TABLE OF CONTENTS
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rules, effective 1 June 2000, with
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Rule 101
Location of Offices and Hours of Business
Rule 102
Transaction of Business by the Commission
The Industrial Commission will remain in continuous session subject to the call of the Chair to meet as a body for the purpose of transacting such business as may come before it.
In reviewing an Opinion and Award of a Deputy Commissioner or of a sole Commissioner acting as the hearing officer, the Full Commission may sit en banc or in panels of three.
Rule 103
Official Forms
The Industrial Commission will supply, on request, forms identified by number and title as follows: [Note: To view or print PDF versions of these forms, you must download and install a free Adobe® Acrobat® Reader.]
Form 17Workers Compensation Notice
Form 18—Notice of Accident to Employer and Claim of Employee or His Personal Representative or Dependents (N.C. Gen. Stat. §§97-22, 97-23, and 97-24)
Form 18BClaim by Employee or His Personal Representative or Dependents for Workers Compensation Benefits for Lung Damage, Including Asbestosis, Silicosis, and Byssinosis (N.C. Gen. Stat. §97-53)
Form 18MEmployees Claim for Additional Medical Compensation
Form 19Employers Report of Employees Injury to the Industrial Commission
Form 21Agreement for Compensation for Disability Pursuant to N.C. Gen. Stat. §97-82
Form 22Statement of Days Worked and Earnings of Injured Employee (Wage Chart)
Form 24Application to Terminate or Suspend Payment of Compensation Pursuant to N.C. Gen. Stat. §97-18.1
Form 25CAuthorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment
Form 25NNotice to the Industrial Commission of Assignment of Rehabilitation Professional
Form 25PItemized Statement of Charges for Drugs
Form 25REvaluation for Permanent Impairment
Form 25TItemized Statement of Charges for Travel
Form UB-92Hospital Bill
Form 26Supplemental Agreement as to Payment of Compensation Pursuant to N.C. Gen. Stat. §97-82
Form 26A—Employer’s Admission of Employee’s Right to Permanent Partial Disability Pursuant to N.C. Gen. Stat. §97-31
Form 26DAgreement for Compensation Under N.C. Gen. Stat. §97-37
Form 28Return to Work Report
Form 28BReport of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation
Form 28TNotice of Termination of Compensation by Reason of Trial Return to Work Pursuant to N.C. Gen. Stat. §97-18.1(b) and N.C. Gen. Stat. §97-32.1
Form 28UEmployees Request that Compensation be Reinstated After Unsuccessful Trial Return to Work Pursuant to N.C. Gen. Stat. §97-32.1
Form 29Supplementary Report for Fatal Accidents
Form 30Agreement for Compensation for Death
Form 30DNotice of Death Award (Approval of Agreement)
Form 31Application for Lump Sum Award
Form 33Request That Claim Be Assigned for Hearing
Form 33RResponse to Request That Claim Be Assigned for Hearing
Form 36Subpoena for Witness and Subpoena to Produce Items or Documents
Form 42Application for Appointment of Guardian Ad Litem
Form 44Application for Review
Form 50Itemized Statement of Charge for Nursing
Form 51Consolidated Fiscal Annual Report of "Medical Only" and "Lost Time" Cases
Form 60Employers Admission of Employees Right to Compensation Pursuant to N.C. Gen. Stat. §97-18(b)
Form 61Denial of Workers Compensation Claim Pursuant to N.C. Gen. Stat. §97-18(c) and (d)
Form 62Notice of Reinstatement of Compensation Pursuant to N.C. Gen. Stat. §97-32.1 and N.C. Gen. Stat. §97-18(b)
Form 63Notice to Employee of Payment of Compensation Without Prejudice to Later Deny the Claim Pursuant to N.C. Gen. Stat. §97-18(d)
Form 90Report of Earnings
Form IZ-510Medical Bill Analysis Used for Approval and Reduction of Medical Bills
Form MSC2Petition for Order Referring Case to Mediated Settlement Conference
Form MSC4Designation of Mediator
Form MSC5Report of Mediator
Form MSC6Mediators Declaration of Interest and Qualifications
Form MSC7Report of Evaluator
Form MSC8Mediated Settlement Agreement
The mailing address for each Industrial Commission form appears at the bottom right corner of the Form.
The use of
any printed forms other than those approved and adopted by the Industrial
Commission is prohibited. Insurance carriers, self-insureds, attorneys and
other parties may reproduce approved forms for their own use, provided:
No statement, question, or information blank contained on the approved Industrial
Commissions form is omitted from the substituted form.
Such substituted form is substantially identical in size and format with the approved
Industrial Commissions form.
The following forms may be utilized in preparing routine orders for the signature of a
Commissioner or Deputy Commissioner, and are appended at the end of these Rules: [Note:
PDF versions of these forms will eventually be listed below. To view or print PDF versions
of these forms, you must download and install a free Adobe® Acrobat®
Reader.]
Form IOrder for Third Party Recovery Distribution per N.C. Gen. Stat. §97-10.2
Form IIOrder Approving Compromise Settlement Agreement (admitted liability, medical paid) and Third Party Distribution
Form IIIOrder
for Approving Compromise Settlement Agreements (admitted liability, medical paid)
Copies of rules, forms, and Industrial Commission Minutes can be obtained by contacting the Administrators Office of the Industrial Commission, 4340 Mail Service Center, Raleigh, NC 27699-4340.
Rule 104
Employers Report of Injury
An employer shall immediately report to its carrier or administrator any injury or occupational disease, or allegation by an employee of an injury or occupational disease, sustained in the course of employment for which the attention of a physician is needed or actually sought. Within five days of knowledge of the injury or allegation, the employer or carrier/administrator or its successor in interest shall file with the Industrial Commission and provide a copy to the employee of a Form 19, Employer’s Report of Employee’s Injury to the Industrial Commission, if injury causes the employee to be absent from work for more than one day or the employee’s medical compensation is greater than an amount which is established periodically by the Industrial Commission in its Minutes. The employer may record the employee’s or another person’s description of the injury on the Form 19 without admitting the truth of the information.
In addition to providing the Form 19 to the employee, the employer or carrier/administrator shall also provide a blank Form 18 for use by the employee.
The front of the Form 19 shall prominently display the following statement: “To the Employee: This Form 19 is not your claim for workers’ compensation benefits. To make a claim, you must complete and sign the enclosed Form 18 and file it with Claims Administration, North Carolina Industrial Commission, 4335 Mail Service Center, Raleigh, NC 28799-4335 within two years of the date of your injury or last payment of medical compensation. For occupational diseases, the claim must be filed within two years of the date of disability and the date your doctor told you that you have a work-related disease, whichever is later.”
Rule 105
Electronic Payment of Costs
Electronic payment is authorized for fees and costs owed to the North Carolina Industrial Commission. The Industrial Commission shall implement guidelines to facilitate electronic payment.
Rule 201
Notice of Employment Subject to the Act
Pursuant to the provisions of N.C. Gen. Stat. §97-93,
all employers subject to the provisions of the Workers Compensation Act shall post
in a conspicuous location in places of employment a Form 17,
Workers’
Compensation Notice,
to give notice to the employees that they are in an employment subject to
the provisions of the Workers’ Compensation Act and that their employer has
obtained workers’ compensation coverage or has qualified as self-insured for
workers’ compensation purposes.
Should the employer allow its workers’ compensation coverage to lapse or cease to qualify as a self-insured, the employer shall remove within five working days any Form 17 and any other notice indicating otherwise.
Rule 301
Proof of Insurance Coverage
(a) Every employer, either personally or through its carrier or third party administrator, subject to the provisions of the Workers' Compensation Act shall file with the Commission proof that it has obtained workers' compensation insurance, and shall post notice of proof of insurance to employees consistent with Rule 201 of this Subchapter.
(b) Upon actual notice of a workers' compensation claim or upon reporting a workers' compensation claim to a carrier, third party administrator, servicing agent, professional employer organization as defined in G.S. §58-89A-5(14), or the Commission, all employers shall provide the injured worker with the name of their insurance carrier and policy number or shall inform the injured worker of their self-insured status, membership in a self-insurance group or relationship with a professional employer organization that provides the insurance coverage.
(c) Every carrier, third party administrator, servicing agent, or other entity filing a Form 19 Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission to the Industrial Commission shall identify by name and address any professional employer organization and the name of the client company employing the employee who is the subject of the Form 19 Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission.
