DI 52145.005: Obtaining Verification/Proof from Outside Sources

changes
←	*	→

~~Effective Dates: 07/31/2017 - Present~~
Effective Dates: 04/04/2018 - Present
BASIC (09-08)
DI 52145.005 Obtaining Verification/Proof from Outside Sources
This section explains how to identify possible sources of WC/PDB information and how to obtain the necessary information from WC/PDB carriers and other outside sources if the number holder (NH) or attorney cannot or will not provide verification.
A. Sources and types of verification
Follow the rules for evidence in GN 00301.015, GN 00301.050, GN 00301.095, and GN 00301.305. If the evidence appears amended or altered, question the evidence. Uncertified photocopies, faxes, etc. received directly from the WC/PDB payer are acceptable evidence of WC or PDB payments as long as there is no reason to question the validity of the information.
NOTE: The information obtained by direct access from WC carriers, state agencies, etc., with or without the NH’s consent, is a third party report. Therefore, advance notification (due process) is required prior to making any adverse adjustment to claimants’ benefits based solely on those records. See GN 03001.025 - Processing Third Party Reports and due process notices in NL 00703.511 - NL 00703.513.
The following are examples of evidence from outside sources that would provide proof of payment.
1. Form SSA-1709 (Request for Workers’ Compensation/Public Disability Benefit Information)
To obtain Form SSA-1709, see OS 15020.295.
If the agency objects to using the SSA-1709, use their form if it provides substantially all of the information requested on the SSA-1709 as described in DI 52145.010.
2. Alternative verification
Use the following for verification of WC/PDB amounts:
* WC award notice
* Copy of court order
* Copy of WC check
* WC check stub
* Computer printout from State records
* Documented direct phone contact with the WC/PDB payer.
B. State WC
Obtain verification for State WC from:
* Insurance carriers,
* State WC agency, board, commission, on-line records, if available,
* Self-insured employer,
* Courts,
* Federal, State or local government entity established to pay WC.
C. Federal WC
Obtain verification for Federal WC from:
* The Office of Workers’ Compensation Payments (part of DOL) servicing the State in which the NH is receiving payments for Federal Employees Compensation Act (FECA) See DI 52115.010.
* The Office of Workers’ Compensation Payments or the insurance carrier for the Longshoreman and Harbor Workers’ Compensation Act (LHWCA). See DI 52115.005.
D. Public disability benefits (PDB)
1. Payments
Verify any PDB payment using any applicable procedures used for WC benefits.
NOTE: WC benefits are usually paid by the insurance carrier and not by the employer. A carrier can also pay a PDB. Make sure that the PDB is paid pursuant to a Federal, State, or local law or plan and is not a private disability insurance benefit. (See DI 52125.001 for PDB information).
2. PDB causes offset
Verify the amount, dates paid, etc. of any PDB that causes offset.
3. Covered service exclusion met
Verify the total service used to establish the PDB and the amount of covered service according to the rules in DI 52125.001.
4. Possible reverse offset
Verify whether the PDB is offsettable or is excluded from offset due to reverse jurisdiction per DI 52105.001 – Public Disability Benefit (PDB) Rules and Definitions.
5. Civil Service Retirement System (CSRS) disability
Follow DI 52130.005 – Civil Service Retirement System (CSRS) Disability Benefits.
6. Federal Employees' Retirement System (FERS) disability
Follow DI 52130.010 – Federal Employee Retirement System (FERS) Disability Benefits.
E. WC court decision online
Some States provide public access to WC court decisions on their websites. Although a high probative value can be placed on these documents because they are housed on State websites, do not rely solely on these online WC court decisions as final verification. Only use these sites in conjunction with direct contact with the NH, confirmation from the carrier, or other normal sources of evidence.
F. Insurance carrier
Obtaining verification from the insurance carrier:
* Review all existing evidence for pertinent information such as WC/PDB claim number, carrier name, carrier phone number and date of injury, etc.
* If unable to locate the address and telephone information for the WC/PDB carrier or other payer, see DI 52145.005G. in this section regarding online verification.
* If the carrier has gone out of business, merged with another carrier or the carriers’ records were destroyed or modified due to storage limitations, try to locate the current carrier by contacting the old carrier, the employer or the WC attorney. In locating the carrier, you may receive a reply after tracking down the current record keeper. The records may be in a form of a total amount paid on the policy with an end date of their payments.
Based on the available evidence, make a determination on how the WC payments will be computed and treat the payments as proven with a code of “P” in ICF. Input the determination on a generic form in paperless (with long term retention) or SSA-5002 Report of Contact.
* Phone contact is the preferred method to get the quickest results. Carriers can tell you immediately whether the information exists and how long it will take to get it.
* Document in the file (MCS claims, electronic folder, NDRed or paperless) all attempts to obtain WC/PDB evidence, including both successful and unsuccessful attempts.
* When unable to obtain information, statement for clarification or required evidence over the phone or via fax, a direct contact letter will be sent by the PCs and FOs to request WC evidence (for the PCs, see DIRCON guidelines in GN 01070.300 – GN 01070.330 and for the FO’s see Mail Development-Evidence in GN 00301.150).
* Maintain strict diary control of all pending development.
G. Online verification
Some PCs and FOs have direct online access to obtain workers’ compensation information from NH State and Federal Workers’ Compensation records. See DI 52120.001 and DI 52135.001 for additional State specific WC and PDB information and instructions.
Use the following websites as resources for locating the address or phone number for a specific insurance carrier or payer:
* MAMPSC WC Database Page: http://kcnet.kc.ssa.gov/mamwc/wc_carrier_database.htm
* NEPSC WC Carrier Information: http://nynet2.ny.ssa.gov/WCWeb/#WCBaccess
* WNPSC WC Carrier Information: http://sfnet.sf.ssa.gov/western/statec.htm
* MAMPSC WC Database Page click here
* NEPSC WC Carrier Information click here.
* WNPSC WC Carrier Information click here
* WC database of the 50 states and other U. S. Areas (American Samoa, Guam, Puerto Rico, etc.): http://www.ic.nc.gov/ncic/pages/wcadmdir.htm#dol
* SEPSC Workers’ Comp Page: http://atlnet2.bi.ssa.gov/SEPSC/WCPage.htm
* National Claims Specialist Resource Kit: http://app-denet.kc.ad.ssa.gov/rk/RK.aspx?KIT=CA
* SEPSC Workers’ Comp Page click here.
* National Claims Specialist Resource Kit click here
* Workers Compensation: http://www.workerscompensation.com/
* Workers’ Comp Resource Page: http://nynet2.ny.ssa.gov/WCWeb/national.asp
* Workers’ Comp Resource Page click here
H. References
* GN 00301.286D. - Electronic Evidence Documentation and Retention
* GN 00301.310 - Non-Disability Repository for Evidentiary Documents (NDRed)
* GN 00301.322 - Retention of Paper Material After Faxing into Either the eDib Folder or Claims Folder using NDRed
* DI 81010.135 - Storing Non-Medical Evidence in the Certified Electronic Folder (CEF)
* GN 03001.015 - Notices Required Before and After Taking A Title II Adverse Action
* NL 00703.123 - Advance Notice-Benefits Will Be Reduced
* GN 01070.305 - GN 01070.330 - Use of Direct Contact (DIRCON) and guidelines
* GN 00301.150 - Mail Development-Evidence
* DI 52125.001 - Public Disability Benefit (PDB)
* DI 52120.001 - State Specific WC Procedures
* DI 52135.001 - State Specific PDB Procedures

POMS Reference

DI 52145.005: Obtaining Verification/Proof from Outside Sources