and Procedure Name:
to Work Data
R. Abrams, Chief Operating Officer
# CP-18-01, effective 11/14/16
I. POLICY PURPOSE
purpose of this policy is to ensure that MCO and BWC staff appropriately
verify, update and/or maintain return to work (RTW) data in the claims
policy applies to MCO and claims services staff.
Return to Work (ARTW): The confirmed date the injured worker (IW) returns to
employment, with or without work restriction(s). This may include an IW that
has returned to the workplace with restrictions, but is participating in a
vocational rehabilitation plan such as:
Return to Work.
Return to Work (ERTW): The anticipated date the IW may be able to return to
Date Worked (LDW):
The last date the IW reported to work prior to taking time off, regardless of
the length of time the IW worked on that date.
to Work Data:
Data that includes any combination of the dates related to return to work, last
date worked, estimated return to work, released to return to work or actual
return to work.
to Return to Work (RRTW): The date the physician of record releases the IW to return
to employment (with or without restrictions). This may include an IW that is
released to return to work with restrictions, and is participating in a
vocational rehabilitation service or program such as:
Search/Job Seeking Skills Training;
and Stop Dates:
The beginning and end dates of a working period or a period of disability/off
Replacement Compensation: Compensation intended to replace an IW’s earnings. This
includes temporary total, living maintenance, living maintenance wage loss,
wage loss (working and non-working), permanent total disability and salary
A. It is the policy of BWC
to rely primarily on the managed care organizations (MCO) to provide accurate
return to work data.
B. It is the policy of BWC
to ensure that return to work data is identified, verified, properly updated
and maintained in the claims management system.
A. BWC staff shall refer
to the Standard Claim File Documentation and Altered Documents policy
and procedure for claim-note requirements and shall follow any other specific
instructions included in this procedure.
B. Medical Only Claims:
The MCO shall provide RTW data on medical only claims, which will
systematically update in the claims management system.
1. The MCO shall determine
the LDW, RRTW, ERTW, and ARTW dates based on documentation received and
contained in the claim file or as provided by the employer, injured worker, provider
or other reliable source.
a. The MCO shall exercise
due diligence in obtaining the ARTW date for all medical only claims.
b. Before submitting an
ERTW that results in seven (7) or fewer missed days for a particular disability
period in a medical only claim, the MCO shall contact the provider to verify
the provider intended the RTW to be an ERTW and not an RRTW, and shall document
the contact in notes.
shall not submit an RRTW date as an ERTW. RRTW dates will be captured on the
Claims Maintenance>Claim Dates page in the claims management system.
C. The MCO shall enter
detailed claim notes reflecting all actions taken to gather RTW data. Every
claim note shall include the following:
data was obtained, what those dates are;
and position of the person the MCO spoke to or the name and date of the
document being relied on to determine the reported dates;
the MCO spoke to the person who provided the RTW information, if applicable;
details, including when “other” is noted as a reason the IW has not returned to
work, if needed; and
information relevant to and supporting the RTW data.
D. Lost Time Claims: For
lost time claims, the MCO shall provide the RTW data to claims services staff
via the Electronic Data Interchange (EDI) 148. Claims services staff shall
presume the reliability of the data when accompanied by a detailed MCO note and
enter the data into the claims management system.
E. If the MCO has not
entered a note containing adequate information, or if for any other reason
further verification is needed, claims services staff shall first contact the
MCO, and then, only if necessary, the employer or employer representative, IW
or IW representative, medical provider, vocational rehabilitation provider or
other reliable resource. Claims services staff may also use documentation in
the claim file for verification, as appropriate.
F. ERTW and End of Period
services staff shall enter the initial ERTW date in order to:
a. Calculate days of work
missed and determine if a claim is a medical only or lost time; and
b. Pay any form of
services staff shall reflect a subsequent ERTW date (even if there is a RRTW
date, or a no RTW reason) by entering a stop date (the day before an ERTW) on a
period of disability. This occurs when:
date is received on a MEDCO-14;
d. When wage continuation
information is received from the employer and there is no estimated date
provided on the MEDCO-14 or other medical documentation.
services staff shall enter an ARTW date when:
a. MCO staff has verified
the IW has actually returned to employment; or
b. BWC staff has verified
the IW has actually returned to employment.
2. When entering ARTW
data, claims services staff shall ensure the following is documented in the
claims management system:
c. Whether the RTW was:
duty (i.e., with restrictions); or
(i.e. with no restrictions); and
d. The RTW job being
returned to was:
same employer; or,
job, same employer; or
iii. Same job, different
iv. Different job,
G. No RTW Information
IW is no longer receiving wage replacement compensation and claims services
staff obtains a specific reason why the IW will not be returning to work,
claims services staff shall update the claims management system to reflect one
of the following reasons:
d. Social Security
e. Voluntary workforce
g. School enrollment;
i. Social Security
services staff shall use the “Other” option as a reason for an IW not returning
to work only when no other listed reason is accurate for the situation.
than one reason applies, claims services staff shall provide the additional
reasons in comments.
services staff shall not delete the ERTW date even when one of the reasons
listed above apply.
services staff shall enter the RRTW date on the Claims Maintenance>Claims
Dates screen in the claims management system when provided.
services staff shall recognize that a release to return to work does not
necessarily indicate that the IW will be immediately returning to work or
otherwise that the ERTW date must be altered.
services staff shall not assume the RRTW date and the ERTW date are the same.
I. Claims services staff
shall ensure that all periods of lost time related to the allowed condition(s)
are reflected in the claims management system with appropriately identified
last date(s) worked and return to work date(s), including periods of lost time
when the IW does not receive compensation.
1. Claims services staff
shall ensure that compensation is not paid over periods of ineligibility.
2. Claims services staff
shall not delete periods of lost time from the claims management system unless
the periods are incorrect.
3. Example 1: The IC has
issued an order which states that temporary total disability (TT) is denied
because the IW violated a written work rule and was fired, and thus the IW
voluntarily abandoned the job. In this case, in the disability management
window in the claims management system, the disability type selected is “off work-ineligible
for compensation”, medical status is “not released”, work status is “no RTW”
and the “reason” is “voluntary workforce abandonment.”
4. Example 2: The IC has
issued an order which states that TT is not payable because the IW lost time from
work because of some reason other than the allowed conditions in the claim. In
this case, in the disability management window in the claims management system,
the disability type selected is “off work-ineligible for compensation”, medical
status is “not released”, work status is “no RTW” and the “reason” is “no
supporting medical documentation.” In addition, if an end date was entered into
the previous working period, the end date should be removed.
The MCO approves surgery for an allowed condition, but the IW does not request
compensation for that period of lost time. In this case, on the disability
management window in the claims management system, the disability type selected
is “off work-ineligible for compensation”, medical status is “not released”,
work status is “no RTW” and the “reason” is “Other” and then enter a comment
indicating compensation not requested, to prevent payment of compensation. A
second row is created and is sent electronically to the MCO to reflect the correct
status. The new row is largely identical, except the disability type is “off
work”, medical status is “not released”, work status is “no RTW”, and the
“reason” is “other.”
J. Permanent Total
1. If the IW is receiving
non-statutory PTD, claims services staff shall remove any ARTW or ERTW date
which is after the most recent last date worked.
2. If an IW is receiving statutory
PTD compensation claims services staff may enter RTW data without affecting
compensation related to the statutory PTD.