(d) A professional employer organization shall, within 30 days of initiation or termination of the professional employer organization's relationship with any client company, notify the Commission of either the initiation or termination of the relationship and the status of the client company's workers' compensation coverage.
(e) Upon notice from the Commission that an employer is non-insured, coverage has lapsed or been canceled, or coverage or self-insured status cannot be verified, an employer shall show proof of coverage to the Commission by:
a certificate of insurance issued by the insurance agent who procured workers' compensation insurance on behalf of the employer;
submitting a copy of the letter of approval, license or amended license with subsidiary information, if applicable, from the North Carolina Department of Insurance or indicating the employer has qualified as a self-insured employer for workers' compensation purposes;
submitting a copy of the Form 18WC Application for Membership indicating the employer is a member of a self-insurance group or fund;
submitting a copy of a declaration of coverage page from an insurance policy procured in another state that indicates North Carolina is a covered jurisdiction under the workers' compensation policy;
submitting the names of the general contractor, subcontractor, professional employer organization or other entity that has provided workers' compensation coverage for the employer; provided however, that coverage shall be verified by the Commission in order to be removed from the non-insured docket; or
submitting other documentation or information relevant to the workers' compensation claim upon request of the Commission.
(f) A principal contractor, intermediate contractor or subcontractor may satisfy the requirements of G.S. §97-19 by obtaining a certificate of insurance issued by the insurance agent who procured insurance on behalf of the subcontractor or a certificate of compliance issued by the Department of Insurance to a self-insured subcontractor. If the subcontractor has notice that the policy of insurance has lapsed, is cancelled, is not renewed, or the subcontractor ceases to qualify as a self-insured employer, the subcontractor shall, within 24 hours, notify any contractor to whom it has provided a certificate of insurance that the certificate or certificate of compliance is no longer valid.
History Note: Authority
G.S. §97-19;
§97-80(a);
§97-93;
Effective January 1, 1990;
Amended Effective January 1, 2013; June 1, 2000.
Rule 302
Required Contact Information from Carriers
All insurance carriers, third party administrators and self-insured employers shall designate a primary contact person for workers’ compensation issues in North Carolina and shall maintain and provide annually to the Director of Claims Administration of the Industrial Commission the primary contact person’s current contact information, including direct telephone and facsimile numbers, mailing addresses, and email addresses. Contact information shall be updated within 30 days of any change. Failure to comply with this Rule may result in sanctions, including those specified in Rule 802. The Industrial Commission shall implement guidelines to facilitate the collection of this information.
ARTICLE IV. DISABILITY, COMPENSATION, FEES
Rule 401
When Disability Begins for Purpose of Computing Compensation
If the
injured employee is not paid wages for the entire day on which the injury
occurred, the seven-day waiting period prescribed by the Act shall include
the day of injury regardless of the hour of the injury.
If the
injured employee is paid wages for the entire day on which he is injured and
fails to return to work on his next regular workday because of the injury,
the seven-day waiting period shall begin with the first calendar day
following his injury, even though this may or may not be a regularly
scheduled workday.
All days, or
parts of days, when the injured employee is unable to earn a full day’s
wages, or is not paid a full day’s wages due to injury, shall be counted in
computing the waiting period even though the days may not be consecutive,
and even though these are not regularly scheduled workdays.
If the permanent disability period, when added to the temporary disability period, exceeds 21 days, there is no waiting period.
Rule 402
Computation of Daily Wage
In all cases involving a fractional part of a week, the daily wage shall be computed on the basis of one-seventh of the average weekly wage.
Rule 403
Manner of Payment of Compensation
All payments
of compensation must be made directly to the employee, dependent, guardian
or personal representative entitled thereto unless otherwise ordered by the
Industrial Commission. At the employee’s request, payment of compensation
shall be mailed by first class mail, postage pre-paid, to an address
specified by the employee, unless otherwise directed by the Industrial
Commission.
All payments of compensation must be made in strict accordance with the award issued by the Industrial Commission.
Rule 404
Termination of Compensation
Payments of
compensation undertaken pursuant to an award of the Industrial Commission
shall continue until the terms of the award have been fully satisfied. In
cases where the award is to pay compensation during disability, there is a
rebuttable presumption that disability continues until the employee returns
to suitable employment. No application to terminate or suspend compensation
shall be approved without a formal hearing if the effect of such approval is
to set aside the provisions of an award of the Industrial Commission.
When an
employer or carrier/administrator seeks to terminate or suspend compensation
being paid pursuant to
N.C.
Gen. Stat. §97-29 for a reason other than those specified in N.C. Gen. Stat.
§97-18(d), payment without prejudice, or N.C. Gen. Stat.
§97-18.1(b), trial return to work,
the employer
or carrier/administrator shall notify the employee and the employee’s
attorney of record, if any, on
Form 24, Application to
Stop Payment of Compensation.
The employer
or carrier/administrator shall specify the legal grounds and the alleged
facts supporting the application, and shall complete the blank space in the
“Important Notice to Employee” portion of
Form 24
by inserting a date 17 days from the date the employer or
carrier/administrator deposits the completed
Form 24
in the mail to the employee and the employee’s attorney of record, if any.
The original of the
Form 24
and the attached documents shall be sent to the Industrial Commission at the
same time and by the same method by which a copy of the
Form 24
and attached documents are sent to the employee and the employee’s attorney
of record, if any. The
Form 24
shall specify the number of pages of documents attached which are to be
considered by the Industrial Commission. Failure to specify the number of
pages may result in the refusal of the Industrial Commission to accept the
same for filing. If the employee or the employee’s attorney of record, if
any, objects by the date inserted on the employer’s
Form 24,
or within such additional reasonable time as the Industrial Commission may
allow, the Industrial Commission shall set the case for an informal hearing,
unless waived by the parties in favor of a formal hearing. A copy of any
objection shall be sent, with any supporting documents, to the employer and
carrier/administrator. The term “carrier/administrator” also includes any
successor in interest.
If an
employee does not object within the allowed time, the Industrial Commission
shall review the
Form 24
and any
attached documentation, and an Administrative Decision and Order may be
rendered without an informal hearing as to whether compensation shall be
terminated or suspended, except as provided in
paragraph (6) below. Either party may seek review of the
Administrative Decision and Order as provided by Rule 703.
If the employee timely objects to the Form 24,
the Industrial
Commission shall conduct an informal hearing within 25 days of the receipt
by the Industrial Commission of the Form 24, unless the time is extended for
good cause shown. The informal hearing may be by telephone conference
between the Industrial Commission and the parties or their attorneys of
record, if any. When good cause is shown, the informal hearing may be
conducted with the parties or their attorneys of record, if any, personally
present with the Industrial Commission in Raleigh or such other location as
is selected by the Industrial Commission. The Industrial Commission shall
make arrangements for the informal hearing with a view towards conducting
the hearing in the most expeditious manner under the circumstances. Except
for good cause shown, the informal hearing shall be no more than 30 minutes,
with each side given 10 minutes to present its case and five minutes for
rebuttal. Notwithstanding the above, the employer or carrier/administrator
may waive the right to an informal hearing, and proceed to a formal hearing
by filing a request for hearing on a
Form 33.
A decision on
the application shall be made within five days after the completion of the
informal hearing.
Either party
may appeal the Administrative Decision and Order of the Industrial
Commission as provided by Rule 703. A Deputy Commissioner shall conduct
a hearing which shall be a hearing de novo. The hearing shall be peremptorily set
and shall not require a Form
33. The
employer has the burden of producing evidence on the issue of the employer’s
application for termination or suspension of compensation. If the Deputy
Commissioner reverses an order previously granting a
Form 24
motion, the employer or carrier/administrator shall promptly resume
compensation or otherwise comply with the Deputy Commissioner’s decision,
notwithstanding any appeal or application for review to the Full Commission
under
N.C. Gen. Stat. §97-85.
In the event
the Industrial Commission is unable to reach a decision after an informal
hearing, the Industrial Commission shall issue an order to that effect which
shall be in lieu of a Form 33 and the case shall be placed on the formal
hearing docket. If additional issues are to be addressed, the employer or
carrier/administrator shall be required within 30 days of the date of the
Administrative Decision and Order to file a
Form
33 or to
notify the Industrial Commission that a formal hearing is not currently
necessary. The effect of placing the case on the docket shall be the same as
if the Form 24
were denied, and compensation shall continue until such time as the case is
decided by a Commissioner or a Deputy Commissioner following a formal
hearing.
