity of a hearing.
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Hearing requests or motions will be screened in order to identify cases likely to be resolved by Board order or the mediation process without a hearing.
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In addition, the ADR Division and each Administrative Law Judge shall have the authority to direct the parties to attend a mediation conference when deemed appropriate by the Board. The Board's authority to direct the parties to attend a mediation conference shall extend to include mediation of disputes which arise in cases designated as "Medical Only." Participation in a mediation conference shall not abridge the rights of the parties to a subsequent evidentiary hearing or ruling on the contested issues should the issues not be successfully resolved through mediation. An expedited hearing may be scheduled by agreement of the parties subsequent to the conference being held. An agreement reached at mediation will be reduced to writing and shall have the full effect of an award or order issued by the Board. A settlement agreement reached through the mediation process must be submitted and reviewed pursuant to O.C.G.A. § 34-9-15 and Board Rule 15.
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Parties requesting a Board mediation for the purpose of an all issues settlement must file a Form WC-100 certifying that all parties are in agreement with the request for a settlement mediation and that the employer/insurer has, or will have by the date of the first scheduled mediation conference, authority to resolve the claim based upon a good faith evaluation. The Form WC-100 must be served on all parties and parties at interest simultaneous with the board filing.
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Notices of Mediation will be sent by electronic mail and shall only be sent to attorneys of record.Whenever electronic transmission is not available, a Notice of Mediation will be sent by mail.
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Communications.
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(1)All communications or statements, oral or written, that take place within the context of a mediation conference are confidential and not subject to disclosure. Such communications or statements shall not be disclosed by any mediator, party, attorney, attendee, or Board employee and may not be used as evidence in any proceeding. An executed Board mediation sheet or written executed agreement resulting from a mediation is not subject to the confidentiality described above.
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threats of violence to the mediator or others;
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security personnel or law enforcement officials;
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party or attorney misconduct;
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legal or disciplinary complaints brought against a mediator or attorney arising out of and in the course of a mediation;
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appearance;
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the list of physicians submitted to an Administrative Law Judge by the parties or attorneys when the parties have been ordered to submit the names of physicians in a change of physician dispute and the dispute is not resolved through mediation.
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Attendance.
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(1)Any party or attorney directed or ordered by the Board to participate in or attend a mediation conference and who fails to attend the scheduled conference without reasonable grounds may be subject to civil penalties, attorney's fees, and/or costs. If the parties or attorneys agree to the postponement and/or rescheduling of a mediation conference, such request may be granted at the discretion of an Administrative Law Judge from the ADR Division or his/her designee upon good cause shown.Any party or attorney requesting cancellation, postponement or rescheduling of a mediation conference shall provide notice to all parties or their attorneys and shall promptly, but in no event later than 4:30 p.m. on the business day immediately before the scheduled mediation conference, notify the ADR Division of the request: (1) first, by telephone call; and (2) if so instructed by the ADR Division, by subsequent written or electronic confirmation.
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No person, party, or attorney shall, during the course of any mediation, engage in any discourteous, unprofessional, or disruptive conduct.
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Practice of Law.
Attorneys Entitled to Practice before the Board: The Rules and Regulations for the Organization and Government of the State Bar of Georgia, as now in effect or as hereinafter amended, are controlling as to the practice of law before the Board and its Administrative Law Judges. The Board and its administrative law judges shall comply with the Code of Judicial Conduct.
Unauthorized recording of conference calls and other court proceedings. No party shall make any audio, video, photographic, electronic recording or court transcription of a Board proceeding, including any conference call with an Administrative Law Judge, unless expressly permitted by the Board.Any such request must be submitted to the Board at least 24 hours prior to the proceeding or conference call with notice to all parties.This Rule does not apply to an official function of a law enforcement agency, the State Bar of Georgia, or the Judicial Qualifications Commission.
Service upon a party or attorney of any form, document, or other correspondence shall be by electronic mail. Whenever electronic mail is not available, service shall be by U.S. Mail.
On all filings with the Board, attorneys shall place their Georgia bar number. In addition, no attorney shall submit any form that has been discontinued or altered. A violation of this rule may result in the rejection of the filing with the Board, and/or the imposition of a civil penalty under O.C.G.A. §34-9-18.
Attorneys, not licensed in the State of Georgia, shall comply with Uniform Rule of Superior Court 4.4 addressing Admission Pro Hac Vice.
Any ex parte communication, including electronic mail, with an Administrative Law Judge or the Board in a pending claim is prohibited.
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Reporting Requirements:
The address of record of an employee shall be that address shown on the most recent document filed with the Board.
An attorney who represents an employee or claimant in a contested matter shall file a fee contract as notice of representation and must serve a copy on all counsel and unrepresented parties.The contract must be dated, conform to Rule 108, and both the attorney and the client must sign the contract.
An attorney who represents a party other than an employee or a claimant in a contested matter must file a notice of representation on a Form WC-102B with the Board, and must serve a copy on all counsel and unrepresented parties.
Any party requesting a hearing shall furnish the correct name and current address of the employee, the employer, and the insurer/self-insurer at the time the hearing is requested.
The address of record of an employer shall be the address shown on the Form WC-1, the address on file with a Licensed Rating Organization filed by the insurer on behalf of the employer, or the principal office of the employer within the State of Georgia.
A party shall provide notice to the Board of the intent to obtain legal representation and the name of its legal representative, if any, within 21 days from the date of the hearing notice, subject to an assessment of penalties for failure to comply.
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Postponements, Leaves of Absence, and Legal Conflicts:
(a) Postponement:If a hearing is on a calendar for the first time, and if all parties agree to postpone it to be rescheduled, they may obtain the postponement without consulting the Administrative Law Judge before whom it is scheduled, absent prior specific instructions from the judge to the contrary.This agreement must be communicated to the judge no later than 2:00 p.m. of the business day immediately preceding the hearing by the party who requested the hearing, or by any other party by agreement.Otherwise and generally, a hearing shall be postponed only upon strict legal grounds, or at the discretion of the Board or an Administrative Law Judge. For a case that has already been postponed, a second or subsequent request by counsel to postpone the case from a calendar must be made no later than 2:00 p.m. on the business day immediately before the scheduled hearing, and the request must be approved by the Administrative Law Judge.For a case to be removed from the calendar with no reset, this notification, as with a postponement request, must be made no later than 2:00 p.m. on the business day immediately before the scheduled hearing.If the judge determines that the case is not ready for trial at this time, the claim may be removed from the calendar, not to be reset until the parties certify that discovery is complete and the case is ready to be tried. Consistent with O.G.C.A.§34-9-102(a) and (c), a postponed hearing shall not be scheduled less than 30 days nor more than 90 days from the date of the hearing notice, unless agreed upon by the parties, in which case it may be scheduled for a shorter or longer period.
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Whenever the pending hearing issues resolve or a case settles prior to a scheduled hearing date, the parties or attorneys shall immediately notify the Board or assigned Administrative Law Judge: (1) first, by telephone call; and (2) if so instructed by the Trial Division, by subsequent written or electronic confirmation.
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Any party or attorney who fails to follow the cancellation, postponement, or rescheduling procedures as outlined above in sections (C)(1)(a) & (b), and who is unable to show good cause for such failure, may be subject to civil penalties, assessed attorney's fees, and/or costs, including but not limited to the cost of the court reporter. If the parties fail to communicate with the Administrative Law Judge whether a scheduled hearing is going forward by 2:00 p.m. on the business day immediately preceding the hearing, the Administrative Law Judge may leave the case on the calendar for a hearing or postpone and reset the case to a future calendar.
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Motions and Interlocutory Orders Pending a Hearing:
(a) All motions and objections shall be made on Form WC-102D, with the exceptions of motion for reconsideration and request for a change of physician/additional medical treatment under Board Rule 200(b)(1). Motions and objections, including briefs and exhibits, shall be limited to 50 pages, unless otherwise approved by an Administrative Law Judge or the Board.When attaching documents as evidence to motions and objections, do not use tabs to separate documents. Any party or attorney filing a motion or objection shall also serve a copy on all counsel and unrepresented parties, along with supporting documents, including a separate certificate of service identifying the names and addresses served.
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When filing a motion for reconsideration, the parties or attorneys shall: (1) immediately notify the Board or assigned Administrative Law Judge by telephone call; (2) use the ICMS doc-type labeled motion for reconsideration; (3) limit their motion to 20 pages, including briefs and exhibits, unless otherwise permitted by the Board or an Administrative Law Judge; and (4) serve a copy on all counsel and unrepresented parties, along with supporting documents, including a separate certificate of service identifying the names and addresses served.
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Conduct of Hearings:
No person shall, during the course of a proceeding before an Administrative Law Judge or Director, engage in any discourteous or disruptive conduct.
(a) Prior to the commencement of a hearing, the parties shall consolidate any and all records, including but not limited to medical records, and any other documentary evidence to be admitted at a hearing in order to avoid any repetition and duplication.
Any violation of the Georgia Rules of Professional Conduct of the State Bar of Georgia may subject an attorney to the assessment of a civil penalty pursuant to O.C.G.A. §34-9-18 and referral to the State Bar of Georgia for disciplinary action.
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All medical evidence regarding the treatment, testing or evaluation of the claimant for the accident which is the subject of the hearing should be exchanged between the parties as soon as practicable, but no later than ten days prior to the hearing, and all depositions should be completed prior to the hearing. Failure to exchange such evidence within ten days of a hearing may, in the discretion of the Administrative Law Judge or the Board, result in:(1) the imposition of civil penalties, (2) award of assessed attorney fees, (3) a continuance, (4) award of costs, (5) award of witnesses fees and expenses, and/or (6) in limited circumstances, the exclusion of evidence at the hearing.
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If the amount of the average weekly wage is in dispute, counsel shall exchange written contentions with respect to their methods of calculation at least ten days prior to the hearing, and shall present the written contentions to the Administrative Law Judge at the commencement of the hearing.
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If accompanied by an affidavit, a written laboratory test result report is admissible into evidence for purposes of authenticity only.Any other evidentiary objections can be raised by the parties in motions or at evidentiary hearings.
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Any challenge to the testimony of an expert under O.C.G.A. § 24-9-67.1 (24-7-702 effective 1/1/13) shall be made not later than 15 days prior to the hearing.Failure to raise a timely challenge shall result in waiver of the challenge unless otherwise agreed to by the attorneys and the Administrative Law Judge.
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Discovery and Submission of Evidence:
Prior or subsequent to a request for hearing being filed in a claim, the parties shall be entitled to receive from each other without cost the documents specified in Form WC-102. These documents shall be provided within 30 days of the date of the certificate of service.Neither the request nor response shall be filed with the Board. Any party or attorney who fails to follow this procedure, and who is unable to show good cause for such failure, may be subject to civil penalties and/or assessed attorney's fees.
All documents, transcripts, exhibits, and other papers filed with the State Board of Workers' Compensation shall be submitted on 8-1/2 by 11 inch paper only.Sufficient space shall be left at the top of all documents (at least one and one-half inches) so that all information will remain readable after the documents have been filed.Copies of items offered in evidence at a hearing must be properly identified and tendered to opposing parties at the hearing. When submitting any documents as evidence, do not use tabs to separate documents.
Discovery documents, including but not limited to depositions, interrogatories, and notices to produce, shall not be filed with the Board until such time as they are tendered in evidence in a proceeding before the Board.Correspondence between the parties shall not be filed with the Board.
Discovery conducted pursuant to the Civil Practice Act shall only be permitted after a hearing has been requested in the claim, or as otherwise specified in these rules, or by agreement of the attorneys or permitted by an Administrative Law Judge or the Board.
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Written Responses: The filing of all written responses will be governed in accordance with O.C.G.A. § 9-11-6(e).
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Attorneys in good standing admitted to practice in the State of Georgia, shall file, sign, and verify documents only by electronic means via ICMS.Only an electronic submission of documents via ICMS shall constitute filing, except as provided for in sections (i) and (j) or as otherwise provided in the Board Rules.
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Pro se litigants who are not attorneys in good standing with the State Bar of Georgia must file all documents with the Board in paper form with any Board office.
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The electronic filing of any document, form, or other correspondence by an attorney who is a registered participant in ICMS shall constitute the signature of that attorney under Board Rule 60(g) and O.C.G.A. § 10-12-2 et seq.The attorney whose login and password are used to accomplish an electronic filing certifies that the attorney and the attorney's law firm have authorized the filing.
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No attorney shall knowingly permit or cause to permit his/her login or password to be used by anyone other than an authorized employee of his/her law firm.
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No person shall knowingly use or cause another person to use the login or password of a registered attorney unless such person is an authorized employee of the law firm.
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Only the original of any form, document, or other correspondence shall be electronically filed with the Board.Duplicate originals shall not be filed with the Board.Where providing a courtesy copy in response to a request from an Administrative Law Judge or the Board, that document shall be identified clearly and prominently as a courtesy copy.
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When electronically filing any form with the Board, and when required by Statute, Rule, or form to serve a copy on an opposing attorney or party, a copy of the form or the ICMS equivalent of the form filed may be used for service.
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Service upon a party or attorney of any form, document, or other correspondence shall be by electronic mail.Whenever electronic mail is not available, service shall be by U.S. Mail.
