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Policy and Procedure Name:
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Federal Black Lung Claims (aka Coal Miners’
Pneumoconiosis)
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Policy #:
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CP-06-05
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Code/Rule Reference:
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R.C. 4131.01; R.C. 4131.03; R.C. 4131.05; O.A.C. 4123-21-08;
30 U.S.C.801
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Effective Date:
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07/22/19
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Approved:
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Kevin R. Abrams, Chief Operating Officer
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-06-05, effective 06/15/16 and Procedure # CP-06-05.PR1,
effective 11/14/16
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History:
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CP-06-05
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New 06/15/16
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CP-06-05.PR1
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Rev. 11/14/16; New 06/15/16
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Federal Black Lung Claims Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
B reader
Coal Workers’ Pneumoconiosis Fund
Federal Black Lung Benefits Program
IV. POLICY
A. General Policy
Statement
B. Questions:
V. PROCEDURE
A. Standard Claim File
Documentation
B. General Provisions
C. U.S. Department of Labor
(DOL) Inquiry and Notice of Claim
D. DOL Schedule for
Submission of Additional Evidence
E. DOL Proposed Decision
and Order
F. Paying Compensation and
Medical Benefits
G. Death Claims
H. Disputes
The purpose of this policy is to ensure that when a coal
mine operator has black lung coverage through BWC, BWC provides the coal miner
and/or the coal miner’s dependents any benefits required by the U.S. Department
of Labor (DOL).
This policy applies to BWC Field Operations.
B reader:
A physician certified by the National Institute for
Occupational Safety and Health (NIOSH) as demonstrating proficiency
in classifying radiographs
of pneumoconiosis.
Coal Workers’
Pneumoconiosis Fund: A separate state of Ohio compensation
fund created pursuant to R.C. 4131.01 to 4131.06, for the payment of
compensation and benefits under the Federal Black Lung Benefits Program.
Federal Black
Lung Benefits Program: A federal program administered by the
DOL that provides monthly payments and medical benefits to coal miners totally
disabled from black lung disease arising from employment in or around the
nation's coal mines and to a coal miner's dependent survivors when the coal
miner dies due to black lung disease.
1. It is the
policy of BWC to:
a. Respond to
requests from the DOL for workers’ compensation information on a coal miner; and
b. Respond to
notifications of Federal Black Lung claims from the DOL.
2. When the
DOL finds BWC to be the insurer for the responsible operator on a Federal Black
Lung claim and orders compensation:
a. BWC shall
disburse payments to the coal miner or the dependents from the coal workers’
pneumoconiosis fund as the order directs; and
b. Manage the
claim in compliance with DOL requirements.
3. It is the
policy of BWC that BWC may:
a. Represent
the interest of the coal workers’ pneumoconiosis fund in all proceedings
pertinent to a contested (controverted) claim; and
b. Charge all
administrative costs associated with administering the claim, including the
representation expenses it incurs, to the coal workers’ pneumoconiosis fund.
4. It is the
policy of BWC that Federal Black Lung claims are not subject to:
a. Deduction
for family support orders;
b. The provisions
for the disabled workers’ relief fund (DWRF); and
c. Deduction
for the purposes of recoupment of overpayment in a BWC state fund claim.
1. Questions concerning
Federal Black Lung claims shall be directed to the U.S. Department of Labor,
Columbus, Ohio Black Lung District Office Toll-Free number: 1-800-347-3771; or
2. BWC Black
Lung Office (Special Claims Department) 614-466-9903.
3. All other
coal miners’ black lung disease claims that do not fall within the scope of the
Federal Black Lung benefits program, are processed in accordance with the Occupational
Disease policy.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note requirements; and
2. Shall
follow any other specific instructions for claim notes included in this
procedure.
1. BWC staff
shall recognize that this procedure provides direction on BWC-specific
procedures and general guidance on the federal procedures and requirements for
claims qualifying under the Federal Black Lung Benefits Program.
2. BWC staff
shall consult with the BWC attorney, as needed, regarding the handling of a
Federal Black Lung claim.
3. The BWC
Special Claims Department shall handle Federal Black Lung claims and inquiries,
unless otherwise assigned by Field Operations management.
4. References
to specific federal forms within this procedure are for the convenience of
Special Claims staff.
a.
Special Claims staff may locate most Federal Black Lung forms on the
Department of Labor (DOL) Division of Coal Mine Workers' Compensation (DCMWC)
website.
b.
If a particular Federal Black Lung form is not available on the DOL
website, Special Claims staff shall contact and obtain the form from the DOL.
c.
Special Claims staff shall always follow the direction of the DOL when
any of the Federal Black Lung forms or requirements change.