Any
Administrative Decision and Order shall be mailed to the non-prevailing
party by certified mail.
No order issued as a result of an informal Form 24 hearing shall terminate or suspend compensation retroactively to a date preceding the filing date of the Form 24. Compensation may be terminated retroactively without a formal hearing where there is agreement by the parties, where allowed by statute, or where the employee is incarcerated. Otherwise, retroactive termination or suspension of compensation to a date preceding the filing of a Form 24 may be ordered as a result of a formal hearing. Additionally, nothing shall impair an employer’s right to seek a credit pursuant to N.C. Gen. Stat. §97-42.
Rule 404A
Trial Return to Work
Except as provided in subparagraph (7), when
compensation for total disability being paid pursuant to N.C. Gen. Stat. §97-29
is terminated because the employee has returned to work for the same or a different
employer, such termination is subject to the trial return to work provisions of N.C. Gen. Stat. §97-32.1.
When compensation is terminated under these circumstances, the employer or
carrier/administrator shall, within 16 days of the termination of compensation, file a Form 28T with the Industrial
Commission and provide a copy of it to the employee and the employees
attorney of record, if any.
If during the trial return to work period, the employee must stop
working due to the injury for which compensation had been paid, the employee should
complete and file with the Industrial Commission a Form 28U, without regard to
whether the employer or carrier/administrator has filed a Form 28T as required by paragraph (1) above, and provide a copy of the completed form to the
employer and carrier/administrator. A Form 28U shall contain a
section which must be completed by the physician who imposed the restrictions or one of
the employees authorized treating physicians, certifying that the
employees injury for which compensation had been paid prevents the employee from
continuing the trial return to work. If the employee returned to work with an employer
other than the employer at the time of injury, the employee must complete the
"Employees Release and Request For Employment Information" section of a Form 28U. An employees
failure to provide a Form 28U
does not preclude a subsequent finding by the Commission that the trial return to work was
unsuccessful.
Upon receipt of a properly completed Form 28U, the employer or
carrier/administrator shall promptly resume payment of compensation for total disability.
If the employee fails to provide the required certification of an authorized treating
physician as specified in subsection 2 above, or if the employee fails
to execute the "Employees Release and Request" section of a Form 28U, if required
pursuant to paragraph (2) above, the employer or carrier/administrator
shall not be required to resume payment of compensation. Instead, in such circumstances,
the employer or carrier/administrator shall promptly return a Form 28U to the employee and
the employees attorney of record, if any, along with a statement explaining the
reason the Form 28U is
being returned and the reason compensation is not being reinstated.
The reinstated compensation shall be due and payable and subject to the provisions of N.C. Gen. Stat.
§97-18(g) on the date and for the period commencing on the date the employer or
carrier/administrator receives a properly completed Form 28U certifying an
unsuccessful return to work. Such resumption of compensation shall not preclude the
employees right to seek, nor the employers or carrier/administrators
right to contest, the payment of compensation for the period prior or subsequent to such
reinstatement. If it is thereafter determined that any temporary total or temporary
partial compensation, including the reinstated compensation, was not due and payable, a
credit shall be given against any other compensation determined to be owed.
When the employer or carrier/administrator has received a properly completed Form 28U and contests the
employees right to reinstatement of total disability compensation, it may suspend or
terminate compensation only as provided in N.C. Gen. Stat. §97-18.1
and/or pursuant to the provisions of N.C. Gen. Stat. §97-83
and N.C. Gen. Stat.
§97-84.
Upon resumption of payment of compensation for total disability, the employer or
carrier/administrator shall complete and file a Form 62 and/or such other
forms as may be required by the Workers Compensation Act or by Industrial Commission
rule. A copy of the Form 62
shall be sent to the employee and the employees attorney of record, if any.
The trial return to work provisions do not apply to the following:
“Medical only” cases, defined as cases in which the
employee is not absent from work more than one day or in which
medical expenses are less than the amount periodically established by the
Industrial Commission in its Minutes;
Cases in which the employee has missed fewer than eight days from work;
Cases wherein the employee has been released to return to work by an authorized treating
physician as specified in subsection 2 above without restriction or
limitation except that if the physician, within 45 days of the employees return to
work date, determines that the employee is not able to perform the job duties assigned,
then the employer or carrier/administrator must resume benefits. If within the same time
period, the physician determines that the employee may work only with restrictions, then
the employee is entitled to a resumption of benefits commencing as of the date of the
report, unless the employer is able to offer employment consistent with the restrictions,
in which case a trial return to work period shall be deemed to have commenced at the time
of the employees initial return to work;
Cases wherein the employee has accepted or agreed to accept compensation for permanent
partial disability pursuant to N.C. Gen. Stat. §97-31,
unless the trial return to work follows reinstatement of compensation for total disability
under N.C. Gen. Stat.
§97-29; and
Claims pending on or filed after 1 January 1995, when the employer or
carrier/administrator contests a claim pursuant to N.C. Gen. Stat.
§97-18(d) within the time allowed thereunder.
This Rule became effective on 15 February 1995, and applies to any employee who leaves work on or after that date due to a compensable injury.
Rule 405
Computation of Compensation for Amputations
Amputation of any portion of the bone of a distal phalange of a finger or toe at or
distal to the visible base of the nail will be considered as equivalent to the loss of
one-fourth (¼) of such finger or toe.
Amputation of any portion of the bone of the distal phalange of a finger or toe proximal
to the visible base of the nail will be considered as equivalent to the loss of one-half
(½) of such finger of toe.
Amputation through the forearm at a point so distal to the elbow as to permit
satisfactory use of a prosthetic appliance with retention of full natural elbow function
shall be considered amputation of the hand. Otherwise, it shall be considered amputation
of the arm.
Amputation through the lower leg at a point so distal to the knee as to permit satisfactory use of a prosthetic appliance with retention of full natural knee function shall be considered amputation of the foot. Otherwise, it shall be considered amputation of the leg.
Rule 406
Discount Table to Be Used in Determining Commuted Values
The Industrial Commission in its discretion will designate the interest rate and methods of computation to be used in arriving at the commuted value of unaccrued compensation payments.
Rule 407
Fees for Medical Compensation (Effective January 1, 2013)
(a) The Commission has adopted and published a Medical Fee Schedule, pursuant to the provisions of G.S. §97-26(a), setting maximum amounts, except for hospital fees pursuant to G.S. §97-26(b), that may be paid for medical, surgical, nursing, dental, and rehabilitative services, and medicines, sick travel, and other treatment, including medical and surgical supplies, original artificial members as may reasonably be necessary at the end of the healing period and the replacement of such artificial members when reasonably necessitated by ordinary use or medical circumstances. The amounts prescribed in the applicable published Fee Schedule shall govern and apply according to G.S. §97-26(c).
(b) The Commission's Medical Fee Schedule contains maximum allowed amounts for medical services provided pursuant to Chapter 97 of the General Statutes. The Medical Fee Schedule utilizes 1995 through the present, Current Procedural Terminology (CPT) codes adopted by the American Medical Association, Healthcare Common Procedure Coding Systems (HCPCS) codes, and jurisdiction-specific codes. A listing of the maximum allowable amount for each code is available on the Commission's website at http://www.ic.nc.gov/ncic/pages/feesched.asp and in hardcopy at 430 N. Salisbury Street, Raleigh, North Carolina.
(c) The following methodology provides the basis for the Commission's Medical Fee Schedule:
CPT codes for General Medicine are based on 1995 North Carolina Medicare values multiplied by 1.58, except for CPT codes 99201-99205 and 99211-99215, which are based on 1995 Medicare values multiplied by 2.05.
CPT codes for Physical Medicine are based on 1995 North Carolina Medicare values multiplied by 1.36.
CPT codes for Radiology are based on 1995 North Carolina Medicare values multiplied by 1.96.
CPT codes for Surgery are based on 1995 North Carolina Medicare values multiplied by 2.06.
(d) The Commission's Hospital Fee Schedule, adopted pursuant to G.S. §97-26(b), provides for payment as follows:
Inpatient hospital fees: Inpatient services are reimbursed based on a Diagnostic Related Groupings (DRG) methodology. The Hospital Fee Schedule utilizes the 2001 Diagnostic Related Groupings adopted by the State Health Plan. Each DRG amount is based on the amount that the State Health Plan had in effect for the same DRG on June 30, 2001.