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ICMS will be available during the Board's business hours of 8:00 a.m. through 4:30 p.m., Monday through Friday, except state holidays.Known systems outages will be posted on the web site, and communicated by email, if possible.In the event of an outage preventing an electronic submission and the time for filing a document is at issue, the document may be filed in paper or by facsimile with any Board office. Any filing by facsimile transmission must be clearly labeled with the name of the claimant, claim number, and Board division or employee to whom the facsimile transmission is directed.
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Proposed consent orders, petitions for guardianships via Form WC-226a and Form WC-226b, claim initiating Form WC-14s where there is no social security number, Form WC-14s adding additional parties, and Form WC-12s, are exempt from section (a) and may be filed in paper only with the Board in Atlanta, Georgia.
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Any filing, document, correspondence, or form filed with the Board that is not in compliance with this rule shall be rejected.
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Upon request, or on its own, the Board, in its discretion, may grant exceptions to this rule.
Unless otherwise provided by rule of the State Board of Workers' Compensation or otherwise ordered by the assigned Judge after appropriate hearing (conducted after notice to all parties and counsel of record) and findings, representatives of the print and electronic public media may be present at and unobtrusively make written notes and sketches pertaining to any proceedings at the Board. In any event, said representatives are to provide the assigned Judge advanced notice of their intent to attend and to make such notes and sketches so the Judge may insure that they do not otherwise interfere with the proceedings. However, due to the inherent distractive nature of electronic or photographic equipment, representatives of the public media utilizing such equipment or seeking permission to do so are subject to the discretion of the Presiding Judge as well as the following restrictions and conditions;
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Persons desiring to broadcast/record/photograph proceedings must file a timely written request (form attached as Exhibit "A"), before the subject proceeding, with the judge involved and all parties of record to the hearing or trial, specifying the particular proceeding for which such coverage is intended; the type equipment to be used in the hearing room; the proceeding to be covered; and the person responsible for installation and operation of such equipment.
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Approval of the judge to broadcast/record/photograph a proceeding, if granted, shall be granted without partiality or preference to any person, new agency, or type of electronic or photographic coverage, who agrees to abide by and conform to these rules, up to the capacity of the space designated for the hearing room. Violation of these rules will be grounds for reporter/technician to be removed or excluded from the hearing room (and contempt proceeding initiated).
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The judge may exercise discretion and require pooled coverage which would allow only one still photographer, one television camera and attendant, and one radio or tape recorder outlet and attendant. Photographers, electronic reporters and technicians shall be expected to arrange among themselves pooled coverage if so directed by the judge and to present the judge with a schedule and description of the pooled coverage. If the covering persons cannot agree on such a schedule or arrangement, the schedule and arrangements for polled coverage may be designated at the judge's discretion.
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The positioning and removal of cameras and electronic devices shall be done quietly and if possible, before or after the hearing or during recesses; in no event shall such disturb the proceedings. In every such case, equipment should be in place and ready to operate before the time the hearing is scheduled to begin.
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Overhead lights in the hearing room shall be switched on and off only by board personnel no other lights, flashbulbs, flashes or sudden light changes may be used unless the judge approves beforehand.
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No adjustment of central audio system shall be made except by persons authorized by the Board. Audio recordings of the proceeding will be from one source, normally by connection to the central audio system. Upon prior approval of the Board, other microphones may be added in an unobtrusive manner to the public address system.
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All television cameras, still cameras and tape recorders shall be assigned to specific portion of the public-area of the hearing room or specially designed access areas, and such equipment will not be permitted to be removed or relocated during the court proceedings.
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Still cameras must have quiet functioning shutters and advancers. Movie and television cameras and broadcasting and recording devices must be quiet running. If any equipment is determined by the judge to be of such noise as to be distractive to the proceedings, then such equipment can be excluded from the hearing room by the judge.
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Reporters, photographers, and technicians must have and produce upon request of Board officials credentials identifying them and the media company for which they work.
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Proceedings shall not be interrupted by a reporter or technician with a technical or an equipment problem.
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Reporters, photographers, and technicians should do everything possible to avoid attracting attention to themselves. Reporters, photographers, and technicians will be accorded full right of access to proceedings for obtaining public information within the requirements of due process of law, so long as it is done without detracting from the dignity and decorum of the hearing.
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Other than as permitted by these rules and guidelines, there will be no photographing, radio or television broadcasting, including video taping pertaining to any proceedings on the floor where the hearing or proceeding is being held or any other floor whereon is located a hearing, whether or not the hearing is actually in session.
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No interviews pertaining to a particular proceeding will be conducted in the hearing room except with the permission of the judge.
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Upon receipt of request pursuant to exhibit "A" which is attached hereto, the board shall give notice to all parties involved in the case and field judges shall contact the administrator of the facility at which the proceeding is going to be held, if the proceeding is not scheduled to be held at a board facility, to determine that facilities rules or requirements with respect to the request and the granting of the request shall be, in addition to the judge's discretion, subject to that facility's administrator giving approval ofthe request.
The attorney's fee shall not exceed 400 weeks of income benefits and may be terminated or suspended sooner as provided by law or at the Board's discretion. The Board may, in its discretion, approve an attorney's fee for a period of greater than 400 weeks so long as the attorney fee is not in excess of 25% of the claimant's weekly benefits.
This contract is subject to the approval of the State Board of Workers' Compensation, and no fee of more than $100.00 shall be paid under the contract unless approved by the Board.
No contract shall be filed with the Board which provides for a fee greater than 25 percent of the recovery of weekly benefits. Any contract with these terms, absent compelling evidence to the contrary, shall be deemed to represent the reasonable fee of the attorney.
No party or any party's attorney shall enter into a loan or assignment with a third party creditor which requires repayment from the proceeds of a workers' compensation claim.
With respect to an accident occurring before July 1, 1992, the contract shall include the following statement:
This contract is subject to the approval of the State Board of Workers' Compensation, and no fee of more than $100.00 shall be paid under the contract unless approved by the Board.
No contract concerning an accident occurring before July 1, 1992, shall be filed with the Board which provides for a fee greater than 25 percent of the recovery of weekly benefits without a hearing, 30 percent of the recovery of weekly benefits with extensive discovery preparatory for a hearing, and 33-1/3 percent of the recovery of weekly benefits after a hearing. Any contract with these terms, absent compelling evidence to the contrary, shall be deemed to represent the reasonable fee of the attorney.
No party or any party's attorney shall enter into a loan or assignment with a third party creditor which requires repayment from the proceeds of a workers' compensation claim.
An attorney who requests approval of his or her fee contract when there is no pending litigation shall file with the Board Form WC-108a. When an attorney requests approval of his or her fee contract after a hearing notice has been issued and after the dispute has been resolved, that attorney shall file Form WC-108a with the Administrative Law Judge who issued the hearing notice.
1. The client consents to associating the other attorney after full disclosure that the fee will be divided; and,
2. The fee division is made in direct proportion to the services and responsibility performed and assumed by each attorney; and,
3. The total fee of the attorneys shall not exceed a reasonable fee for the claim.
No party shall be required to pay for the services of an attorney who violates the provisions of O.C.G.A. §34-9-108(c).
Upon receipt of information establishing an employer's inability to meet its obligations under the Act, or upon notice from an employer that it is unable to meet its obligations under the Act, the Board shall make demand of the surety for payment of the bond or other security held. The Board shall give written notice of the demand for payment to the employer, and all claimants affected by this proceeding.
After the Board receives the proceeds of the bond or other security, then the Board shall determine whether the amount of the security is sufficient to pay all of the employer's obligations arising under this Chapter. If it is not sufficient, the Board shall apportion the proceeds of the bond, or other security held for distribution.
The Board may enter into an agreement with a servicing agent or the Georgia Self-Insurers Guaranty Trust Fund to administer the settlement of claims pursuant to this section.
The expiration date documented by a Licensed Rating Organization shall be considered the date of termination on all non-renewals.
A mid-term cancellation by a licensed insurer documented with a Licensed Rating Organization is evidence that coverage is terminated, effective not less than 15 days after filing except where the provisions of Title 33 provide for an earlier effective date.
In order for a certificate to be granted by the Board under O.C.G.A. §34-9-127, the employer desiring to become a self-insurer must designate an office in the State of Georgia for the handling of claims or, if claims are handled out of state, shall designate an agent located in the State of Georgia who shall be authorized to execute instruments for the payment of compensation in an emergency (or, if necessary). Every service organization or office handling claims for self-insurance under the law shall be staffed during normal working hours and be available for immediate telephone contact with the Board and the public through a toll free telephone number. During normal working hours at this office, at least one staff member shall be authorized to execute (negotiable instruments) checks for the payment of compensation. Certificates to self-insure shall be continuous unless the self-insurer fails to meet the requirements of the Board.
The most recent address for servicing agents/claims offices submitted by an insurer, self-insured employer, or group self-insurer, on a Form WC-121, Form WC-131, Form WC-131a, self-insurer's member information annual update shall be used as the address of record for service of forms, notices, orders, and awards.
If an agreement cannot be reached, the party requesting the change shall make the request on a Form WC-200b.When filing the WC-200b, the moving party shall sign the Form WC-200b, attach supporting documentation including a separate certificate of service identifying the names and addresses serviced attached to the end of the request, and serve a copy on all counsel and unrepresented parties.In cases that have been designated as "Medical Only", the requesting party shall file a Form WC-14 Notice of Claim or a Form WC-1 along with the Form WC-200b in order for the Board to process the request. The party making the request must specify the reason for the requested change, as well as the date that the change shall be effective. If the argument in support of the request is based on testimony, then an affidavit must be attached to the form, and if the argument refers to documents, then a copy of the documents must be attached. Do not use tabs to separate documents used as evidence.If the Board grants a change, the effective date will be the date that the Form WC-200b was filed, unless otherwise specified.
Any party who objects to the request for a change of physician or treatment shall also file their objection on a Form WC-200b with the Board within 15 days of the date of the certificate of service on the request, including a separate certificate of service identifying the names and addresses served attached to the end of the objection, and serving a copy on all unrepresented parties and counsel.Affidavits and documents must be attached as specified above.
All requests and objections to change of physicians shall be filed on a Form WC-200b and shall be limited to 50 pages, including briefs and exhibits, unless otherwise permitted by an Administrative Law Judge or the Board.
Whenever the pending issues in a request resolve, in part or in whole, the parties or attorneys shall immediately notify the assigned Administrative Law Judge: (1) first, by telephone call; and (2) if so instructed, by subsequent written or electronic confirmation.Any party or attorney who fails to follow this procedure, and who is unable to show good cause for such failure, may be subject to civil penalties and/or assessed attorney's fees.
If a hearing has been requested, the party requesting a change of physician or treatment may include the request in the original request for hearing, or amend the hearing request within 15 days prior to the date of the hearing to include the issue of change of physician or treatment. Upon consideration of the evidence, the Administrative Law Judge will render a decision on all the issues presented.
If the parties agree on a change of physician or treatment, a properly executed Form WC-200a may be filed with the Board, with copies provided to the named medical provider(s) and parties to the claim, which form shall be deemed approved and made the order of the Board pursuant to O.C.G.A. §34-9-200(b), unless otherwise ordered by the Board.
The employer/insurer shall not file with the Board a medical report for any injury which occurred after January 1, 1989, except as follows:
Any additional medical reports required shall be filed within 10 days of the employer/insurer's receipt of same. The employer/insurer shall maintain copies of all medical reports in their files and shall not file medical reports except in compliance with this Rule.
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The time for application for review commences on the date shown on the notice of award and is computed as in paragraph (3) of subsection (d) of O.C.G.A. § 1-3-1.
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Appearance before the Appellate Division shall be by brief only unless a request for oral argument is made at the time the application for review is filed by appeal or cross appeal. Within 10 days from the date of the certificate of service on the application for review, the appellee or cross appellee may request oral argument. Oral argument shall be limited to five minutes for each party.
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The Board will apply the law of Georgia regarding the tenure and character of newly discovered evidence required for the granting of a new trial.
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The Board will not accept an application for review of an interlocutory order unless the Administrative Law Judge, in the exercise of his or her discretion, certifies that the order or decision is of such importance to the case that immediate review should be had. In the event the Administrative Law Judge certifies his or her interlocutory order for immediate review, in order for the Appellate Division to have jurisdiction under O.C.G.A. § 34-9-103(a), a party must file an application for review with the Appellate Division within twenty days of the date of the original interlocutory order.
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No person appearing before the Appellate Division shall engage in any undignified or discourteous conduct.
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Upon determining that an appeal has been prosecuted without reasonable grounds, the Appellate Division shall have the authority to assess penalties and attorneys' fees against the offending party.
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To unilaterally convert the employee's income benefits from temporary total disability income benefits to temporary partial disability income benefits under O.C.G.A. § 34-9-104(a)(2), the employer/insurer shall file a Form WC-104 with the Board and shall serve the employee and the employee's attorney the Form WC-104 no later than 60 days from the date the employee was released to work with restrictions by the employee's authorized treating physician.In addition, the employer/insurer shall attach to the Form WC-104 the supporting medical report from employee's authorized treating physician demonstrating the employee is capable of performing work with restrictions.
