260 R.I. Code R. 260-RICR-50-05-12.3

Current through December 3, 2024

Section 260-RICR-50-05-12.3 - Rules and Procedures for Requesting Reimbursement

A. Request for reimbursement from the Workers' Compensation Administrative Account under R.I. Gen. Laws § 28-35-20(f) must be filed by the insurer within two (2) years of the trial decree entry date.

B. A properly submitted request shall consist of the following:

1. Request for reimbursement letter containing:

a. amount of request

b. date the right to reimbursement accrued

c. proof of payment to the employee/medical care provider

d. trial decision and decree

e. pretrial order or preliminary determination order

f. proof of insurance

g. A brief statement indicating the reason why the employee or medical services provider was not entitled to the payment(s) made pursuant to the pretrial order.

C. Request for reimbursement from the Workers' Compensation Administrative Account under R.I. Gen Laws §§ 28-37-4 and 28-37-4 must be filed by the insurer within two (2) years of the date the right to reimbursement accrued pursuant to R.I. Gen. Laws § 28-37-4(b).

1. A properly submitted request shall consist of:

a. A letter requesting reimbursement

b. Documentation supporting that the employee sustained a compensable injury

c. Medical documentation supporting a compensable injury

d. Documentation supporting the employee sustained a compensable second injury

e. Medical documentation supporting:

(1) a compensable second injury,

(2) aggravation, and

(3) greater disability or loss of earnings than would have resulted from the second injury alone.

f. Documentation, if any, of court orders, reports of payment, memorandum of agreement, non-prejudicial agreement, termination of benefits, suspension agreements, mutual agreements, wage statements, dependency

g. forms, commutations, suspension agreements, nonpayment of indemnity benefits.

h. Proof of insurance

i. Proof of payment to the employee

j. Application and receipt of a R.I. Department of Business Regulation credit rating if applicable

k. Written documentation evidencing knowledge of the preexisting disability at the time of the employee's hire

D. If an incomplete request is submitted, a letter will be sent to the sender for proper completion, notifying the sender of the basis upon which the request is deemed to be incomplete. A sixty (60) day timeframe will be permitted to allow the sender time to properly submit all information. If the complete and proper request is not received within sixty (60) days from the mailing date of the letter, the request will be considered void and the file will be closed.

E. A request for reimbursement will not be considered filed with the department until the request is properly submitted. When a properly completed request has been received, it will be stamped with the filing date and begin processing by the claims unit for approval or denial of the request. The parties will be notified in writing within forty-five (45) days from receipt of the properly completed request as to the approval or denial of the request.

F. Any party disputing an initial decision by the claims unit may file a written objection within thirty (30) days of the mailing date with the Director of the Department of Labor & Training for a determination of the claim for reimbursement. Upon receipt of a written objection, proper hearing notice shall be sent to all parties. Failure to file an objection within thirty (30) days will constitute a waiver of said party's right to object, and the Director/designee will proceed with the final decision.

G. The Director/designee on its own motion may schedule a pre-hearing conference in order to reduce the issues in dispute and to arrange a hearing schedule. The pre- hearing conference will be scheduled within thirty (30) days of the request and proper notice will be sent.

H. Continuances shall be addressed to the sound discretion of the Director/designee assigned to the hearing. The Director/designee shall give due regard to provide prompt hearings. No continuance will be granted without good cause.

I. If any party, or an officer or agent of a party, without good cause, fails to appear for hearing after being served with proper notice, the Director/designee may make such orders in regard to the failure, including, but not limited to:

1. entering orders adverse to that party and

2. requiring that party to pay the reasonable costs associated with the hearing.

J. The Department will arrange for a stenographer to be present at all Administrative Account hearings.

K. If any party disagrees with the final decision of the Director/designee, the party may file a petition to review at the Workers' Compensation Court together with a copy of the decision and order to be reviewed. Appeal of the final agency decision shall be made pursuant to the Workers' Compensation Court Rules of Procedure, §2.32.

L. These rules will be applied retroactive and prospective regardless of the date of injury. All notice/requests of claims for reimbursement that have been date-stamped by the Department of Labor and Training prior to the effective date of these rules and procedures will be deemed filed for the purpose of determining the two (2) year filing requirement.

260 R.I. Code R. 260-RICR-50-05-12.3