DRG amounts are further subject to the following payment band that establishes maximum and minimum payment amounts:
The maximum payment is 100 percent of the hospital's itemized charges.
For hospitals other than critical access hospitals, the minimum payment is 75 percent of the hospital's itemized charges. Effective February 1, 2013, the minimum payment rate is the amount provided for under Subparagraph (5) below, subject to adjustment on April 1, 2013 as provided therein.
For critical access hospitals, the minimum payment is 77.07 percent of the hospital's itemized charges. Effective February 1, 2013, the minimum payment rate is the amount provided for under Subparagraph (5) below, subject to adjustment on April 1, 2013 as provided therein.
Outpatient hospital fees: Outpatient services are reimbursed based on the hospital's actual charges as billed on the UB-04 claim form, subject to the following percentage discounts:
For hospitals other than critical access hospitals, the payment shall be 79 percent of the hospital's billed charges. Effective February 1, 2013, the payment is the amount provided for under Subparagraph (5) below, subject to adjustment on April 1, 2013 as provided therein.
For critical access hospitals, the payment shall be 87 percent of the hospital's billed charges. For purposes of the hospital fee schedule, critical access hospitals are those hospitals designated as such pursuant to federal law (42 CFR 485.601 et seq.). Effective February 1, 2013, the critical access hospital's payment is the amount provided for under Subparagraph (5) below, subject to adjustment on April 1, 2013 as provided therein.
Ambulatory surgery fees: Ambulatory surgery center services are reimbursed at 79 percent of billed charges. Effective February 1, 2013, the ambulatory surgery center services are reimbursed at the amount provided for under Subparagraph (5) below, subject to adjustment on April 1, 2013 as provided therein.
Other rates: If a provider has agreed under contract with the insurer or managed care organization to accept a different amount or reimbursement methodology, that amount or methodology establishes the applicable fee.
Payment levels frozen and reduced pending study of new fee schedule: Effective February 1, 2013, inpatient and outpatient payments for each hospital and the payments for each ambulatory surgery center shall be set at the payment rates in effect for those facilities as of June 30, 2012. Effective April 1, 2013, those rates shall then be reduced as follows:
Hospital outpatient and ambulatory surgery: The rate in effect as of that date shall be reduced by 15 percent.
Hospital inpatient: The minimum payment rate in effect as of that date shall be reduced by 10 percent.
Effective April 1, 2013, implants shall be paid at no greater than invoice cost plus 28 percent.
(e) A provider of medical compensation shall submit its statement for services within 75 days of the rendition of the service, or if treatment is longer, within 30 days after the end of the month during which multiple treatments were provided. However, in cases where liability is initially denied but subsequently admitted or determined by the Commission, the time for submission of medical bills shall run from the time the health care provider received notice of the admission or determination of liability. Within 30 days of receipt of the statement, the employer, carrier, or managed care organization, or administrator on its behalf, shall pay or submit the statement to the Commission for approval or send the provider written objections to the statement. If an employer, carrier, administrator, or managed care organization disputes a portion of the provider's bill, the employer, carrier, administrator, or managed care organization, shall pay the uncontested portion of the bill and shall resolve disputes regarding the balance of the charges through its contractual arrangement or through the Commission.
(f) Pursuant to G.S. §97-18(i), when the 10 percent addition to the bill is uncontested, payment shall be made to the provider without notifying or seeking approval from the Commission. When the 10 percent addition to the bill is contested, any party may request a hearing by the Commission pursuant to N.C. Gen. Stat. §97-83, and N.C. Gen. Stat. §97-84.
(g) When the responsible party seeks an audit of hospital charges, and has paid the hospital charges in full, the payee hospital, upon request, shall provide reasonable access and copies of appropriate records, without charge or fee, to the person(s) chosen by the payor to review and audit the records.
(h) The responsible employer, carrier, managed care organization, or administrator shall pay the statements of medical compensation providers to whom the employee has been referred by the treating physician authorized by the insurance carrier for the compensable injury or body part, unless the physician has been requested to obtain authorization for referrals or tests; provided that compliance with the request shall not unreasonably delay the treatment or service to be rendered to the employee.
(i) Employees are entitled to reimbursement for sick travel when the travel is medically necessary and the mileage is 20 or more miles, round trip, at the business standard mileage rate set by the Internal Revenue Service per mile of travel and the actual cost of tolls paid. Employees are entitled to lodging and meal expenses, at a rate to be established for state employees by the North Carolina Director of Budget, when it is medically necessary that the employee stay overnight at a location away from the employee's usual place of residence. Employees are entitled to reimbursement for the costs of parking or a vehicle for hire, when the costs are medically necessary, at the actual costs of the expenses.
(j) Any employer, carrier or administrator denying a claim in which medical care has previously been authorized is responsible for all costs incurred prior to the date notice of denial is provided to each health care provider to whom authorization has been previously given.
Rule 408
Additional Medical Compensation
The Industrial Commission may enter an order as contemplated by N.C. Gen. Stat. §97-25.1
providing for additional medical compensation on its own motion or pursuant to a
stipulation of the parties or by approval of an agreement of the parties for additional
medical compensation reflected in a Form 21 or a Form 26.
If the parties have not reached an agreement regarding additional medical compensation,
an employee may file a claim with the Industrial Commission for an order pursuant to the
terms of N.C. Gen.
Stat. §97-25.1, for payment of additional medical compensation within two years of
the date of the last payment of medical or indemnity compensation, whichever shall last
occur. The claim may be made on a Form 18M or by written
request to the Industrial Commission. The filing of this claim tolls the time limit
contained in this paragraph and in N.C. Gen. Stat. §97-25.1.
The original and one copy of the claim must be filed with the Industrial Commissions
Office of the Executive Secretary, one copy must be provided to the employer or
carrier/administrator, and one copy must be provided to the attorney of record, if any.
Upon receipt of the claim, the Industrial Commission will notify the employer or
carrier/administrator that the claim has been received by providing a copy of a Form 18M or a written claim.
The employer or carrier/administrator shall, within 30 days, send to the Industrial
Commission and to the employee and the employees attorney of record, if any, a
written statement as to whether the employees request is accepted or denied. If the
request is denied, the employer or carrier/administrator shall state in writing the
grounds for the denial and shall attach any supporting documentation to the statement of
denial.
In cases where the employees right to additional medical compensation is
contested, the Form 18M,
Request for Additional Medical Compensation, shall be treated as a Motion to the Executive
Secretary for future medical compensation. Defendants shall have 30 days to respond. An
administrative ruling shall thereafter be made subject to the right of either party to
appeal such administrative decision by filing a Form 33, Request for Hearing,
pursuant to the 15 day time limitation contained in Rule 703. An appeal
of the Administrative Decision shall have the effect of staying the decision, provided
that the stay may be dissolved in the discretion of the Commission for good cause shown.
This Rule applies to injuries by accident occurring on or after July 5, 1994.
Rule 409
Claims for Death Benefits
(ii) In order to protect the interests of an incompetent beneficiary, the Industrial Commission in its discretion may order that benefits be paid to the beneficiarys duly appointed general guardian for the beneficiarys exclusive use and benefit, or to the Clerk of Court in the county in which he resides for the beneficiarys exclusive use and benefit as determined by the Clerk of Court.
(iii) Upon a change in circumstances, any interested party may request that the
Industrial Commission amend the terms of any award with respect to a minor or incompetent
to direct payment to another party on behalf of the minor or incompetent. When a
beneficiary reaches the age of 18, any remaining benefits shall be paid directly to
the beneficiary.
Rule 501
Agreements for Payment of Compensation
To facilitate the prompt payment of compensation
within the time prescribed in
N.C. Gen.
Stat. §97-18, the Industrial Commission will accept memoranda of agreements
on Industrial Commission forms.
No agreement for permanent disability will be approved until the material medical and vocational records known to exist in the case have been filed with the
Industrial Commission. When requested by the Industrial Commission, the
parties shall file any additional documentation necessary to determine whether
the employee is receiving the disability compensation to which he or she is
entitled and that an employee qualifying for disability compensation under both
N.C. Gen.
Stat. §97-29 or
§97-30
and
N.C. Gen.
Stat. §97-31 has the benefit of the more favorable remedy.
All memoranda of agreements must be submitted to the Industrial Commission in
triplicate on Industrial Commission forms, as specified in paragraph 6 below.