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After filing the Form WC-104 with the Board and serving the employee and the employee's attorney sufficient and timely notice under section (a), if the employee has been released to work with restrictions for 52 consecutive weeks or 78 aggregate weeks, the employer/insurer may unilaterally convert the employee's income benefits from temporary total disability income benefits to temporary partial disability income benefits by filing a Form WC-2 with the Board. Copies of all filings and supporting documents shall be served on the employee and the employee's attorney, if represented.
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Pursuant to Board Rule 60(c), all documents filed with the Board shall contain the employee's name, date of injury, and Board claim number.Any document that does not contain this information shall be rejected by the Board.
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The date that benefits may be converted from temporary total disability benefits to temporary partial disability benefits shall be determined by the date the employee was released to work with restrictions.
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The prevailing party shall supply the Board with copies of the following documents:
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The non-prevailing party shall supply the Board with the following documents:
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The party dismissing an appeal shall file a copy of the dismissal with the Board.
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In the event of a settlement during the pendency of an appeal, it shall be the joint obligation of the parties to supply the Board with copies of all documents necessary to restore jurisdiction to the Board to consider the settlement.
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Copies of the documents listed above shall be submitted to the Board by regular mail within five days of filing in the appropriate court.
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Any party filing with the Board an appeal to Superior Court shall pay the reasonable copying and transmittal costs of the Board.Upon good cause shown, the Board may waive the copying and transmittal costs.
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An appeal shall be filed electronically through ICMS.However, in the event of an outage preventing an electronic submission and the time for filing an appeal is at issue, an appeal may be filed in paper or by facsimile with any Board office. Any filing by facsimile transmission must be clearly labeled with the name of the claimant, claim number, and Board division or employee to whom the facsimile transmission is directed.
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Attorney fee contracts. Immediately upon being employed by an employee or claimant in a matter which is before the Board, the attorney shall file a contract of employment and fees with the Board. This contract shall include the following attorney typed information:(1) name, (2) bar number, (3) firm name, (4) address, (5) phone number, (6) fax number, (7) email address, and (8) Board claim number.If the Board claim number is not known, this contract shall include the employee's first name, last name, social security number, and date of injury.Finally, all contracts shall include the employee's name and address.This contract shall be dated, and shall be signed by both the attorney and the client, and shall include the following statement with respect to an accident occurring on or after July 1, 1992:
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(1) The value of the services of the attorney may be agreed upon by the parties subject to approval of the Board.
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Solicitation of Services. See O.C.G.A. §§ 34-9-22, 34-9-30, 34-9-31 and 34-9-32.
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An attorney who has made an appearance by filing Form WC-14 or Form 102B or by filing a fee contract and who wishes to withdraw as counsel for any party therein, shall file a Form WC-108b with the Board and serve a copy on all counsel an unrepresented parties, including the former client. At the time of withdrawal, the attorney shall provide all current contact information for the former client to the Board and all parties.
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An attorney of record who chooses to file a lien for services and/or expenses must do so by filing written notice of the contended value of such services and/or expenses with the Board on Form WC-108b within 20 days after (i) withdrawal from the case, or (ii) notice of termination of the contract in writing by the client. The attorney of record filing a lien shall serve a copy of Form WC-108b on all unrepresented parties and counsel. Failure to attach supporting documentation will result in the lien being denied.If theBoard includes the issue of approval of the lien for determination at a hearing or mediation, and the attorney who filed the lien fails to appear and present evidence in support of the lien, then it shall be void. If all parties agree to resolution of a lien request prior to the initiation of litigation, then one of them must file with the Board Form WC-108b. Failure to perfect a lien in this manner will be considered a waiver of further attorneys' fees.
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No attorney shall charge to any client as an expense of litigation any portion of any referral fee or membership charged by any lawyer referral service, or nonspecific office costs.
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A compensation policy must cover all of the operations of an employer, except as hereinafter provided. An employer has the right to place insurance with more than one insurer; but if this is done with respect to distinct operations, the policies must be concurrent and the written portions must read alike. If there is any difference in coverage, it can be expressed as applying to a fractional part thereof. If an employer has more than one place of business, each operation can be covered separately unless the business is interchangeable. Each insurer on the risk must cover alike all the employees coming under the law.
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Any employer desiring to become a self-insurer shall apply on the form prescribed by the Self-Insurers Guaranty Trust Fund Board of Trustees and approved by the Board. Such employer shall provide the Board with sufficient information for the Board to make an adequate assessment of the employer's workers 'compensation exposure and liabilities and shall further provide evidence satisfactory to the Boardof such employer's financial ability to pay the compensation directly in the amount and manner when due, as provided in this chapter.All inquiries must be answered fully and will be treated as strictly confidential. The Self-Insurers Board of Trustees, with the approval of the Board, shall set the amount of security in the form of a surety bond or letter of credit to be required, but in no event shall the amount be less than $250,000.00. It shall be at the discretion of the Self-Insurers Guaranty Trust Fund Board of Trustees if other forms of security are acceptable. Each case will be considered on its own merits with strict regard to the hazards of the business involved. So long as an employer shall continue solvent and promptly pay any and all compensation legally due in accordance with the provision of the law there shall be no effort to collect under the securities.
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Excess insurance for self-insured governmental entities. Counties, municipalities, and other political subdivisions must qualify as self-insurers or obtain insurance coverage. Permission for self-insurance by counties, municipalities and political subdivisions may be granted by application therefor and without deposit of surety bonds security. Assurance must be given the Board, however, that provision will be made for the payment of all workers' compensation benefits conferred by this chapter. Each active participant shall be required to purchase excess insurance in an amount and with specific retention levels acceptable to the Board.
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When an insurer, self-insurer, or group self-insurance fund obtains the services of a servicing agent or third party administrator for the purpose of administering workers' compensation matters, the insurer, self-insurer, or group self-insurance fund shall give notice to the Board on a Form WC-121 (or annual update) of the name and address of each servicing agent or third party administrator handling Georgia claims, the name, address and telephone number of a contact person with that third party administrator or servicing agent, the effective date of the servicing agent's or third party administrator's commencement of services, and if applicable, the ending date of those services, and shall file Form WC-121 with the Board no later than the agreed commencement date of those services. The insurer, self-insurer, or group self-insurance fund shall also give notice by regular mail or electronic mail of the servicing agent's or third party administrator's name, address and telephone number to the claimants in all existing claims for which it is commencing administration within 14 days of commencing services. When the relationship between the insurer, self-insurer or group self-insurance fund and the servicing agent or third party administrator is terminated, the insurer, self-insurer, or group self-insurance fund shall file Form WC-121 with the State Board of Workers' Compensation no later than 30 days prior to the date of cessation of services, and shall give notice, by regular mail or electronic mail to all claimants in existing claims which it has been administering.
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Within 10 days from the date an employer determines its inability to make payment for workers' compensation benefits, the employer shall notify its surety and the Board in writing of its inability to fulfill its obligations under the Act.
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Rules for third party administrators/servicing agents.
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Open indemnity files must be current as of the date of transfer and the transferring (former) third party administrator/servicing agent must include in the file a complete current Form WC-4 (completed within the last 30 days) reflecting all payments made as of the date of transfer. The transferring third party administrator/servicing agent must at the date of transfer provide the receiving third party administrator with a payment history on all Medical Only claims with an occurrence date of 90 days or less as of the date of transfer. Penalties for noncompliance by the transferring third party administrator/servicing agent would be in accordance with O.C.G.A. § 34-9-18(a).
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The receiving (new) third party administrator/servicing agent must notify all active (open) claimants of the change in administration within 14 days of receiving the files. Vendors must be notified within 60 days of receipt of medical bills or service invoices.
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Every employer insured by a licensed insurer shall have proof of coverage documented by its insurer directly with a Licensed Rating Organization through their policy information system. Every employee leasing company shall have proof of coverage documented with a Licensed Rating Organization of the initiation or termination of any contractual relationship with a client company; for the purposes of this Rule, the term employee leasing company shall refer to both; (1) any employee leasing company defined in O.C.G.A. § 34-8-32, and (2) any professional employer organization as defined in O.C.G.A. § 34-7-6. Reports will be made to the Licensed Rating Organization pursuant to procedures outlined by the Licensed Rating Organization and approved by the Georgia State Board of Workers' Compensation.
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Non-renewals
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Mid-term cancellation by a licensed insurer
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Group self-insurance funds operating pursuant to the Georgia Workers' Compensation Act shall file with the Board a separate report for each insured member employer on Standard Coverage Form WC-11 on or before the effective date of coverage.
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Self-insurers must give written notice to the Board when they add or delete subsidiaries, affiliates, divisions or locations to their self-insurance certificate, or make any changes in their excess insurance policies. (See Rule 382(d).)
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(1)The employer/insurer have a duty to provide all reasonable and necessary medical treatment in a timely manner and to give appropriate assistance in contacting medical providers when necessary.The employee has a continuing obligation to cooperate with medical providers in the course of their treatment for work related injuries.
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(1)Changes in treatment. Except as provided in subsection (b) of O.C.G.A. § 34-9-201, changes of physician or treatment are made only by agreement of the parties or by order of the Board. If there has been no hearing requested, a party requesting a change shall make a good faith effort to reach agreement on the change before requesting an order from the Board.
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Proximity of physician's office to employee's residence;
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Accessibility of physician to employee;
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Excessive/redundant performance of medical procedures;
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Necessity for specialized medical care;
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Language barrier;
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Referral by authorized physician;
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Noncompliance of physician with Board Rules and procedures;
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Panel of physicians;
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Duration of treatment without appreciable improvement;
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Number of prior treating physicians;
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Prior requests for change of physician/treatment;
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Employee released to normal duty work by current authorized treating physician;
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Current physician indicates nothing more to offer.
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(1)As long as an employee is receiving compensation, he or she shall submit himself or herself to examination by the authorized treating physician scheduled by the employer/insurer at reasonable times and with reasonable notice. If the employee refuses to submit himself or herself to or in any way obstructs such an examination requested by and provided for by the employer, upon order of the board his or her right to compensation shall be suspended until such refusal or objection ceases and no compensation shall at any time be payable for the period of suspension unless in the opinion of the board the circumstances justify the refusal or obstruction.
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The employer/insurer may suspend weekly benefits for refusal of the employee to submit to treatment only by order of the Board.
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Medical Reports
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(1)Requests for Medical Information. The employee shall, upon the request of the employer/insurer, furnish copies of all medical records and reports which are in his/her possession concerning the treatment for the accident which is the subject of the claim. The employee shall furnish the copies within 30 days of the date of the request. The employer/insurer shall pay the reasonable cost of the copies as provided by the Board-approved fee schedule.
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Physicians as defined in O.C.G.A. § 34-9-201(a) may be called upon and may be issued a subpoena requiringtheir testimony as expert witnesses based upon their examinations and treatment of employees alleging work-related injuries.In lieu of live testimony at hearings in cases pending before the State Board of Workers' Compensation regarding matters subject to the Act, as permitted under O.C.G.A. § 24-10-24 (24-13-24 effective 1/1/13), depositions may be taken pursuant to O.C.G.A. § 34-9-26 et seq and O.C.G.A. § 34-9-102(d)(3), and said physicians shall be compensated for their preparation time and actual time pursuant to the provisions of the Board approved Fee Schedule or by a fee agreement agreed to by the parties and the physician.
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REHABILITATION SUPPLIERS. A rehabilitation supplier delivers and coordinates services under an individualized rehabilitation plan; facilitates coordination of medical care; provides vocational counseling, exploration, and assessment; performs job analysis, job development, modification, and placement; evaluates social, medical, vocational, psychological, and psychiatric information; and may provide additional services upon agreement of the parties or Board order.
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Qualified Certifications or Licenses. To provide rehabilitation services, the supplier must be registered with the Board. To provide services in catastrophic claims, the supplier must be registered with the Board as a catastrophic supplier.
Any rehabilitation supplier who wishes to supply services in a Workers' Compensation claim shall hold one of the following certifications or licenses:
Certified Occupational Health Nurse Specialist (COHN-S).
Certified Occupational Health Nurse (COHN); or
Licensed Professional Counselor (LPC);
Licensed Professional Counselor (LPC);
Work Adjustment and Vocational Evaluation Specialist (WAVES);
Certified Rehabilitation Registered Nurse (CRRN);
Certified Disability Management Specialist (CDMS);
Certified Rehabilitation Counselor (CRC);
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Registration with the Board.
To register as a rehabilitation supplier or a catastrophic rehabilitation supplier, an applicant shall follow the application process as provided in the Board's Rehabilitation & Managed Care Procedure Manual.
Within twenty (20) days of the date of a denial of an application for registration as a supplier, an appeal may be initiated by filing a written request with the Director of Managed Care and Rehabilitation (MC&R) for a conference. The applicant will be notified in writing of the date, time, and place of the conference within thirty days of the appeal. An applicant dissatisfied with the decision following the conference may request a hearing by written request within twenty (20) days of the conference decision.
Notice of a rehabilitation supplier's registration approval will contain a supplier registration number with the November 30th expiration date, which shall be included on all reports submitted to the Board by the rehabilitation supplier.