1. Upon
receipt of a Request for State or Federal Workers’ compensation Information”
(CM-905) form from the DOL – Division of Coal Mine Workers’ Compensation,
Special Claims staff shall:
a. Search
the claims management system for the information requested using the coal
miners’ name and Social Security number; and
b. Provide
the information requested to the DOL in a timely manner.
2. Notice of
Claim from the DOL
a. When
a “Notice of Claim” for black lung is received from the DOL, Special Claims
staff shall search the claims management system for any existing Federal Black
Lung claim.
i. If
no claim currently exists, Special Claims staff shall obtain a claim number
utilizing the following information:
a) Name;
b) Social
Security Number;
c) Date of
birth;
d) Address;
e) Date of
filing (equals the Date of Injury);
f) Employer
name; and
g) Employer
policy number.
ii. If
a Federal Black Lung claim number does exist, field staff shall use the
existing claim number.
b. Special
Claims staff shall complete an Operator Response to Notice of Claim
(CM-2970a) and return it to the DOL within 30 days of receipt.
i. Special
Claims staff shall deny liability on the part of BWC (referred to as the “operator”
by the DOL).
ii. Other
parties to the claim are not copied on this response.
c. The
BWC attorney may file a motion with the DOL to dismiss the claim if it is
determined BWC is not the appropriate carrier or for any other legal reason.
1. Upon
receipt from the DOL of a Schedule for Submission of Additional Evidence
(SSAE), Special Claims staff shall:
a. Prepare
an Operator Response to Schedule for Submission of Additional Evidence
(CM-2970) when:
i.
Disagreeing with the designation of BWC as the responsible operator
liable for the claim; and
ii.
Contesting the claimant’s entitlement to benefits.
b. Return
the CM-2970 to the DOL; and
c.
Refer the claim to the medical services specialist (MSS) for review.
2. The
MSS shall:
a. Determine
if an independent medical examination (IME), including a review by a B-reader,
is needed.
b. Staff
their recommendation with the Black Lung team (legal, field operations).
3. Independent
Medical Exam
a. If
an IME is needed, Special Claims staff shall:
i.
Create a case in the claims management system;
ii.
Prepare and send a letter to the physician inserting the appropriate ad
hoc questions; and
iii.
Prepare and send notice of examination to the:
a) Coal miner
(and his/her representative);
b) DOL; and
c) Employer
(and his/her representative).
b. If
the coal miner does not show for the exam, Special Claims staff shall work with
the coal miner and the physician to reschedule the examination. Special Claims
staff shall not suspend the claim for failing to appear for an examination.
c.
When an examination needs to be rescheduled or there is the possibility
that Special Claims staff will not obtain the exam report within the time
provided by the DOL, Special Claims staff may request from the DOL additional
time to submit evidence in response to the SSAE.
d. Upon
receipt of the IME report and the Service Invoice (C-19), Special Claims
staff shall:
i.
Send a copy of the IME report to the coal miner and the coal miner’s
representative, if applicable, the DOL and the employer and employer’s
representative, as applicable;
ii.
Email a copy of the IME report to the legal representative of the Black
Lung team;
iii.
Send the C-19 or equivalent document for payment to the Medical Billing
and Adjustments (MB&A) department.
e. Special
Claims staff shall reimburse the coal miner’s travel expenses as directed by
the DOL.
i.
Special Claims staff shall consult with the DOL on any unusual travel
expenses or travel reimbursement questions.
ii.
All other processing steps shall follow the Travel Reimbursement
policy and procedure.
f.
Special Claims staff shall refer to the Interpreter Services
policy and procedure when the coal miner requests or demonstrates a need for an
interpreter for BWC scheduled exams. Otherwise, interpreter services shall be
provided at the direction and in the manner directed by the DOL.
1. Withdrawal
of Claim - If Special Claims staff receives notice from the DOL that the coal
miner/claimant has withdrawn his/her claim, staff shall:
a. Dismiss
the claim in the claims management system;
b. Enter
a note in the claims management system reflecting the notification from the DOL
of the withdrawal.
2. Denial
of benefits - If Special Claims staff receives a “Proposed Decision and Order”
(PDO) from the DOL that the claim is denied, Special Claims staff shall:
a. Deny
the claim in the claims management system;
b. Enter
a note in the claims management system reflecting the notification of denial of
the claim from the DOL;
c.
Set a work item in the claims management system for six weeks to contact
the DOL to determine if the coal miner has submitted an appeal/request for
hearing; and
d. If
the coal miner has submitted an appeal/request for hearing, notify the BWC
attorney.