Agreements in proper form and conforming to the provisions of the Workers’
Compensation Act will be approved by the Industrial Commission and a copy
returned to the employer or carrier/administrator and a copy sent to the
employee, unless amended by award, in which event a copy of the award will be
returned with the agreement.
The employer or carrier/administrator, or the attorney of record, if any, shall
provide the employee and the employee’s attorney of record, if any, a copy of a
Form 21,
Form 26,
Form 26D, and
Form 30, when
the employee signs said forms, and the employer or carrier/administrator will
send a copy of a
Form 28B to the employee and the employee’s attorney of record, if any,
within 16 days after the last payment of compensation for either temporary or
permanent disability, pursuant to
N.C. Gen.
Stat. §97-18.
All memoranda of agreements
for cases which are currently calendared for hearing before a Commissioner
or Deputy Commissioner shall be sent directly to that Commissioner or Deputy
Commissioner. Before
a case is calendared, or once a case has been continued, or removed, or after
the filing of an Opinion and Award, all memoranda of agreements shall be
directed to the Claims Section of the Industrial
Commission.
After the employer or carrier/administrator has received a memorandum of agreement which has been signed by the employee and employee’s attorney of record, if any, it shall have 20 days within which to submit the memorandum of agreement to the Industrial Commission for review and approval or within which to show good cause for not submitting the memorandum of agreement signed only by the employee; provided, however, that for good cause shown, the 20 day period may be extended.
Rule 502
Compromise Settlement Agreements
All compromise settlement agreements must be submitted to the Industrial Commission for
approval. Only those agreements deemed fair and just and in the best interest of all
parties will be approved.
No compromise agreement will be approved unless it contains the following language or
its equivalent:
Where liability is admitted, that the employer or carrier/ administrator undertakes to
pay all medical expenses to the date of the agreement.
Where liability is denied, that the employer or carrier/ administrator undertakes to pay
all unpaid medical expenses to the date of the agreement. However, this requirement may be
waived in the discretion of the Industrial Commission. When submitting an agreement for
approval, the employee or employees attorney, if any, shall advise the Commission in
writing of the amount of the unpaid medical expenses.
That the employee knowingly and intentionally waives the right to further benefits under
the Workers Compensation Act for the injury which is the subject of this agreement.
That the employer or carrier/administrator will pay all costs incurred.
That no rights other than those arising under the provisions of the Workers
Compensation Act are compromised or released.
That the employee has, or has not, returned to a job or position at the same or a
greater average weekly wage as was being earned prior to the injury or occupational
disease.
Where the employee has not returned to a job or position at the same or a greater wage
as was being earned prior to the injury or occupational disease, that the employee has, or
has not, returned to some other job or position, and, if so, the description of the
particular job or position, the name of the employer and the average weekly wage earned.
This subsection of the Rule shall not apply where the employee is represented by counsel
or, even if the employee is not represented by counsel, where the employee certifies that
partial wage loss due to an injury or occupational disease is not being claimed.
Where the employee has not returned to a job or position at the same or a greater
average weekly wage as was being earned prior to the injury or occupational disease, the
agreement shall summarize the employees age, educational level, past vocational
training, past work experience, and any impairment, emotional, mental or physical, which
predates the current injury or occupational disease. The parties will be relieved of this
duty only upon a showing that providing such information creates an unreasonable burden
upon them. This subsection of the Rule shall not apply where employee is represented by
counsel or, even if the employee is not represented by counsel, where the employee
certifies that total wage loss due to an injury or occupational disease is not being
claimed.
No compromise agreement will be considered unless the following additional requirements
are met:
The material medical, vocational, and rehabilitation reports known to exist, including but not
limited to those pertinent to the employees future earning capacity, must be
submitted with the agreement to the Industrial Commission by the employer, the
carrier/administrator, or the attorney for the employer.
The parties and all attorneys of record must have signed the agreement.
The settlement agreement must contain a list of all
of the known medical expenses of the employee related to the injury to the date
of the settlement agreement, including medical expenses that the employer or
insurance carrier disputes, when the employer or carrier has not agreed to pay
all medical expenses of the employee related to the injury up to the date of the
settlement agreement.
If there are unpaid medical expenses which the employer or insurance carrier
agree to pay under the settlement agreement, the agreement must contain a list
of these unpaid medical expenses, if known, that will be paid by the employer or
insurance carrier.
The settlement agreement must contain a finding
that the positions of the parties to the agreement are reasonable as to the
payment of medical expenses.
When a settlement has been reached, the written agreement must be submitted to the
Industrial Commission within a reasonable time. All compromise settlement agreements which
are currently calendared for hearing before a Commissioner or Deputy Commissioner shall be
sent directly to that Commissioner or Deputy Commissioner at the Industrial Commission.
Before a case is calendared, or once a case has been continued, or removed, or after the
filing of an Opinion and Award, all compromise settlement agreements shall be directed to
the Executive Secretary of the Industrial Commission.
Once a compromise settlement agreement has been approved by the Industrial Commission,
the employer or carrier/administrator shall furnish an executed copy of said agreement to
the employee or his attorney of record, if any.
An attorney seeking fees in connection with a Compromise Settlement Agreement shall submit to the Commission a copy of the fee agreement with the client.
Rule 503
Approval of Agreement Constitutes Award
An agreement for the payment of compensation approved by the Industrial Commission shall thereupon become an award of the Industrial Commission and shall be a part of the record in any further proceedings in the matter.
Rule 601
Employer Obligations Upon Notice, Sanctions, and Denial of Liability
The employer or its insurance carrier shall promptly investigate each injury reported or known to the employer and at the earliest practicable time shall admit or deny the employee’s right to compensation or commence payment of compensation as provided in N.C. Gen. Stat. §97-18(b), (c), or (d).
When an employee files a claim for compensation with the Commission, the Commission may order reasonable sanctions against the employer or its insurance carrier which does not, within 30 days following notice from the Commission of the filing of the claim, or 90 days when a disease is alleged to be from exposure to chemicals, fumes, or other materials or substances in the workplace, or within such reasonable additional time as the Commission may allow, do one of the following:
Notify the Commission and the employee in writing that it is admitting the employee’s right to compensation and, if applicable, satisfy the requirements for payment of compensation under N.C. Gen. Stat §97-18(b).
Notify the Commission and the employee that it denies the employee’s right to compensation consistent with N.C. Gen. Stat §97-18(c).
Initiate payments without prejudice and without liability and satisfy the requirements of N.C. Gen. Stat §97-18(d).
For purposes of this Rule, reasonable sanctions shall not prohibit the employer or its insurance carrier from contesting the compensability of and its liability for the claim.
Requests for extensions of time to comply with this rule may be addressed to the Executive Secretary.
If the employer or insurance carrier denies liability in any case, a detailed statement of the basis of denial must be set forth in a letter of denial or Form 61, which shall be sent to the plaintiff or his attorney of record, if any, all known health care providers which have submitted bills to the employer/carrier, and the Industrial Commission.
The detailed statement of the basis of denial shall set forth a statement of the facts, as alleged by the employer, concerning the injury or any other matter in dispute; a statement identifying the source, by name or date and type of document, of the facts alleged by the employer; and a statement explaining why the facts, as alleged by the employer, do not entitle the employee to workers compensation benefits.
Rule 602
Request for Hearing
Contested claims shall be set on the hearing docket only upon the written request of one of the parties, unless the Industrial Commission orders on its own motion, a hearing or rehearing of the case in dispute. The request for hearing shall contain the following:
The basis of the disagreement between the parties, including a statement of the specific
issues raised by the requesting party.
The date of the injury.
The part of the body injured.
The city and county where the injury occurred.
The names and addresses of all doctors and other expert witnesses whose testimony is
needed by the requesting party.
The names of all lay witnesses to be called to testify for the requesting party.
An estimate of the time required for the hearing of the case.
The telephone number(s) and address(es) of the party(ies) requesting the hearing.
A Form 33, Request for Hearing, completed in full, shall constitute compliance with this Rule. A copy of the Request for Hearing shall be forwarded to the self-insured employer or insurance carrier if not represented, or to the defendants attorney, if one has been retained.
Rule 603
Response to Request for Hearing
No later than 45 days from receipt of the Request for Hearing, the self-insured employer, insurance carrier, or counsel for the defendant(s) shall file with the Industrial Commission a response to the Request for Hearing.