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CATASTROPHIC REHABILITATION SERVICES.
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Appointment of Catastrophic Rehabilitation Supplier.
Where catastrophic designation is undisputed, the employer/insurer shall appoint a registered catastrophic rehabilitation supplier within 48 hours of accepting the injury as compensable or notification of a final determination of compensability by filing a Form WC-R1 which may be filed simultaneously with the Employer's First Report of Injury (WC-1). If the employer/insurer does not timely appoint a registered catastrophic rehabilitation supplier as required pursuant to this subsection, the employee may file a WC-R1 to request the appointment of a registered catastrophic rehabilitation supplier with service to all parties and the requested supplier.
When a Board determination is made by the MC & R or an administrative law judge that an injury is catastrophic, the employer/insurer shall have twenty(20) days from the date of notification of the determination to select a Board registered catastrophic rehabilitation supplier by filing a WC-R1.If the employer/insurer fails to select a supplier, or files an appeal of the determination to the Appellate Division and the catastrophic designation is upheld on appeal, the Board will select the catastrophic rehabilitation supplier, and may, in the Board's discretion, appoint a supplier requested by the employee.
Objection to the WC-R1CATEE must be filed on a Form WC-Rehab Objection with the Board within twenty (20) days of the certificate of service on the WC-R1CATEE.In the alternative, either party may file a Form WC-14 requesting an evidentiary hearing within twenty (20) days of the certificate of service on the WC-RICATEE.In the event a Form WC-14 is filed, the file shall be transferred to an administrative law judge for an evidentiary hearing without an administrative decision being rendered by the Rehabilitation Coordinator.The timeliness of the objection or hearing request will be processed in accordance with provisions of O.C.G.A. §9-ll-6(e).
When a catastrophic designation is disputed, employee or employee's attorney shall file a WC-R1CATEE to request catastrophic designation and appointment of a registered catastrophic rehabilitation supplier. The WC-R1CATEE must be accompanied by documentation as specified in the current edition of the Board's Rehabilitation & Managed Care Procedure Manual, or as requested by the Board, unless a hearing is requested within twenty (20) days of the filing of the WC-R1CATEE.
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Catastrophic Rehabilitation Supplier Duties.
A catastrophic rehabilitation supplier is not a party to the case.The registered catastrophic rehabilitation supplier shall have sole responsibility for the rehabilitation aspects of each individual case.The registered catastrophic rehabilitation supplier shall communicate with the injured employee and others to assess, plan, implement, coordinate, monitor and evaluate options and services to meet an injured employee's rehabilitation needs to effect a cure, give relief or restore the employee to suitable employment.
The assigned rehabilitation supplier shall not perform any additional services for either party for compensation not contemplated by the approved plan, unless all parties agree.
A rehabilitation supplier shall not accept any additional compensation or reward from any source as a result of settlement of a case. A rehabilitation supplier shall not accept any additional compensation or reward from any source as a result of settlement of a case.
Rehabilitation suppliers shall advise a non-represented injured employee to direct questions outside his/her area of expertise to the State Board of Workers' Compensation and a represented injured employee to direct questions to his or her counsel.
A rehabilitation supplier shall refrain from activity pertaining to settlement negotiations, surveillance or provision of legal advice.
The rehabilitation supplier shall insure the confidentiality of the injured employee's medical records and shall not disclose the medical records to non-parties without the written consent of the injured employee or unless otherwise legally required to do so.
The rehabilitation supplier shall recognize that the authorized treating physician directs the medical care of an injured employee.
The rehabilitation supplier shall disclose any known conflicts of interest.
A rehabilitation supplier will inform all parties of the responsibility to provide services in accordance with their professional qualifications.The rehabilitation supplier shall function within the scope of his or her role, training, and technical competency and will accept only those referrals and/or assignments for which he or she is professionally qualified.
Form WC-R2 with accompanying progress/status reports shall be filed no less than every ninety days.
The designated rehabilitation supplier may arrange for services outside of his/her scope of expertise and qualifications.
The registered catastrophic rehabilitation supplier shall meet with the injured employee within thirty (30) days of appointment and complete an initial rehabilitation evaluation and an appropriate plan (WC-R2A) for medical and/or vocational services.
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Rehabilitation Plans.
The initial rehabilitation plan must be filed with the Board on Form WC-R2A within ninety (90) days of the supplier's appointment to the claim, unless excused by the Board.A current Rehabilitation Plan must be filed with the Board during all phases of service delivery and shall be in place no longer than one year. All rehabilitation plans shall provide for reasonable and necessary items and services and be submitted with supporting documentation.If the Board rejects the proposed rehabilitation plan, the registered catastrophic rehabilitation supplier shall have 30 days to submit a revised plan.An amended rehabilitation plan on a WC-R2A shall be filed at any time the circumstances change significantly.Amended or extended rehabilitation plans shall be submitted thirty days prior to the expiration of the current approved plan.
Signed plans submitted without objection are approved automatically.
Any party objecting to a proposed rehabilitation plan shall file a WC-Rehab Objection Form with the Board within twenty (20) days of the date of the certificate of service.The Rehabilitation Division will issue an administrative decision and may hold a rehabilitation conference.
Return-to work plans, in order of preference, are:a) return to same job with the same employer; b) return to different job with same employer; c) return to work with new employer; d) short-term training; e) long-term training; or f) self-employment.
Plans may include any or all of the items and services, including housing and transportation, which are reasonable and necessary to return the catastrophically injured employee to the least restrictive lifestyle possible, and/or return to work including:Medical Care Coordination, Independent Living, Extended Evaluation, Job Placement, Training and/or Self Employment.
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Communication.
A catastrophic rehabilitation supplier shall simultaneously provide copies of all correspondence, written communication, and documentation of oral communications with the treating physician to all parties and their attorneys.
The catastrophic rehabilitation supplier shall not obtain medical information regarding an injured employee in a private meeting with any treating physician unless the catastrophic rehabilitation supplier has reserved with the physician sufficient appointment time for the conference and the injured employee and his or her attorney were given ten days advance notice of their option to attend the conference. If the injured employee or the physician does not consent to a joint conference, or if, in the physician's opinion, it is medically contraindicated for the injured employee to participate in the conference, the catastrophic rehabilitation supplier shall note this in his or her report and may in those specific instances communicate directly with the physician.Exceptions to the above notice requirements may be made in cases of medical necessity or with the consent of the injured employee or his or her attorney.
The employee has the right to a private physical examination with the medical provider.The catastrophic rehabilitation supplier shall attend such examination, only with revocable written consent of the employee, or his or her representative, after the employee has been advised of the right to a private examination. The catastrophic rehabilitation supplier may meet with the physician and the employee after the private exam.
The catastrophic rehabilitation supplier shall provide professional identification and shall explain his or her role to any physician at the initial contact with the physician.
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Rehabilitation Conferences.
A rehabilitation conference may be scheduled at the request of a party or the catastrophic rehabilitation supplier by filing a WC-R5, or at the discretion of an Administrative Law Judge or the Board's rehabilitation coordinator.
Following the rehabilitation conference, the Board will issue a conference administrative decision.
Any person notified by the Board who fails to attend a Board scheduled rehabilitation conference without reasonable grounds may be subject to sanction pursuant to O.C.G.A. §34-9-18.Any party requesting cancellation or rescheduling of a rehabilitation conference shall notify the Board and other parties with adequate notice to all parties.
All parties, attorneys of record, and the catastrophic rehabilitation supplier may be required to attend the conference or to be represented by a person with full authority to resolve the pending disputes.Only the parties, attorneys of record, and catastrophic rehabilitation supplier may attend a scheduled mediation or rehabilitation conference.Exceptions to attendance may be granted if approved in advance by the Board rehabilitation coordinator.
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Rehabilitation Closure.
The registered catastrophic rehabilitation supplier shall submit a WC-R3, Request for Closure, with a closure report as follows: (a)sixty days after the employee's return to work; (b)at any time it is determined that further services are not needed or feasible; (c)when a stipulated settlement that does not include rehabilitation services has been approved by the Board; or (d)when the Board directs rehabilitation closure.
Any party objecting to a proposed WC-R3 shall file a WC-Rehab Objection Form setting forth the specific reasons within twenty (20) days of the date of the certificate of service.The Board will issue an administrative decision on all requests for closure.
A party may request that the Board close rehabilitation services by filing a WC-R3 setting forth the specific reasons in support of their request for closure with copies to all parties and the supplier.
At any time, upon review of the file, the Board may determine that rehabilitation closure is appropriate and may issue an order or an administrative decision to close rehabilitation.
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Request to Reopen Rehabilitation.
A request to reopen rehabilitation services may be submitted only by parties to the claim and must be approved by the Board.The WC-R1 requesting that rehabilitation services be reopened shall include the name and address of the catastrophic rehabilitation supplier and the specific reasons for such request.The requesting party shall complete the certificate of service and send copies of the WC-R1 to all parties, their attorneys and the catastrophic rehabilitation supplier.
Any party objecting to a proposed reopening shall file a WC-Rehab Objection Form with supporting documentation within twenty days of the date of the certificate of service.The M C & R will issue an administrative decision on all requests to reopen rehabilitation.
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Change in Registered Catastrophic Rehabilitation Supplier.
A change in registered catastrophic rehabilitation supplier shall be requested only by parties to the claim and must be approved by the Board.The WC-R1 requesting a change in supplier shall include the names and addresses of the involved suppliers and the specific reasons the change is requested.The requesting party shall complete the certificate of service and send copies of the WC-R1 to all parties, their attorneys and the catastrophic rehabilitation suppliers.
Any party objecting to a change of catastrophic rehabilitation supplier shall file a WC-Rehab Objection Form setting forth the reasons in support within fifteen (15) days of the date of the certificate of service.The Rehabilitation Division may hold a rehabilitation conference.The Rehabilitation Division will issue an administrative decision on all change of supplier requests.
When a WC-R1 is filed to request a change of registered catastrophic rehabilitation supplier, the current Board appointed rehabilitation supplier shall maintain responsibility for providing necessary rehabilitation services until all appeals have been exhausted, unless excused by the Board.
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Challenges to Administrative Decisions.
Any party to the claim dissatisfied with an administrative decision must file a WC-14, Request for Hearing, served on all parties and their attorneys and involved rehabilitation supplier(s) within twenty (20) days of the date of the administrative decision.The Board, in its discretion, may order the parties to participate in a mediation or rehabilitation conference before the scheduling of the de novo hearing.The administrative decision shall be admissible in evidence.
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Failure of a Party or Counsel to Cooperate.
Benefits may be suspended for failure or refusal to accept or cooperate with authorized rehabilitation services only by order of the Board.
A party or attorney may be subject to civil penalty or to fee suspension or reduction for failure to cooperate with rehabilitation services.
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VOLUNTARY REHABILITATION.
For non-catastrophic injuries, the parties may elect that the employer/insurer will provide a rehabilitation supplier on a voluntary basis for so long as the parties agree. The employee's consent must be in writing.The rehabilitation supplier utilized by the parties must hold one of the certifications or licenses specified in Rule 200.1(I.A.) and be registered with the State Board of Workers' Compensation.
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Duties of voluntary rehabilitation supplier.
The voluntary rehabilitation supplier shall simultaneously provide copies of all correspondence, written communications, and documentation of oral communications with the treating physician to all parties and their attorneys.
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Ethical standards required of voluntary rehabilitation supplier.
The rehabilitation supplier shall adhere to the ethical standards set forth by the approved professional certifying bodies.
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ADMINISTRATIVE ENFORCEMENT - PROFESSIONAL CONDUCT, FEES AND COMPLIANCE WITH BOARD RULES.
Complaints against rehabilitation suppliers and medical case managers for revocation or suspension of registration, excessive or fraudulent charges, provision of unnecessary services or unethical or unprofessional behavior shall be filed in writing on a Rehab Complaint with the Director of Managed Care and Rehabilitation with copies sent to all parties and affected suppliers and case managers.Registration may be revoked or suspended, and/or penalties assessed.
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The Director of MC shall appoint a peer review panel of nine (9) registered suppliers who will review complaints regarding reasonable fees, appropriate services and unprofessional or unethical behaviors.The appointees shall serve for terms of three (3) years and may be re-appointed for a maximum of nine (9) years.
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The registration of a medical case manager or a rehabilitation supplier may be revoked or suspended, and/or penalties assessed upon a determination of violation of Board rules, excessive or fraudulent charges, provision of unnecessary services or unethical or unprofessional behavior.
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A written complaint against a medical case manager or rehabilitation supplier shall be filed with the Director of MC&R and copies sent to all parties to the case and to the medical case manager or rehabilitation supplier.Upon receipt of the written complaint, or upon the Board's knowledge of a violation, the Director of MC& R shall provide notification to the case manager/rehabilitation supplier by providing a copy of the written complaint.
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Within fifteen (15) calendar days of the notice by the Director of MC, the Director shall appoint a panel of three (3) members from the peer review panel to review the complaint.Where possible, at least one of the three (3) shall have the same certification or licensure as the person who is the subject of the complaint.The Director of MC shall provide Review Panel contact information to the complainant and the person who is the subject of the complaint.