3. Award
of benefits - If Special Claims staff receives a PDO from the DOL that the coal
miner/claimant is entitled to benefits, Special Claims staff shall:
a. Notify
the BWC attorney of the decision (The BWC attorney may contest the award by
requesting a formal hearing before an administrative law judge);
b. Allow
the claim in the claims management system;
c.
Enter a note in the claims management system reflecting that the DOL has
awarded benefits;
d. Prepare
the first payment of benefits as directed by the DOL and consistent with
section V.F.1 below;
e. Sign,
date and return to the DOL the Agreement to Pay Benefits (CM-941) and
Certificate of First Payment of Benefits (CM-906); and
f.
Send a medical benefits letter to the coal miner, which advises the coal
miner that:
i.
His/her application has been approved for Federal Black Lung benefits;
ii.
BWC is the carrier for the Federal Black Lung claim and responsible for
authorizing and paying medical benefits; and
iii.
The coal miner needs to advise all Federal Black Lung health-care and
servicing providers of where and how invoices need to be submitted to BWC.
1. Compensation:
Special Claims staff shall convert the monthly rate provided by the DOL to a
weekly rate by multiplying the monthly rate by twelve (12) months, then
dividing by 52 weeks. Special Claims staff shall then pay compensation bi-weekly.
a. Special
Claims staff shall not apply family support deduction orders or provisions for
the Disabled Workers’ Relief Fund (DWRF) to Federal Black Lung claims.
b. Special
Claims staff shall not recoup an overpayment of a BWC state fund claim from a
Federal Black Lung claim.
c.
Every January, Special Claims staff shall:
i.
Check www.dol.gov/owcp/dcmwc for the current benefit
rate;
ii.
Manually convert the increase to the DOL monthly rate to a weekly rate
that is paid through the claims management system;
iii.
Send the coal miner/claimant and the DOL notice of the wage adjustment;
and
iv. Send
an annual contact letter to the coal miner/claimant.
2. Medical
Benefits
a. Medical
Bills
i.
Special Claims staff shall review any medical service invoice received
for the coal miner to ensure:
a) The
Healthcare Common Procedure Coding System (HCPCS), Current Procedural
Terminology (CPT) and International Classification of Diseases (ICD) codes are
included;
b) The
provider is an enrolled and active BWC provider and the provider number is
included.
i) If
the provider is not enrolled, Special Claims staff shall pend approval of the
medical service invoice; and
ii) Send
the provider the Application for Provider Enrollment and Certification
(MEDCO-13A).
ii.
If the medical service invoice is approved, Special Claims staff shall:
a) Place the
date, initials and his or her “A” number on the invoice;
b) Indicate
if the invoice is approved or denied and if denied, the reason for the denial;
and
c) Send it to
Medical Billing and Adjustments (MB&A).
iii.
If the medical service invoice is disapproved, MB&A will send notice
and the reason for disapproval to the provider and parties to the claim.
b. Request
for Medical Service Reimbursement or Recommendation for Additional Conditions
for Industrial Injury or Occupational Disease (C-9): Special Claims staff
shall refer a C-9 or equivalent to the MSS for review. Based upon the review by
the MSS, Special Claims staff shall:
i.
Approve or deny the C-9 or equivalent request or recommendation;
ii.
Fax the decision to the medical provider’s office; and
iii.
Notify the coal miner by letter of the decision.
3. Reimbursement
to DOL: If Special Claims staff receives a “Request for Reimbursement” from the
DOL, Special Claims staff shall process reimbursement at the full amount as
instructed by the DOL within 10 days, in accordance with BWC procedures for
generating such payment.
1. When
Special Claims staff receives notice that the coal miner with an existing
Federal Black Lung claim has died, field staff shall:
a. Stop
compensation; and
b. Notify
the DOL using the Notice of Termination, Suspension, Reduction, or increase in
Benefit Payments (C-908) that benefit payments have been terminated and the
reason for the termination.
2. Special
Claims staff will take no further action until a PDO is received from the DOL.
3. If
the DOL orders the continuation of compensation to a spouse, ex-spouse, minor
child, full-time student/child, or unmarried disabled adult child, Special
Claims field staff shall pay compensation consistent with section VI.A of this
procedure.
1. Special
Claims staff shall staff disputes in a claim (e.g., claimant’s disagreement
with a compensation rate or disapproval of a medical service invoice) with the
BWC attorney.
2. Disputes
in a Federal Black Lung claim shall not be referred to the Industrial
Commission or to the Alternative Dispute Resolution (ADR) process.
3. Special
Claims staff shall refer claimant inquiries regarding his/her appeal rights
under the Federal Black Lung Program to the Office of Workers’ Compensation
Programs website for national and/or regional Federal Black Lung Program office
phone numbers.