This response shall contain the following:
The basis of the disagreement between the parties, including a statement of the specific
issues raised by the plaintiff which are conceded and the specific issues raised by the
plaintiff which are denied.
The date of the injury, if it is contended to be different than that alleged by the
plaintiff.
The part of the body injured, if it is contended to be different than that alleged by
the plaintiff.
The city and county where the injury occurred, if they are contented to be different
than that alleged by the plaintiff.
The names and addresses of all doctors and other expert witnesses whose testimony is
needed by the defendant(s).
The names of all lay witnesses known by the defendant(s) whose testimony is to be
taken.
An estimate of the time required for the hearing of the case.
The telephone number(s) and address(es) of the party(ies) responding to the Request for Hearing.
Utilization of a Form 33R, Response to Request for Hearing, which is completed in full, shall be the sole means of compliance with this Rule. A copy of the Response to Request for Hearing shall be forwarded to all opposing parties or their attorneys, if such have been retained. In the event of a request for hearing by a defendant, the employee shall not be required to respond. Extensions of time within which to file a response shall be granted for good cause shown.
Rule 604
Appointment of Guardian Ad Litem
In all cases where it is proposed that minors or incompetents shall sue by their
guardian ad litem, the Industrial Commission shall appoint such guardian ad
litem upon the written application of a reputable person closely connected with such
minor or incompetent; but if such person will not apply, then, upon the application of
some reputable citizen; and the Industrial Commission shall make such appointment only
after due inquiry as to the fitness of the person to be appointed.
In no event, however, shall any compensation be paid directly to the guardian ad litem. Rather, compensation payable to a minor or incompetent shall be paid as provided in N.C. Gen. Stat. §97-48 and N.C. Gen. Stat. §97-49. The use of the word "guardian" in N.C. Gen. Stat. §97-49 does not mean a guardian ad litem. The Commission may assess a fee to be paid by the employer or the carrier, to an attorney who serves as a guardian ad litem for actual services rendered upon receipt of an affidavit of actual time spent in representation of the minor or incompetent.
Rule 605
Discovery
In addition to depositions and production of books and records provided for in N.C. Gen. Stat. §97-80, parties may obtain discovery by the use of interrogatories as follows:
Any party may serve upon any other parties written interrogatories, up to 30 in number, including subparts thereof, to be answered by the party served or, if the party served is a public or private corporation or a partnership or association or governmental agency, by any officer or agent, who shall furnish such information as is available from the party interrogated.
Interrogatories may, without leave of the Industrial Commission, be served upon any party after the filing of a Form 18, Form 18B, or Form 33, or after approval of Form 21.
Each interrogatory shall be answered separately and fully in writing under oath, unless it is objected to, in which event the reasons for objection shall be stated in lieu of an answer. The answers are to be signed by the person making them and the objections signed by the party making them. The party on whom the interrogatories have been served shall serve a copy of the answers, and objections, if any, within 30 days after service of the interrogatories. The parties may stipulate to an extension of time to respond to the interrogatories. A motion to extend the time to respond shall represent that an attempt to reach agreement with the opposing party to informally extend the time for response has been unsuccessful and the opposing parties position or that there has been a reasonable attempt to contact the opposing party to ascertain its position.
If there is an objection to or other failure to answer an interrogatory, the party
submitting the interrogatories may move the Industrial Commission for an order compelling
answer. If the Industrial Commission orders answer to an interrogatory within a time
certain and no answer is made or the objection is still lodged, the Industrial Commission
may issue an order with appropriate sanctions, including but not limited to the sanctions
specified in Rule 37
of the North Carolina Rules of Civil Procedure.
Interrogatories may relate to matters which are not privileged which are
relevant to an issue presently in dispute or which the requesting party
reasonably believes may later be disputed. Signature of a party or attorney
serving interrogatories constitutes a certificate by such person that he or
she has personally read each of the interrogatories, that no such
interrogatory will oppress a party or cause any unnecessary expense or
delay, that the information requested is not known or equally available to
the requesting party and that the interrogatory relates to an issue
presently in dispute or which the requesting party reasonably believes may
later be in dispute. A party may serve an interrogatory, however, to obtain
verification of facts relating to an issue presently in dispute. Answers to
interrogatories may be used to the extent permitted by the rules of
evidence.
Additional methods of discovery as provided by the North Carolina Rules of Civil
Procedure may be used only upon motion and approval by the Industrial Commission or by
agreement of the parties.
Notices of depositions, discovery requests and responses pertinent to a pending motion,
responses to discovery following a motion or order to compel, and post-hearing discovery
requests and responses shall be filed with the Commission, as well as served on the
opposing party. Otherwise, discovery requests and responses, including interrogatories and
requests for production of documents, shall not be filed with the Commission.
Sanctions may be imposed under this Rule for failure to comply with a Commission order compelling discovery. A motion by a party or its attorney to compel discovery under this Rule and Rule 607 shall represent that informal means of resolving the discovery dispute have been attempted in good faith and state briefly the opposing parties position or that there has been a reasonable attempt to contact the opposing party and ascertain its position.
Rule 606
Discovery Post Hearing
Discovery may not be conducted after the initial hearing on the merits of a case unless allowed by order of a Commissioner or Deputy Commissioner.
Rule 607
Discovery of Records and Reports
Upon written request, any party shall furnish, without cost, the requesting party a copy of any and all medical, vocational and rehabilitation reports, employment records, Industrial Commission forms, and written communications with medical providers in its possession, within 30 days of the request, unless objection is made within that time period. This obligation exists whether or not a request for hearing has been filed. This obligation is a continuing one, and any such reports and records which come into the possession of a party after receipt of a request pursuant to this Rule shall be provided to the requesting party within 15 days from its receipt of these reports and records.
Upon receipt of a request, an insurer or administrator for an employers workers compensation program shall inquire of the employer concerning the existence of records encompassed by the request.
Rule 608
Statement About Incident Leading to Claim
At the outset of taking a statement, the employer or his agent shall advise the employee
that the statement is being taken to be used in part to determine whether the claim will
be paid or denied. Any plaintiff who gives his employer, or its carrier, or any agent
either a written or recorded statement of the facts and circumstances surrounding his
injury shall be furnished a copy of such statement within 45 days after request. Further,
any plaintiff who shall give a written or recorded statement of the facts and
circumstances surrounding his injury shall, without request, be furnished a copy no less
than 45 days from the filing of a Form 33 Request for Hearing.
Such copy shall be furnished at the expense of the person, firm or corporation at whose
direction the statement was taken.
If any person, firm or corporation fails to comply with this rule, then an order may be entered by a Commissioner or Deputy Commissioner prohibiting that person, firm or corporation, or its representative, from introducing the statement into evidence or using any part of it.
Rule 609
Motions Practice in Contested Cases
Motions brought before the Commission shall be addressed as follows:
All motions in cases which are currently calendared for hearing before the Full Commission
or Deputy Commissioner shall be sent directly to the Chair of the Full Commission panel
or Deputy Commissioner before whom the case is pending.
Motions filed before a case is calendared before a Deputy Commissioner, or
once a case has been continued, or removed from a Deputy Commissioner calendar, or after
the filing of an Opinion and Award when the time for taking appeal has run, shall be
directed to the Executive Secretary of the Industrial Commission. Motions to reconsider or
amend an Opinion and Award, made prior to giving notice of appeal to the Full Commission,
shall be directed to the Deputy Commissioner who authored the Opinion and Award.
Motions filed after notice of appeal to the Full Commission has been given but prior to
the calendaring of the case shall be directed to the Chair of the Industrial Commission.
If a case has been continued from the Full Commission hearing docket, motions shall be
directed to the Chair of the panel of Commissioners who ordered the continuance.
Motions filed after the filing of an Opinion and Award by the Full Commission but prior
to giving notice of appeal to the Court of Appeals shall be directed to the Commissioner
who authored the Opinion and Award.
A motion shall state with particularity the grounds on which it is based, the relief
sought, and a brief statement of the opposing partys position, if known. Service
shall be made on all opposing attorneys of record, or on all opposing parties, if not
represented.
Motions to continue or remove a case from the hearing calendar on which the case is set
must be made well in advance of the scheduled hearing and may be made in written or oral
form. In all cases the moving party must provide just cause for the motion and state
that the other parties have been advised of the motion and relate the position, if known,
of the other parties regarding the motion. Oral motions must be followed with a written
confirmation from the moving party.