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The medical case manager or rehabilitation supplier who is the subject of the complaint shall be provided fifteen (15) calendar days from the date of said notice from the Director to provide a written response to the allegations of the complaint.A copy of the response shall be served on the Director of MC&R the Review Panel, and the person who filed the complaint.
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The complainant may reply to the response within 10 days by serving a copy on the Director of MC&R, the person who is the subject of the complaint, and the Review Panel.
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The Review Panel may request additional information regarding the circumstances of the complaint from any person or party having relevant knowledge.Such additional information shall be provided to the person who is the subject of the complaint who will have 10 days to respond.
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The Review Panel shall report its findings and recommendations to the Director of MC&R within thirty (30) days of the final response. The Director of MC shall promptly provide a copy of the findings and recommendations to the medical case manager or rehabilitation supplier who is the subject of the complaint and the complainant.
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If the Review Panel determines that there is no inappropriate conduct, the Director of MC&R shall issue an administrative decision incorporating the Review Panel's findings and recommendation.Copies of the finding shall be sent to all parties to the case and to the medical case manager or rehabilitation supplier who was the subject of the complaint. The complainant or any party dissatisfied with the finding may challenge the finding by filing a WC-14 Request for Hearing within 20 days. The administrative decision shall be admissible in evidence.
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If the Review Panel determines that a violation has occurred, the Director of MC&R will refer the findings and recommendation to the Enforcement Division for further appropriate action which may include referral to an Administrative Law Judge for a hearing.If a hearing is held, the Administrative Law Judge shall issue a decision providing for any available remedy, including dismissal of the complaint, assessment of penalties, probation, and/or revocation or suspension of the registration of the rehabilitation supplier.The rehabilitation supplier may appeal the decision of the Administrative Law Judge in accordance with O.C.G.A. § 34-9-103 and § 34-9-105.
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The Director of MC shall also have the authority to order replacement of the rehabilitation supplier in the case where the conduct occurred if, in the judgment of the Director of MC&R, such action is necessary to effectuate the purpose of the Act.
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When appeals have been exhausted, the Director of MC&R shall report any violations to the appropriate certification or licensing Board.
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The members of the peer review panel shall be immune from any subpoena requiring their testimony in any form regarding their participation in the review process.
In claims involving non-catastrophic injuries, employers/insurers may voluntarily utilize qualified medical case managers to provide telephonic or field medical case management services. Qualified medical case managers must possess certification or licensure of at least one licensing agency contained in Board Rule 200.1(I)(A). Such medical case management services may be provided at the expense of the employer/insurer. Consent of the employee or the employee's attorney shall be required for any medical case manager to work with the injured worker. Consent shall be in writing when attending any medical appointment. Where consent is required, it may be withdrawn and the employee shall be informed in writing that such consent may be refused. Consent of the employee shall not be required for such qualified medical case manager to contact the treating physician for purposes of assessing, planning, implementing and evaluating the options and services required to effect a cure or provide relief. All communications are subject to the provisions of Rule 200.1(II)(D). Nothing in this rule shall be construed to allow or promote utilization review on the part of the medical case manager. The medical case manager may assist with approval of job descriptions only as consistent with O.C.G.A. §34-9-240 and Board Rule 240. Violations of this rule may be referred to the Rehabilitation Division for peer review as contemplated by Rule 200.1(IV).
Case managers may be involved in cases where the employer/insurer has contracted with a certified workers' compensation managed care organization (WC-MCO). These case managers shall operate pursuant to the provisions of O.C.G.A. §34-9-208 and Board Rule 208.
Nothing contained in this Rule shall apply to a direct employee of the insurer, third party administrator or employer, or to an attorney representing a party, provided that their specific role is identified.
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The employer may satisfy the requirements for furnishing medical care under O.C.G.A. § 34-9-200 in one of the following manners:
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In the event that the Board has granted any exceptions to the panel requirements,all exceptions must be posted at the same location as the panel.
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The employer has enrolled with the specified WC/MCO to provide all necessary medical treatment for workers' compensation injuries.An employee with an injury prior to enrollment may continue to receive treatment from the non-participating authorized treating physician until the employee elects to utilize the WC/MCO;
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The effective date of the WC/MCO;
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The geographical service area (by counties);
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The telephone number and address of the administrator for the employer and/or WC/MCO who can answer questions about the managed care plan;
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How the employee can access care with the WC/MCO and the toll-free 24-hour telephone number of the managed care plan that informs employees of available services.
The peer review organizations approved by the Board are as follows: Georgia Psychological Association; Georgia Chiropractic Association, Inc.; Appropriate Utilization Group, LLC; Medical Consultants Network (MCN); and such other organizations as designated by the Board.
If any charges for health care goods or services are not paid when due, or any reimbursement for health care goods or services paid by the employee or any charges for mileage incurred by the employee are not paid when due, penalties shall be added to such charges and paid at the same time as, and in addition to, the charges claimed for the health care goods and services. For any payment of charges made more than 30 days after their due date, but paid within 60 days of such date, there shall be added to such charges an amount equal to 10 percent of the amount due. For any payment of charges made more than 60 days after the due date, but paid within 90 days of such date, there shall be added to such charges an amount equal to 20 percent of the amount due. For any charges not paid within 90 days of the due date, in addition to the 20 percent add-on penalty, the employer or insurer shall pay interest on the combined total in an amount equal to 12 percent per annum from the 91st day after the date the charges were due until full payment is made. All such penalties and interest shall be paid to the provider of the health care goods or services.
The employer/insurer shall not suspend weekly benefits on the ground that a subsequent nonwork related injury has broken the chain of causation between the compensable injury and the employee's disability except by the order of the Board.
The burden of proving that the chain of causation has been broken shall be upon the employer/insurer.
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The employer/insurer cannot restrict treatment of the employee to the panel of physicians or WC/MCO when the claim has been controverted. However, if the controverted claim is subsequently found to be or is accepted as compensable, the employee is authorized to select one of the physicians who has provided treatment for the work-related injury prior to the finding or acceptance of compensability, and after notice has been given to the employer, that physician so selected becomes the authorized treating physician. The employee may thereafter make one change from that physician to another physician without approval of the employer and without an order of the Board. However, any further change of physician or treatment must be in accordance with O.C.G.A. § 34-9-200 and Board Rule 200.
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When a case has not been controverted but the employer fails to provide any of the procedures for selection of physicians as set forth in O.C.G.A. § 34-9-201(c), the employee is authorized to select a physician who is not listed on the employer's posted panel of physicians or WC/MCO.After notice has been given to the employer, that physician so selected becomes the authorized treating physician, and the employee may make one change from that physician to another physician without approval of the employer and without an order of the Board.However, any further change of physician or treatment must be in accordance with O.C.G.A. § 34-9-200 and Board Rule 200.
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A party requesting a change of physician must do so in the manner prescribed by Board Rule 200.
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Examinations contemplated by O.C.G.A. § 34-9-202 shall include physical, psychiatric and psychological examinations. An examination shall also include reasonable and necessary testingas ordered by the examining physician.
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The examining physician may require prepayment pursuant to the Fee Schedule base amount for up to the first two hours ($1200.00).Payment for any additional charges pursuant to the Fee Schedule shall be due within 30 days of receipt of the report and charges by the employer/insurer.
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The employer shall give ten days written notice of the time and place of any requested examination. Advance payment of travel expenses required by Rule 203(e) shall accompany such notice.
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The employer/insurer shall not suspend weekly benefits for refusal of the employee to submit to examination except by order of the Board.
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Within 120 days of the employee's receipt of any income benefits, the employee shall provide written notice to the employer/insurer of his/her intent to exercise the right to have a one-time independent medical examination at a reasonable time and place.
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Medical expenses shall be limited to the usual, customary and reasonable charges as found by the Board pursuant to O.C.G.A. § 34-9-205. Employer/insurers may automatically conform charges according to the fee schedule adopted by the Board and the charges listed in the fee schedule shall be presumed usual, customary, and reasonable and shall be paid within 30 days from the date of receipt of charges. Requests for reimbursement of mileage expenses incurred by the employee shall be paidwithin 15 days after receipt of an itemized written request. Employer/insurers shall not unilaterally change any CPT-4 or CDT code of the provider. All automatically conformed charges according to the fee schedule adopted by the Board shall be for the CPT-4 or CDT code listed by the provider. In situations where charges have been reduced or payment of a bill denied, the carrier, self-insured employer, or third party administrator shall provide an Explanation of Benefits with payment information explaining why the charge has been reduced or disallowed, along with a narrative explanation of each Explanation of Benefits code used. In all claims, any health service provider whose fee is reduced to conform to the fee schedule and who disputes that fee, or employer/insurers who dispute the CPT-4 or CDT code used by the provider for services rendered shall, in the first instance, request peer review of the charges, and may thereafter request a mediation conference or an evidentiary hearing by filing Form WC-14 with the Board. For charges not contained in the fee schedule and which are disputed within 30 days as not being reasonable, usual and customary, the aggrieved party shall follow the procedures provided in subsection (c).
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(1)A medical provider or an employee who has incurred expenses for healthcare goods and services or other medical expenses shall submit the charges to the employer or its workers' compensation carrier for payment within one year of the date of service. In the event that the claim or the expense is controverted, the medical expenses or request for reimbursement must be submitted for payment within one year of the date of service or within one year of the date that the claim is accepted or established as compensable, whichever is later. Failure by the medical provider or employee to submit expenses within the time prescribed shall result in waiver of such expenses.
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Disputes
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Medical expenses shall include the reasonable cost of attendant care that is directed by the treating physician, during travel or convalescence.
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Medical expenses shall include but are not limited to the reasonable cost of travel between the employee's home and the place of examination or treatment or physical therapy, or the pharmacy. When travel is by private vehicle the rate of mileage shall be 40 cents per mile. This rate is subject to change based upon changes in fuel costs. Reimbursement for any charges for mileage incurred by the employee shall be paid within 15 days from the date that the employer or the insurer receives the itemized written request required by the Board.Travel expenses beyond the employee's home city shall include the actual cost of meals and lodging. Travel expenses shall further include the actual cost of meals when total elapsed time of the trip to obtain outpatient treatment exceeds four hours. Cost of meals shall not exceed $30 per day.
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Reports required by the Board include State Board of Workers' Compensation Form WC-20(a), 1500 Claim Form, UB-04, or American Dental Association Form 2012 and supporting narrative, if any, properly filled out and with supporting itemized hospital charges, discharge summary, and billings from other authorized providers of service and shall be furnished at no charge to the party responsible for payment.In addition, health care providers may submit and payers may receive and pay bills for medical services and products provided to the injured employee electronically in accordance with the Medical Billing and Reimbursement for Workers' Compensation procedures outlined in an Appendix to the Georgia Fee Schedule.Medical services provided pursuant to the Workers' CompensationActarenotconfidentialtotheemployer/insurerwhobylaware responsible for the payment of services. Hospitals and other medical providers who by their own rules require medical releases shall be responsible for obtaining same at the time of treatment.
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(1)Medical treatment/tests prescribed by an authorized treating physician shall be paid, in accordance with the Act, where the treatment/tests are:
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Related to the on the job injury;
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Reasonably required and appear likely to accomplish any of the following:
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In the event the insurer/self-insurer furnish an initial written refusal to authorize the requested treatment or testing within the five business day period, then within 21 days of the initial receipt of the WC-205, the insurer/self-insurer shall either: (a) authorize the requested treatment or testing in writing; or (b) file with the Board a Form WC-3 controverting the treatment or testing indicating the specific grounds for the controversion.
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Except as provided in Rule 205(e);
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(1)If medical treatment is controverted on the ground that the treatment is not reasonably necessary, the burden of proof shall be on the employer. If the treatment is controverted on the grounds that the treatment is either not authorized or is unrelated to the compensable injury, the burden of proof shall be upon the employee.
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If an employer or insurer utilizes a Board-certified WC/MCO pursuant to O.C.G.A. § 34-9-201(b)(3), and a dispute regarding authorization of the treatment/testing prescribed by an authorized treating physician is not resolved within 30 days, then the employee or the employee's attorney may initiate the WC-PMT proceedings in subsection (c) of this Rule.Where no WC-PMT is filed, and the dispute is not resolved within 30 days as outlined in Rule 208(f), then the employer or insurer has 15 days from notification by the WC/MCO to authorize the treatment/test or controvert the treatment/test.In no event will the employer or insurer utilizing a WC/MCO have more than 45 days from the receipt of the notice of a dispute as set forth in Rule 208(f) to comply with this provision.
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Only a party to a claim, a group insurance company or other healthcare provider who covers the costs of medical treatment or provides medical services to the employee may file a Form WC-206
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Form WC-206, shall include supporting documentation and an explanation of any dispute and shall be submitted to the Board by the party seeking reimbursement during the pendency of the claim. Copies shall also be sent by the party requesting reimbursement to all counsel and unrepresented parties at interest.
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When the Board receives a request for reimbursement and designation as a party at interest, the Board will provide the requesting party with notice of any hearing at which the party at interest will be permitted to present evidence of its claimed interest.
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Application and certification.