The responding party to a motion shall have 10 days after a motion is
served during which to file and serve copies of response in opposition to the motion. The
Industrial Commission may shorten or extend the time for responding to any motion.
Notwithstanding the provisions of paragraph 4 above, a motion may be
acted upon at any time by the Commission, despite the absence of notice to all parties,
and without awaiting a response thereto. A party who has not received actual notice of
such a motion or who has not filed a response at the time such action is taken and who is
adversely affected by the action may request that it be reconsidered,
vacated, or modified. Motions will be determined without oral argument, unless the
Industrial Commission orders otherwise.
In all cases where correspondence relative to a case before the Industrial Commission is
sent to the Industrial Commission, copies of such correspondence shall be
contemporaneously sent by the same method of transmission to the opposing party or, if
represented, to opposing counsel. Written communications, whether addressed
directly to the Commission or copied to the Commission, may not be used as an opportunity
to introduce new evidence or to argue the merits of the case, with the exception of the
following instances:
Written communications, such as a proposed order or legal memorandum, prepared pursuant
to the Commissions instructions;
Written communications relative to emergencies, changed circumstances, or scheduling
matters that may affect the procedural status of a case such as a request for a
continuance due to the health of a litigant or an attorney;
Written communications sent to the tribunal with the consent of the opposing lawyer or
opposing party if unrepresented; and
Any other communication permitted by law or the rules or procedures of the Commission.
At no time may written communications, whether addressed directly to the Commission or
copied to the Commission, be used as an opportunity to cast the opposing party or counsel
in a bad light.
All motions made before the Industrial Commission must include a proposed Order to be
considered by the Industrial Commission.
Except as otherwise expressly provided by statute, rule, or by order of the Commission, in computing any period of time prescribed or allowed by the Commission Rules, by order of the Commission, or by any applicable statute, the day of the act, event, or default after which the designated period of time begins to run is not to be included. The last day of the period so computed is to be included, unless it is a Saturday, Sunday, or a legal holiday, in which event the period runs until the end of the next day which is not a Saturday, Sunday or a legal holiday. When the period of time prescribed or allowed is less than seven days, intermediate Saturdays, Sundays, and holidays shall be excluded in the computation. Whenever a party has the right to do some act or take some proceedings within a prescribed period after the service of any document, three days shall be added to the prescribed period.
Rule 609A
Medical Motions and Emergency Medical Motions
Expedited Medical Motions
Medical motions pursuant to
N.C. Gen. Stat. §97-25 brought before the Office
of the Executive Secretary for an administrative ruling shall comply with
applicable provisions of Rule 609 and shall be submitted electronically to
medicalmotions@ic.nc.gov,
unless electronic submission is unavailable to the party.
A party may file with the Deputy Commissioner
Section a request for an administrative ruling on a medical motion. A party,
also, may appeal an Order from the Executive Secretary’s Office on an
Expedited Medical Motion by giving notice of appeal to the Dockets
Department within 15 days of receipt of the Order or receipt of the ruling
on a Motion to Reconsider the Order filed pursuant to Rule 703(1). The
Motion shall contain a designation as an administrative “Expedited Medical
Motion”, documentation in support of the request, including the most recent
medical record/s and a representation that informal means of resolving the
issue have been attempted in good faith, and the opposing party’s position,
if known.
A Pre-Trial Conference will be held immediately to clarify the issues.
Parties are encouraged to consent to a review of the contested issues by
electronic mail submission of only relevant medical records and opinion
letters.
If depositions are deemed necessary by the Deputy Commissioner, only a brief
period for taking the same will be allowed. Preparation of the transcript
will be expedited and will initially be at the expense of defendants.
Requests for independent medical examinations may be denied unless there is
a demonstrated need for the evaluation.
Written arguments and briefs shall be limited in length, and are to be filed
within five days after the record is closed.
A party may appeal an Order by a Deputy Commissioner on an Expedited Medical
Motion by giving notice of appeal to the Full Commission within 15 days of
receipt of the Order or receipt of the ruling on a Motion to Reconsider the
Order filed pursuant to Rule 703(1).
A letter expressing an intent to appeal a Deputy Commissioner’s Order on an
Expedited Medical Motion shall be considered notice of appeal to the Full
Commission, provided that it clearly specifies the Order from which appeal
is taken.
After receipt of notice of appeal, the appeal will be acknowledged by the
Dockets Department within three (3) days by sending an appropriate Order
under the name of the Chair of the Panel to which the appeal is assigned.
The parties may be permitted to file briefs on an abbreviated schedule in
the discretion of the panel chair. The panel chair will also determine if
oral arguments are to be by telephone, in person, or waived. All
correspondence, briefs, or motions related to the appeal shall be addressed
to the panel chair with a copy to the law clerk of the panel chair.
Emergency Medical Motions:
Motions requesting emergency medical relief administratively shall contain the following:
A boldface, or otherwise emphasized, designation as “Emergency
Medical Motion.”
An explanation of the need for a shortened time period for review,
including any hardship that warrants immediate attention/action by
the Commission.
A statement of the time-sensitive nature of the request, with
specificity.
Detailed dates and times related to the issue raised and to the date
a ruling is requested.
Documentation in support of the request, including the most recent
medical records.
A representation that informal means of resolving the issue have
been attempted in good faith, and the opposing party’s position, if
known.
A party may file an Emergency Medical Motion with the Executive
Secretary’s Office, the Chief Deputy Commissioner, or the Office of the
Chair. A proposed Order shall be provided with the motion. The
non-moving party(ies) will be advised regarding any time allowed for
response and may be advised whether informal telephonic oral argument is
necessary.
Emergency Medical Motions and responses thereto shall be submitted
electronically, unless electronic submission is unavailable to the
party.
Emergency Medical Motions and responses thereto filed with the
Executive Secretary’s Office shall be submitted to
medicalmotions@ic.nc.gov.
Emergency Medical Motions filed with the Chief Deputy Commissioner
shall be submitted electronically directly to the Chief Deputy
Commissioner and his/her legal assistant.
Emergency Medical Motions filed with the Chair of the Commission
shall be submitted electronically to the Chair, his/her legal
assistant, and his/her law clerk.
Rule 610
Pre-Trial Conference and Pre-Trial Order
A Commissioner or Deputy Commissioner may order the parties to appear at a pre-trial
conference to determine specific matters. This conference may be conducted at such place
and by such method as the Commissioner or Deputy Commissioner deems appropriate, including
conference telephone calls.
Any party may request a pre-trial conference when that party deems that such a
conference would aid in settling the case or resolving some issues prior to trial.
Requests for such pre-trial conferences shall be directed to the Deputy Commissioner
before whom the claim has been calendared, or to the Team Coordinator for the geographical
area, if any.
A Commissioner or a Deputy Commissioner may issue a Pre-Trial Order requiring the parties to submit a Pre-Trial Agreement. The parties shall have 15 days following the hearing within which to schedule the taking of medical depositions unless otherwise extended by the Commission.
If not specified in the Pre-Trial Agreement, the parties shall file with the Deputy Commissioner within 15 days following the trial a list specifically identifying all expert witnesses to be deposed and the dates of their depositions.
Within ten days after each expert witness deposition, defendants’ counsel shall submit to the Deputy Commissioner, via email, a request to approve such expert’s fee. In these requests, counsel shall provide to the Deputy Commissioner, in a cover letter along with the invoice (if provided to counsel), the following: (1) the name of the expert deposed; (2) his/her practice’s name; (3) his/her fax number; (4) his/her area of specialty and board certifications, if any; and (5) the exact length of the deposition and the length of time the expert spent preparing for the deposition. Counsel shall submit a proposed Order that shows the expert’s name, practice name and fax number under the “Appearances” section. Failure to make prompt payment to an expert witness following the entry of a fee order will result in the assessment of a 10 percent penalty.
Pre-Trial Agreement shall be prepared in a form which substantially complies with the Order on Final Pre-Trial Conference adopted in the North Carolina Rules of Practice for the Superior and District Courts. Should the parties fail to comply with a Pre-Trial Order, the Commissioner or Deputy Commissioner may remove the case from the hearing docket. Should the parties thereafter comply with the Pre-Trial Order after the removal of the case, the Pre-Trial Agreement must be directed to the Commissioner or Deputy Commissioner who removed the case from the docket; and the Commissioner or Deputy Commissioner will order the case returned to the hearing docket as if a Request for Hearing had been filed on the date of the Order to return the case to the hearing docket. No new Form 33 Request for Hearing is required.