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An audited financial statement evidencing the ability of the Managed Care Organization to comply with any and all financial requirements to insure the delivery of services the Board may prescribe.
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Complete disclosure should be made of the following individuals (an individual may act in more than one capacity):
The names, addresses and resume of all directors and officers of the WC/MCO;
The name and address or any other information requested by the Board regarding any entity, other than individual health care providers, with whom the WC/MCO has a joint venture or other agreement to perform any of the functions of the managed care plan, and a description of the specific function to be performed by each entity.
The name, address and telephone number of the WC/MCO's communication liaison for the Board, the insurer, the employer, and the employee; and
The name, address, medical specialty and resume of the medical director;
The title, name, address, telephone number and resume of the person to be the administrator of the financial affairs of the WC/MCO;
The title, name, address, telephone number and resume of the person to be the day-to-day administrator of the WC/MCO;
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The WC/MCO must insure provisions of quality services that meet all uniform treatment standards required by Georgia law and provide appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service.
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The WC/MCO must provide a description of its proposed geographic service area by county and specify the times, places and manner of providing services, including a statement describing how the WC/MCO will insure that an adequate number of each category of health care provider is available to give employees convenient geographic accessibility to all categories of providers and adequate flexibility to choose health care providers from among those who provide services under the plan.
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The WC/MCO must include minority providers, and at a minimum, the following types of health care services and providers, unless the WC/MCO provides evidence that a particular service or type of provider is not available in the geographical service area:
Medical doctors, including specialists in at least one of the following fields:family practice, internal medicine, occupational medicine, or emergency medicine;
Hospital, outpatient surgery, and emergency care services.
Radiology services; and
Diagnostic pathology and laboratory services;
Psychologists or psychiatrists;
Physical and occupational therapists;
Chiropractors;
General surgeons;
Neurologists and neurosurgeons;
Orthopedic surgeons, including specialists in hand and upper extremity surgery;
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The WC/MCO must submit sample copies of all types of agreements with providers who will deliver services under the WC/MCO and a description of any other relationships with providers who may deliver services to a covered employee.
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The WC/MCO must attach to each type of sample agreement a corresponding list of names, clinics, addresses and types of license and specialties for the health care providers with whom they have utilized the agreement.
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In all agreements with the WC/MCO and any other provider of services, the agreement shall contain the following provision: "It is the intent of the parties to this agreement to insure quality services that meet all uniform treatment standards required by Georgia law, and any provision herein which may be inconsistent with that intent shall be void."
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The WC/MCO must submit a statement certifying that all licensing requirements for the providers and medical case managers are current and in good standing in Georgia or the state in which the provider is practicing.
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The WC/MCO must provide a referral for specialty services that are not specified in subparagraph (E) and that may be reasonable and necessary to effect a cure or give relief as required under O.C.G.A. § 34-9-200.The employer or the workers' compensation insurance carrier remains liable for any health service required under the Workers' Compensation Act, provided that the services meet all other requirements of the Workers' Compensation Act.
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The WC/MCO must include procedures to insure that employees will receive services in accordance with the following criteria:
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The medical case manager shall inform the employee of his right to choose from the providers designated in Rule 208(a)(1)(E), inform the employee that a list of medical providers is available and provide assistance in obtaining the list if necessary. The medical case manager shall assist the employee in choosing a provider appropriate to the injury. The physician so chosen shall be deemed the "authorized treating physician" for all purposes under the Workers' Compensation Act. Employees must be allowed to change authorized treating physicians within the managed care plan at least once without proceeding through the managed care plan's dispute resolution process. In such cases, employees shall give notice to the manage care plan for a change in their authorized treating physician;
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Employees must be able to receive information on a 24-hour basis regarding the availability of necessary medical services available within the managed care plan. The information may be provided through recorded toll-free telephone messages after normal working hours. The message must include information on how the employee can obtain emergency services or other urgently needed care and how the employee can access an evaluation within a reasonable time after request;
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Employees must receive initial evaluation by a participating licensed health care provider within twenty-four hours after the employee's request for treatment, following a work-related injury;
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In cases where the employee has received treatment for the work injury by a health care provider outside the managed care plan, the employee must receive initial evaluation or treatment by a participating health care provider within five (5) working days of the employee's request for a change of doctor or referral to the managed care plan;
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Employees must receive any necessary treatment, diagnostic tests or specialty services in a manner that is timely, effective and convenient for the employee, and reasonable under the circumstances;
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Employees must have reasonable access to health care providers. If the employee is medically unable to travel to a participating provider, the managed care plan shall refer the employee to an available or non-participating provider to receive necessary treatment for the injury.
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The WC/MCO must designate the procedures for approval of services from a health care provider outside the managed care plan.
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The WC/MCO must include a procedure for peer review and utilization, consistent with Rule 208(g).
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The WC/MCO must include a procedure for internal dispute resolution, including a method to resolve complaints by injured employees, medical providers, employers and insurers.
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The WC/MCO must inform employees of all choices of medical services provided within the plan and how employees can gain access to those providers including but not limited to a wallet-sized card containing this information in a format suitable for carrying on the employee's person.The plan must submit a proposed publication which may be customized according to the needs of the employer, but must include the information required in Rule 201(a)(3) and must also include a complete list of all WC/MCO medical providers in the applicable geographical service area. All employees of covered employers shall be provided with the publication.
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The WC/MCO must provide the information required by Rule 208(h) and describe how medical case management will be provided for injured employees, and an effective program for return-to-work and cooperative efforts by the employees, the employer and the managed care plan to promote workplace health and safety and other services.
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The WC/MCO must provide such other information as the Board considers necessary to determine compliance with the Workers' Compensation Act.
Within 60 days of receipt of an application, the Board must notify an applicant for certification of any additional information required or modification that must be made.The Board must notify the applicant in writing of the approval or denial of certification within 60 days of receipt of the additional information or modification. If certification is denied, the applicant must be provided, in writing, with the reason or reasons for the denial.
Any person aggrieved by a denial of certification by the Board may make written request for a hearing within 30 days of the date the denial is served and filed. The Appellate Division shall hold all hearings and issue a final decision.
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Coverage responsibility of WC/MCO.
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Reporting requirements for Board certified WC/MCO's.
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Contracts between the WC/MCO and any employer or workers' compensation insurer, prior to utilization of the contract. If the Board does not issue a written approval or denial within 90 days, then the contract shall be approved. Any contract rejected by the Board shall be deemed void for purposes of this Rule. Standard contracts may be submitted instead of individual contracts if no modifications are made. Standard contracts must include a list of signatories and a listing of all employers covered by each contract, including the employers' name, business address and estimated number of employees governed by the WC/MCO. Amendments and addendums to the contracts must be submitted to the Board within 30 days of execution. Contract provisions must be consistent with O.C.G.A. § 34-9-208 and this Rule. The contract must specify the billing and payment procedures and how the medical case management and return-to-work functions will be coordinated.
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New types of agreements between participating health care providers and the WC/MCO that are not identical to the agreements previously submitted to the Board shall not be effective until approved by the Board.Any contract which is neither approved nor rejected by the Board within 90 days from submission shall be deemed approved.
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Contracts between the WC/MCO and any entity, other than individual participating providers that performs some of the functions of the WC/MCO.
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Any changes in the individuals or information required by Board Rule 208(a)(1)(B)(1)-(5).
In order to maintain certification, each WC/MCO shall provide on the first working day following each anniversary of certification the following information in the form of a certified annual report:
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A current listing of all individuals identified in Board Rule 208(a)(1)(B)(1)-(5) and all participating health care providers, including provider names, types of license, specialty, business address, telephone number and a statement that all licenses are current and in good standing;
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A summary of any sanctions or punitive actions taken by the WC/MCO against any participating providers;
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A report that summarizes peer review, utilization review, supplier profiles, reported complaints and dispute resolution proceedings showing cases reviewed, issues involved, and any action taken; and
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An audited financial statement for the most recent fiscal year, upon request of the Board.
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The annual report must be accompanied by a non-refundable fee of $500.00.
Any proposed changes to the Board certified WC/MCO falling within the categories enumerated below, other than changes to the health care provider list, may not be implemented under the plan until approved by the Board:
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Amendments to any contract with participating health care providers;
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Amendments to contracts between the WC/MCO and another entity performing functions of the managed care plan; and
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Any other amendments to the WC/MCO as certified.
The WC/MCO must report to the employer or insurer any data regarding medical services and suppliers related to the workers' compensation claim required by the self-insured employer or insurer to determine compensability under the Workers' Compensation Act, and any other data required by the Board. The Board may require additional information from the managed care organization if the information is relevant to the Workers' Compensation Act.
If payment to the minor or incompetent adult is pursuant to a WC-2, theconservatorship petition should be filed with the Board and a conservator appointed prior to the payment of any monetary benefits to them.
Attaching a properly completed Form WC-240A will satisfy the requirements for making a proper offer of employment as set forth herein.
An employer/insurer seeking a credit as provided by O.C.G.A. §34-9-243 shall file with the Board Form WC-243, and shall report on Form WC-243 the amount of unemployment compensation and/or weekly income payments made on behalf of an employee pursuant to a disability plan, a wage continuation plan, or a disability insurance policy and shall set forth the ratio of the employer's contributions to the total contributions of such plan or policy no later than 10 days prior to a hearing. A copy of this form shall be sent to all counsel and unrepresented parties by the employer/insurer at the same time that it is filed with the Board.
When the employee is no longer receiving weekly benefits under O.C.G.A. §§34-9-261 or34-9-262, and a permanent partial disability (PPD) rating has not previously been requested or issued, the employer/insurer shall have thirty days to request, in writing, from an authorized physician, that the employee be rated in accordance with the "Guides to the Evaluation of Permanent Impairment, Fifth Edition," published by the American Medical Association.The employer/insurer shall furnish a copy of the medical report of rating to the employee, and commence payment not later than 21 days after knowledge of the rating. The employer/insurer are presumed to have knowledge of the rating not later than 10 days after the date of the report establishing the rating.
The insurer or self-insurer in no-dependency death cases, shall pay to the State Board of Workers' Compensation the amount set forth in Code Section 34-9-265(b).
The Board of trustees shall possess all powers necessary to accomplish objectives prescribed in this article including the following:
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Commencement and termination of contract between the WC/MCO and participating providers.
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A health care provider who is not a participating health care provider may provide medical services to an employee covered by a WC/MCO in any other circumstances provided below:
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Disputes which arise on an issue related to managed care shall first be processed without charge through the dispute resolution process of the WC/MCO. The WC/MCO dispute resolution process must be completed within 30 days of a written notice.If the dispute cannot be resolved, the WC/MCO must immediately notify the employer or insurer. If the dispute involves treatment/test prescribed by the authorized treating physician, the employer or insurer must follow the procedure outlined in Rule 205.
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Utilization review and peer review.
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Medical case management.
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Monitoring records.
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Suspension; revocation.
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The date of disability is the first day the employee is unable to work a full day. If, however, the employee is paid in full for the date of injury, the date of disability shall begin the next day following the date of injury.
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Entitlement to benefits for the first seven days of disability, or any part thereof, requires 21 consecutive days of disability. The employer/insurer shall pay compensation for the first seven days of disability on the 21st consecutive day.
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An injured employee who receives regular wages during disability shall not be entitled to weekly benefits for the same period.
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Payment shall be made to the address of record or account specified by the claimant, in cash, by negotiable instrument, or upon agreement of the parties by electronic funds transfer.Payment by negotiable instrument shall denote the pay period which the payment represents.Mailed payments shall be sent to the claimant in accordance with the procedure prescribed by O.C.G.A. § 34-9-221(b).
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For the purpose of calculating time periods, the date of injury shall be deemed to be the date of disability and a week shall be deemed to be seven calendar days. See Rule 220(a).
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In all cases, including payment of salary for compensable disability, upon making the first payment and upon suspension of payment, Forms WC-1 or WC-2 or, in case of death, Form WC-2A shall be filed with the Board. If the Forms WC-1 or WC-2 show payment is less than the maximum weekly benefit under either O.C.G.A. § 34-9-261 or O.C.G.A. § 34-9-262, as applicable, a Form WC-6 or other sufficient explanation shall be filed with the Board with the accompanying Form WC-1 or WC-2. To report any change in weekly benefits, payment of salary during period of compensability, classification, or rating of disability, a Form WC-2 shall be filed with the Board. An injured employee who receives regular wages during disability shall not be entitled to weekly benefits for the same period.
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To controvert in whole or in part the right to income benefits or other compensation, use Forms WC-1 or WC-3. Failure to file the Forms WC-1 or WC-3 before the 21st day after knowledge of the injury or death may subject the employer/insurer to an assessment of penalties or attorney's fees. See paragraphs (2) and (3) of subsection (b) of O.C.G.A. § 34-9-108.
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Any penalty for late payment shall be stated as a separate item on Forms WC-1, WC-2 or WC-2A.
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Accrued benefits payable under the terms of an award are due on the date the award is issued.
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Within 30 days after final payment of compensation, a final Form WC-4 shall be filed with the Board.
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Subsection (h) of O.C.G.A. § 34-9-221 applies only when income benefits are being paid under Forms WC-2, WC-2A, or subsection B of Form WC-1. To suspend payment on the ground of a change in condition, file Forms WC-2 or WC-2A.
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(1)Suspension of benefits at any time on the ground of change in condition requires advance notice of 10 days unless the employee has actually returned to work.
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If suspending benefits for release to return to work without restrictions, and if filing via EDI, section (i)(4)(a) shall be followed and the employer/insurer shall simultaneously mail to, or electronically file with, the Board the filed Subsequent Report of Injury (SROI) or Form WC-2 and a copy of the supporting medical report from employee's authorized treating physician.Pursuant to Board Rule 60(c), all documents filed with the Board shall contain the employee's name, date of injury, and Board claim number.Any document that does not contain this information shall be rejected by the Board. Copies of all filings shall be served on the employee and the employee's attorney, if represented.If service is performed by regular mail to the employee, three additional days shall be added to the prescribed notice period.
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The Board will consider an application for a lump sum payment of all remaining income benefits or a lump sum advance of a portion of the remaining income benefits, but will not consider any application unless benefits have been continued for at least 26 weeks. The employer/insurer may make a lump sum payment or lump sum advance without commutation of interest and without an award from the Board.
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In lieu of a hearing, the Board will consider applications for lump sum advances and lump sum payments in accordance with the following procedure:
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A petition for the Board to appoint a temporary conservator to bring or defend an action under this chapter and/or receive and administer workers' compensation benefits for a minor or incompetent adult should be filed with the Board at the time the WC-14 is filed.In the case of any stipulated settlement, a conservatorship petition shall be filed prior to, and separately from, the filing of a stipulated settlement agreement.
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Any applicant for conservatorship shall consent to a criminal history record check via a Form WC-226(a) or Form WC-226(b) at the time the petition for conservatorship is submitted to the Board. In addition, the applicant shall attach supporting documentation necessary to process the request.
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If a petition is filed on behalf of a minor child or children, the petitioner shall inform, in writing, the Board whether the minor child or children reside with the petitioner.
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If a petition is filed with the Probate Court or any other court, the parties are directed to immediately notify, in writing, the Board.If the Probate Court or any other court appoints a conservator, the parties shall file a copy of the order with the Board.
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(1)All objections shall be made on Form WC-102D. When attaching documents as evidence to objections, do not use tabs to separate documents.
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For suspension and reinstatement of income benefits by interlocutory order generally, see Board Rule 102D.
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When an employee unjustifiably refuses to accept employment which has been approved by the authorized treating physician(s) suitable to his/her impaired condition and offered to the employee in writing, the employer/insurer may suspend payment of income benefits to that employee without an order of the Board in the following manner:
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A description of the essential job duties to be performed, including the hours to be worked, the rate of payment, and a description of the essential tasks to be performed;
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The written approval of the authorized treating physician(s) of the essential job duties to be performed;
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The location of the job, with the date and time that the employee is to report to work.
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Should the employee accept the employment offered by the employer/insurer and attempt the proffered job for eight cumulative hours or one scheduled workday, whichever is greater, but fail to continue working for more than the prescribed fifteen (15) scheduled work days, the employer/insurer, whether or not they have sent a WC-240, shall immediately reinstate payment of income benefits and shall file with the Board and serve upon the employee the appropriate Form WC-2 reflecting the reinstatement of income benefits.
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Failure to immediately reinstate benefits pursuant to Board Rule 240 (c), shall result in the waiver of the employer/insurer's defense of the suitability of employment for the period of time the employer/insurer did not pay the employee's weekly income benefits when due.
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When the employer/insurer immediately reinstates benefits pursuant to Board Rule 240 (c), the employer/insurer are entitled to seek reimbursement of such benefits at a hearing addressing the suitability of the proffered employment.
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When calculating the fifteen (15) scheduled work days provided by statute, the employer/insurer shall include as a work day each day or part thereof during which the employee is scheduled to perform his/her job duties.
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The employer/insurer shall also be entitled to suspend payment of weekly benefits to the employee pending a hearing by an order of the Board finding an unjustifiable refusal of the employee to accept employment procured for him/her suitable to his/her capacity.A motion requesting this order may be made simultaneously with the filing of a request for hearing or at any time during the pendency of the hearing and award and shall be filed on Form WC-102D, and must be accompanied by an affidavit from the employer setting forth that suitable employment has been offered to the employee as set forth in (b) above, the offer is continuing, and analysis of the job is attached. The employer/insurer shall have the employee examined by the authorized treating physician(s) within 60 days prior to this request for suspension of income benefits.No request for suspension of income benefits for failure to accept suitable employment shall be granted unless the authorized treating physician(s) approve(s) the job offered by the employer/insurer. A party who objects to this motion shall file their response on Form WC-102D with the Board within 15 days of the date of the certificate of service on the request, and shall serve a copy on all counsel and unrepresented parties.
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The Board may also issue an interlocutory order reinstating weekly income benefits pending a hearing.A party making this motion shall file Form WC-102D, and shall serve a copy, along with a copy of supporting documents, on all counsel and unrepresented parties.A motion requesting this order may be made simultaneously with the filing of a request for hearing based on a change in condition or at any time during the pendency of the hearing and award and must be accompanied by an affidavit of the employee setting forth his contentions, along with current medical records when applicable. A party who objects to this motion shall file Form WC-102D with the Board within 15 days of the date of the Certificate of Service on Form WC-102D and shall serve a copy on all counsel and unrepresented parties.
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In the event the employee's weekly benefits are suspended pursuant to O.C.G.A. 34-9-240(b)(2), the employer/insurer shall comply with O.C.G.A. 34-9-263 and Board Rule 263.
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A provider of disability benefits who requests reimbursement shall file Form WC-244 with the Board, and shall serve a copy on all counsel and unrepresented parties.
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Form WC-244 shall provide supporting documentation including the policy/plan provision authorizing the provider to obtain reimbursement and an explanation of any dispute and shall be submitted to the Board by the party seeking reimbursement during the pendency of the claim.
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Computation of wages shall include, in addition to salary, hourly pay, or tips, the reasonable value of food, housing, and other benefits furnished by the employer without charge to the employee which constitute a financial benefit to the employee and are capable of pecuniary calculation.
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Unless the contrary appears, it is assumed that a normal workweek is five days, that the normal workday is eight hours, and that the employee's daily wage is one-fifth of the weekly pay. Fractional parts of a day shall be credited proportionately in computing the daily wage. For example, the daily wage of a five-and-one-half day worker is the weekly wage divided by 5.5.
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If the employee has similar concurrent employment the wages paid by all similar concurrent employers shall be included in calculating the average weekly wage.
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The average weekly wage the employee is able to earn after the injury may be determined according to the method of computation in O.C.G.A § 34-9-260(1).
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For the purposes of calculating temporary partial benefits as contemplated by O.C.G.A. § 34-9-104(a)(2), see method of calculation set forth in O.C.G.A. § 34-9-104(a)(3).
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When paying weekly temporary partial disability income benefits, file a Form WC-262 with the Board at 13 week intervals or when such benefits are suspended, whichever comes first.When filing the Form WC-262 with the Board, send a copy to the employee and the employee's counsel, if represented.
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"Applicant" means an employee entitled to workers' compensation benefits.
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"Board" means the State Board of Workers' Compensation.
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"Board of trustees" means the Board of trustees of the Fund.
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"Company" means a corporation, association, partnership, proprietorship, firm, or other form of business organization.
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"Fund" means the Self-Insurers Guaranty Trust Fund.
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"Insolvent self-insurer" means a self-insurer who files for relief under the Federal Bankruptcy Act, a self-insurer against whom involuntary bankruptcy proceedings are filed, or a self-insurer for whom a receiver is appointed in a federal or state court of this state or any other jurisdiction or a self-insurer who is determined by the Board to be in noncompliance with workers' compensation obligations or requirements according to rules and regulations of the Board.
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"Participant" means a self-insurer who is a member of the Fund.
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"Self-insurer" means a private employer, including any hospital authority created pursuant to the provisions of Article 4 of Chapter 7 of Title 31, the "Hospital Authorities Law," that has been authorized to self-insure its payment of workers' compensation benefits pursuant to this Chapter, except any governmental self-insurer or other employer who elects to group self-insure pursuant to Code Section 34-9-152, or captive insurers as provided for in Chapter 41 of Title 33, or employers who, pursuant to any reciprocal agreements or contracts of indemnity executed prior to March 8, 1960, created funds for the purpose of satisfying the obligations of self-insured employers under this chapter. A "self-insurer" shall further not include any individual or company who enters into a contract or agreement with an employer under which the employer outsources its workers' compensation risks, responsibilities, obligations or liabilities to such individual or company; and pursuant to such contract or agreement, is required to provide workers' compensation benefits to an injured employee even though no common-law master-servant relationship or contract of employments exists between the injured employee and the individual or company providing the benefits.
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"Trustee" means a member of the Self-Insurers Guaranty Trust Fund Board of Trustees.
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The purpose of creating a Self-Insurers Guaranty Trust Fund is to make payments in accordance with this chapter for the benefit of workers injured on the job in the event a participant becomes insolvent. The Fund shall be administered by an administrator appointed by the Chairperson of the Board of trustees with approval of the Board of trustees. The fund assets shall be invested only in obligations issued or guaranteed by the United States government.
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All returns on investment shall be retained by the Fund. In addition to paying benefits, and administrative fees, operating costs of the fund, attorneys' fees incurred by the Board of trustees and other costs reasonably incurred by the Board will be paid from this Fund.
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As a condition of self-insurance all private employers must make application and be accepted in the Self-Insurers Guaranty Trust Fund.
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Membership in the Fund shall not be permitted for any of the following:
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Self-insurers must give written notice to the Board when they add or delete subsidiaries, affiliates, divisions or locations to their self-insurance certificate, or make any changes in their excess insurance policies. (See Rule 126(c).)
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Each member of the Board of trustees shall be an employee of a participant. The Board of trustees shall consist of a chairperson and six trustees elected by the participants. The Board of trustees shall initially be appointed by the Governor not later than August 1, 1990. Three of the initial trustees shall be appointed for terms of office which shall end on January 1, 1993, and the chairperson and the three other initial trustees shall be appointed for terms of office which shall end on January 1, 1995. Thereafter, each trustee shall be elected to a four-year term and shall continue to serve unless otherwise ineligible under subsection (b) of this Code section. No later than 90 days prior to the end of any member's term of office, the chairperson shall select a nominating committee from among the participants to select candidates for election by the participants for the following term. In the event the chairperson fails to complete his or her term of office, a successor will be elected by the Board of trustees to fill the unexpired term of office.
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A vacancy in the office of the Board of trustees shall occur for the following reasons:
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The Board of trustees may remove any trustee from office for:
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The Board of trustees, within 30 days after the office of any elected member becomes vacant, shall elect a successor for the unexpired term.
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Submit to the Board, for approval within 90 days from appointment, bylaws, rules, regulations, resolutions and application fee of $500.00. Board of trustees may carry out its responsibilities by contract or other instrument; may purchase services, borrow money, purchase excess insurance, levy penalties and fines, and collect funds necessary to effectuate its activities. The Board of trustees shall appoint, retain and employ staff necessary to achieve the purposes of the Board of trustees with expenses incurred paid from the Fund.
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The Board of trustees shall meet quarterly or upon the call of the chairman issued to the trustees in writing not less than 48 hours prior to the day and hour of the meeting; upon a request submitted to the chairman 72 hours prior to the proposed day and hour by a majority of the trustees whereupon the chairman will provide notice as set forth above or by unanimous written agreement of the trustees.
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Any trustee may participate in a meeting of the board of trustees by telephone conference or similar communications technology which allows all individuals participating in the meeting to hear and speak with each other.Participation in a meeting pursuant to this subparagraph shall constitute presence at such meeting.
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Four trustees constitute a quorum.
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The Board of trustees shall serve without compensation; each member will be entitled to reimbursement for actual expenses incurred in the discharge of his official duties.
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The Board of trustees shall have the right to bring and defend actions in the name of the Fund. The administrator, the trustees, employers, agents, and employees shall not be liable jointly or individually for matters arising from or out of authorized conduct of the Fund in accordance with this article.
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Within 30 days of the occurrence of filing for relief under the Federal Bankruptcy Act or against whom bankruptcy proceedings are filed or for whom a receiver is appointed, the participant shall file a written notice with the Board and the Board of trustees.
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Any individual who files an application for adjustment of a claim against a participant who is or becomes an insolvent self-insurer shall file a written notice of such participant's status with the Board and the Board of trustees within 30 days of such individual having knowledge of the participant becoming an insolvent insurer.
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Upon receipt of any notice as provided in subsections (a) and (b) of this Code Section, the Board shall determine whether the participant is an insolvent self-insurer. The Board of trustees shall refer for investigation all facts, circumstances, and information in its possession to a properly designated authorized certified public accountant for determination of the question of insolvency according to generally accepted accounting principles. Upon receipt of the notice referenced herein, a participant shall be required to execute a release of any and all financial information, banking records, books of account, tax returns or other records determined by the Board of trustees to be necessary in making a determination of insolvency and the participant shall assist in the production of said information when requested to do so by the Board of trustees.
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When a participant is determined to be an insolvent self-insurer, the Board of trustees is empowered and shall assume on behalf of the participant the following:
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The fund shall be a party in interest in all proceedings in the payment of workers' compensation claims for a participant and shall be subrogated to the rights of the participant. The Fund may exercise all rights and defenses of the participant including:
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Should payment of benefits be stayed in bankruptcy court, the Board of trustees or a designated representative shall appear in the bankruptcy court and move to lift the stay.
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The Board of trustees shall notify all employees with pending claims of the name, address and telephone number of the party administering and defending against their claim.
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The Board has the discretion to direct the Fund to pay, in whole or in part, the contractual fee arrangement between an attorney and a claimant pursuant to § 34-9-108(a).The attorney must apply to the Board and provide notice to the employee with a pending claim.Any party may make an objection to the application and all objections will be considered by the Board.
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This code section shall not impair any claims, to the extent those claims are unpaid, in the insolvent self-insurer's bankruptcy by the board of trustees, any employees, or any provider of services related to the insolvent self-insurer's workers' compensation obligations, to the extent those claims remain unpaid. Provider of services includes, but is not limited to, medical providers or the attorneys representing the insolvent self-insurer or the claimant, if the services provided are related to the insolvent self-insurer's workers' compensation obligations.
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(1)The Board of trustees shall, commencing January 1, 1991, assess each participant in accordance with paragraph (2) of this subsection. Upon reaching a funded level of $15 million, all annual assessments against participants who have paid at least three prior assessments shall cease except as specifically provided in paragraph (4) of this subsection.
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Levy fines or penalties;
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Proceed in court for judgment against the participant, including the amount of the assessment, fines, penalties, the costs of suit, interest, and reasonable attorneys' fees;
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Proceed directly against the security pledged by the participant for the collection of same; or
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Seek revocation of the participant's self-insured status.
The organization of the Board of Trustees of the Subsequent Injury Trust Fund shall be as follows:
Authority O.C.G.A. Sec. 34-9-354(d). Administrative History. Original Rule entitled "Board of Trustees" was filed on May 26, 1987; effective June 15, 1987.
Authority O.C.G.A. Sec. 34-9-354(d). Administrative History. Original Rule entitled "Cost of Administration: Budget" was filed on May 26, 1987; effective June 15, 1987.
For accident dates prior to July 1, 1995, the employers' payments to the Subsequent Injury Trust Fund in no-dependency death cases will be initiated through the use of a Subsequent Injury Trust Fund Form "F", referred to as a "No Dependency Agreement."This agreement must be submitted to the State Board of Workers' Compensation for approval and, upon approval, the employer will process the payment in accordance with Code Section 34-9-358.
Authority O.C.G.A. Sec. 34-9-354(d). Administrative History. Original Rule entitled "Payment of Non-Dependency Benefits into the Subsequent Injury Trust Fund" was filed on May 26, 1987; effective June 15, 1987. Amended: F. June 16, 1995; eff. July 12, 1995.
Each insurer and self-insurer shall make payments to the fund in an amount equal to that proportion of 175 percent of the total disbursement made from the fund during the preceding calendar year less the amount of the net assets in the fund as of December 31 of the preceding calendar year which the total workers' compensation claims paid by the insurer or self-insurer bears to the total workers' compensation claims paid by all insurers and self-insurers during the preceding calendar year. The administrator is authorized to reduce or suspend assessments for the fund when a completed actuarial survey shows further assessments are not needed. Adjustments relative to any prior years' assessment will be added to or credited against each insurer's or self-insurer's most recent calendar year's assessment when total claims losses reported to the fund necessitated revising the prior years' assessment rate. An employer who has ceased to be a self-insurer prior to the end of the calendar year shall be liable to the fund for the assessment of the calendar year and/or the adjusted assessment, if any, of the previous calendar years.
Authority O.C.G.A. Sec. 34-9-354(d). Added: effective Dec. 9, 1998.
Authority O.C.G.A. Sec. 34-9-354(d). Added: effective Dec. 9, 1998.
Authority O.C.G.A. Sec. 34-9-354(d). Administrative History. Original Rule entitled "Filing Claims Against the Subsequent Injury Trust Fund" was filed on May 26, 1987; effective June 15, 1987.Amended: F. Dec. 20, 1990; eff. Jan. 9, 1991. Amended: July 1, 1998. Amended: July 11, 2000.
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(1)The Fund shall be liable for claims arising out of injuries occurring after January 1, 1991; provided, however, no claim may be asserted against the Fund until the funding level has reached $1.5 million.
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A participant who ceases to be a self-insurer shall be liable for any and all assessments, penalties and fines made pursuant to this code section for so long as indemnity or medical benefits are paid for claims which originated when the participant was a self-insurer. Assessments of such a participant shall be based on the indemnity benefits paid by the participant during the previous calendar year.
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Upon refusal to pay assessments, penalties, or fines to the Fund or upon refusal to comply with a board order, the Fund may treat the self-insurer as being in default with this Chapter and the self-insurer shall be subject to revocation of its Board authorization to self-insure and forfeiture of its security.
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The Board of trustees shall have the right and duty to obtain reimbursement from any participant for compensation obligations in the amount of the participant's compensation obligations assumed by the Board of trustees and paid for claims as well as reasonable administrative and legal costs. The amount of the claims for reimbursement of reasonable administrative and legal costs shall be approved by the Board of trustees.
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The Board of trustees shall have the right to use the security deposit of a participant, its excess insurance coverage, and any other guarantee to pay the participant's workers' compensation obligations assumed by the Board of trustees including reasonable administrative and legal costs.The amount of the claims for reimbursement of reasonable administrative and legal costs shall be subject to the approval of the Board of trustees.
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The Board of trustees shall be a party in interest in any action or proceeding to obtain the security deposit of a participant for the payment of the participant's compensation obligations, in any action or proceeding under the participant's excess insurance policy, and in any other action or proceeding to enforce an agreement of any security deposit; or captive or excess insurance carrier; and from any other guarantee to satisfy such obligations.The fund is authorized to file a claim against an insolvent participant or the participant's agents and seek reimbursement for any payments made by the fund on behalf of the participant pursuant to this chapter.The fund is subrogated to the claim of any employee whose benefits are paid by the fund.Further, the find shall have a lien against any reimbursement payments the participant is entitled to from the Subsequent Injury Trust fund in an amount equal to the payments made by the fund to satisfy the participant's liability for workers' compensation benefits.
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Report to Board of trustees when the Board has cause to believe participant examined may be in danger of insolvency.
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The Board shall, at the inception of the participant's self-insured status and at least annually thereafter, so long as the participant remains self-insured, furnish the Board of trustees with a complete, original bound copy of each participant's audited annual financial statement performed in accordance with generally accepted accounting standards by an independent certified public accounting firm, three to five years of loss history, name of the individual or company to administer claims, and any other pertinent information submitted to the Board to authenticate the participant's self-insured status. The Board of trustees may contract for the services of a qualified certified public accountant or firm to review, analyze, and make recommendations on these documents. All financial information submitted by a participant shall be considered confidential and not public information.
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The Board of trustees shall make reports and recommendation to the Board on any matter germane to solvency, liquidation or rehabilitation of any participant. Reports and documents shall not be considered public documents.
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The Board of trustees shall review all applications and shall make recommendations to the Board for acceptance of self-insurers. If the Board rejects the recommendations of the Board of trustees, the Board shall notify the Board of trustees in writing within ten days prior to accepting the application for self-insurance.
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Meetings are to be held at least quarterly.
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Special meetings can be held upon reasonable notice in writing to Board Members by the Chairman or any two voting members.
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Three voting members must be present to constitute a quorum for conducting business.
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Time, place, names of those present, all official action of the Board, and when requested, a member's approval or dissent with reasons shall be recorded in the Minutes.
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The Administrator shall cause the Minutes to be transcribed and presented for approval or amendments at the next regular meeting.
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Minutes, or a true copy, shall be open for inspection during regular office hours.
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As soon as practicable after January 1 but not later than January 31 of each calendar year, the administrator shall forward to each insurer and self-insured employer a questionnaire asking for the total amount of compensation, medical benefits, and rehabilitation benefits paid by each insurer and self-insurer employer during the preceding calendar year. The total amount shall consist of all gross paid losses consisting of indemnity, medical, and rehabilitation benefits paid including those paid through deductibles and self-insured retentions. The insurer or self-insurer may deduct from the gross paid losses those amounts the Subsequent Injury Trust Fund paid during the preceding calendar year, third party (Workers' Compensation) recoveries, and losses under federal compensation laws. Insurers and self-insured employers cannot use paid Workers' Compensation Board and Subsequent Injury Trust Fund assessments to reduce gross claims payments reported. This report is to be completed and returned to the administrator no later than March 1 of the same calendar year in which the request for this information is submitted. Failure to submit the report to the administrator carrying a post mark date on or prior to March 1 shall result in an automatic penalty of $50.00 per day for each day the report is delinquent or 10 percent of the assessment, whichever is greater. This penalty will be added to the assessment.
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Any assessment levied or established in a specified amount shall constitute a personal debt of every employer or insurer so assessed and shall be due and payable to the Subsequent Injury Trust Fund when payment is called for by the administrator. In the event of failure to pay any assessment upon the date determined by the administrator, the administrator may file a complaint for collection against the employer or insurer in a court of competent jurisdiction.
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Employer's knowledge statement pursuant to Rule 622-1-.05 of the Rules and Regulations of the Subsequent Injury Trust Fund;
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Documentation supporting merger between the subsequent injury and prior impairment; and
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Proof of payment of weekly income benefits to the injured employee in excess of 104 weeks and/or payments for medical benefits in excess of $5,000.00.
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The required format to complete the above will be available from the Subsequent Injury Trust Fund or its website.
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Failure to provide certification as required above, or if evidence indicates failure to reduce reserves, reimbursement from Subsequent Injury Trust Fund will be suspended.
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If the employee, in a case accepted by the Subsequent Injury Trust Fund for reimbursement, returns to work with the same employer, and the same employer has exhausted both indemnity and medical deductibles, the Subsequent Injury Trust Fund will resume reimbursements without further deductibles applicable to the employer.
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In the above example, if the employee returns to work and sustains a new injury, and the employer has exhausted the indemnity deductible but not the medical deductible, the Subsequent Injury Trust Fund will resume indemnity reimbursements without further indemnity deductibles applicable to the employer, and the employer will exhaust the remaining portion of the medical deductible on the previous accident that resulted in Subsequent Injury Trust Fund acceptance for reimbursement before the Fund will reimburse medical expenses.
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If the employee returns to work and sustains a new accident, and the employer has not exhausted the indemnity deductible but has exhausted the medical deductible, the Subsequent Injury Trust Fund will resume reimbursement of medical expenses with no further medical deductibles applicable to the employer.The employer will be required to exhaust the remaining indemnity deductible as a result of the previous claim that required Subsequent Injury Trust Fund reimbursement before the Fund will reimburse indemnity expenses.
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Paragraphs (a), (b) and (c) will apply in the event a new insurer has assumed coverage for the employer.
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This provision does not apply if the employee returns to work for a new employer or there has been a break in service by the employee and employer.
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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.
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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.
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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.
Authority O.C.G.A. Sec. 34-9-354(d). History. Original Rule entitled "Procedures for Payment of Reimbursement Benefits by the Fund" was filed on May 26, 1987; effective June 15, 1987. Amended: F. Dec. 20, 1990; eff. Jan. 19, 1991; F. June 16, 1995; eff. July 12, 1995; eff. June 18, 1998; eff. July 1, 1998; eff. July 11, 2000; eff. Apr. 7, 2002; eff. Dec. 31, 2002.
After the employer/insurer and the administrator of the Subsequent Injury Trust Fund reach an agreement with respect to reimbursement and the reimbursement agreement is approved by the State Board of Workers' Compensation, the employer/insurer shall keep the administrator of the Subsequent Injury Trust Fund informed as to any settlement discussion with the employee. The employer/insurer shall obtain the approval of the Subsequent Injury Trust Fund administrator on all settlements entered into for the employer.
Authority O.C.G.A. Sec. 34-9-354(d). Administrative History. Original Rule entitled "Settlements Subsequent to Reimbursement Agreements" was filed on May 26, 1987; effective June 15, 1987; F. June 16, 1995; eff. July 12, 1995; eff. July 1, 1998.
Where the Subsequent Injury Trust Fund has been placed on notice of a potential claim against the Fund, the employer/insurer shall keep the Fund advised and cooperate with the administrator or his designee while defending the claim. Where the administrator or his designee acknowledges in writing that the Fund does not raise an objection to the manner in which the claim is defended or resolved, the Fund will not raise Code §34-9-366 as a defense to reimbursement liability by the Fund; provided, however, that the Fund reserves the right to intervene where the administrator or his designee deems it appropriate.
Authority O.C.G.A. Sec. 34-9-354(d). Administrative History. Original Rule entitled "Fund Not Bound as to Certain Matters" was filed on May 26, 1987; effective June 15, 1987; F. June 16, 1995; eff. July 12, 1995.