Rule 611
Hearings Before the Industrial Commission
The Industrial Commission may on its own motion order a hearing or rehearing of any case
in dispute.
The Industrial Commission shall set a contested case for hearing in a location deemed
convenient to witnesses and the Industrial Commission, and conducive to an early and just
resolution of disputed issues.
In setting contested cases for hearing, cases in which the payment of workers
compensation benefits is at issue shall take precedence over those cases in which the
payment of workers compensation benefits is not at issue.
The Industrial Commission will give reasonable notice of hearings in every case.
Postponement or continuance of a duly scheduled hearing will rest entirely in the
discretion of a Commissioner or Deputy Commissioner. Where a party has not notified the
Industrial Commission of the attorney representing the party prior to the mailing of
calendars for hearing, notice to that party shall constitute notice to the partys
attorney.
The only parts of the Industrial Commission file in a contested case which are a part of
the record on which a decision will be rendered are prior Opinion and Awards, form
agreements, awards, and orders of the Industrial Commission; provided, however, that if
provisions of the Workers Compensation Act designate other documents as part of the
record, such documents shall also be a part of the record. Any other documents which the
parties wish to have included in the record must be introduced and received into evidence.
Hearing costs shall be assessed in each case set for hearing, including those cases
which are settled after being calendared and notices mailed, and shall be payable upon
receipt of a statement from the Industrial Commission.
In the event of inclement weather or natural disaster, hearings shall be cancelled if the proceedings in the General Court of Justice in the county in which the hearings are set are cancelled.
Rule 612
Depositions and Additional Hearings
When additional testimony is necessary to the disposition of a case, a Commissioner or
Deputy Commissioner may order the deposition of witnesses to be taken on or before a day
certain not to exceed 60 days from the date of the ruling; provided, the time allowed
may be enlarged for good cause shown. The costs of such depositions shall be borne
by defendants for those medical witnesses who examined plaintiff at defendants
expense, in those instances in which defendants are requesting the depositions, and in any
other case which, in the discretion of the Commissioner or Deputy Commissioner, it is
deemed appropriate.
In cases where a party, or an attorney for either party, refuses to stipulate medical
reports and the case must be reset or depositions ordered for testimony of medical
witnesses, a Commissioner or Deputy Commissioner may in his discretion assess the costs of
such hearing or depositions, including reasonable attorney fees, against the party who
refused the stipulation.
Except under unusual circumstances, all lay evidence must be offered at the initial hearing. Lay evidence can only be offered after the initial hearing by order of a Commissioner or Deputy Commissioner. The costs of obtaining lay testimony by deposition shall be borne by the party making the request unless otherwise ordered by the Commission.
Rule 613
Dismissals and Removals
Dismissals
No claim filed under the Workers Compensation Act shall be dismissed without
prejudice at plaintiffs instance except upon order of the Industrial Commission and
upon such terms and conditions as justice requires; provided, however, that no voluntary
dismissal shall be granted after the record in a case is closed.
Unless otherwise ordered by the Industrial Commission, a plaintiff shall have one year
from the date of the Order of Voluntary Dismissal to refile his claim.
Upon proper notice and an opportunity to be heard, any claim may be dismissed with or
without prejudice by the Industrial Commission on its own motion or by motion of any party
for failure to prosecute or to comply with these Rules or any Order of the Commission.
Removals
A claim may be removed from the hearing docket by motion of the party requesting the
hearing or by the Industrial Commission upon its own motion.
Upon settlement of a case or approval of a form agreement, the parties shall
submit a request for removal and/or a dismissal and proposed Order.
A removed case may be reinstated by motion of either party; provided that when the
issues have materially changed since the Order of Removal or where the motion to reinstate
is filed more than one year after the Order of Removal, a Form 33 Request for Hearing
will be required.
When a plaintiff has not requested a hearing within two years of the filing of an Order of Removal requested by the plaintiff or necessitated by the plaintiff’s conduct, and not pursued the claim, upon proper notice and an opportunity to be heard, any claim may be dismissed with prejudice by the Industrial Commission, in its discretion, on its own motion or by motion of any party.
Rule 614
Attorneys Retained for Proceedings
Any attorney who is retained by a party in a proceeding before the
Industrial Commission shall immediately file a notice of appearance with the Industrial
Commission. A copy of this notice shall be served on all other counsel and on all
unrepresented parties. Thereafter, all notices required to be served on a party shall be
served upon the attorney. No direct contact or communication concerning contested matters
may be made with a represented party by the opposing party or any person on
its behalf, without the attorneys permission except as permitted by
law or Industrial Commission Rules.
Any attorney who wishes to withdraw from representation in a proceeding before the
Industrial Commission shall file with the Industrial Commission, in writing:
A Motion
to Withdraw which shall contain a statement of reasons for the request and
that the request has been served on the client.
The attorney shall make reasonable efforts to ascertain the last known
address of the client and shall include this information in the motion.
A Motion to Withdraw before an award is made shall state whether the withdrawing
attorney requests an attorney fee from the represented party once an award of compensation
is made or approved.
An attorney may withdraw from representation only by written order of the
Industrial Commission. The issuance of an award of the Industrial Commission does not
release an attorney as the attorney of record.
An attorney withdrawing from representation whose client wishes to appeal an Order, Decision, or Award to the Full Commission shall timely file a notice of appeal on behalf of his or her client either before or with his or her Motion to Withdraw.
Rule 615
Disqualification of a Commissioner or Deputy Commissioner
In their discretion, Commissioners or Deputy Commissioners may recuse themselves from the hearing of any case before the Industrial Commission. For good cause shown, a majority of the Full Commission may remove a Commissioner or Deputy Commissioner from hearing a case.
Rule 616
Foreign Language Interpreters
Services of Foreign Language Interpreters Required.
When a person who does not speak or understand the English language is called to
testify in a hearing, other than in an informal hearing conducted pursuant to N.C. Gen. Stat. §97-18.1,
the person, whether a party or a witness, shall be assisted by a qualified foreign
language interpreter.
Qualifications of Interpreters.
To qualify as a foreign language interpreter, a person must possess sufficient
experience and education, or a combination of experience and education, speaking and
understanding English and the foreign language to be interpreted, to qualify as an expert
witness pursuant to N.C.
Gen. Stat. §1C-1, Rule 702. A person qualified as an interpreter under this Rule
shall not be interested in the claim and must make a declaration under oath or affirmation
to interpret accurately, truthfully and without any additions or deletions, all questions
propounded to the witness and all responses thereto.
Notice to Industrial Commission and Opposing Party of Need for Interpreter.
Any party who is unable to speak or understand English, or who intends to call as a
witness a person who is unable to speak or understand English, shall so notify the
Industrial Commission and the opposing party, in writing, not less than 21 days prior to
the date of the hearing. The notice shall state with specificity the language(s) that must
be interpreted for the Commission.
Designation of Interpreter.
Upon receiving or giving the notice required in paragraph (3) of this
Rule, the employer or insurer shall retain a qualified, disinterested interpreter, either
agreed upon by the parties or approved by the Industrial Commission, to
appear at the hearing and interpret the testimony of all persons for whom the notice in
paragraph (3) has been given or received.
Interpreter Fees.
The interpreters fee shall constitute a cost as contemplated by
N.C. Gen. Stat. §97-80.
A qualified interpreter who interprets testimony for the Industrial Commission shall be
entitled to payment of the fee agreed upon by the interpreter and employer or insurer that
retained the interpreter. Except in cases where a claim for compensation has been
prosecuted without reasonable ground, the fee agreed upon by the interpreter and employer
or insurer shall be paid by the employer or insurer. Where it is ultimately determined by
the Commission that the request for an interpreter was unfounded, attendant costs may be
assessed against the movant.
Interpreter Ethics.
Foreign language interpreters shall abide by the code of ethical conduct for court interpreters promulgated by the North Carolina Administrative Office of the Courts and adopted by the Industrial Commission and shall interpret as word for word as is practicable, without editing, commenting, or summarizing, testimony or other communications.
Rule 617
Electronic Service and Verification of Service by the Commission
Consistent with the provisions in N.C. Gen. Stat. §§97-84, 97-85, and 97-86, the Commission shall establish guidelines for the electronic submission, including electronic mail and facsimile, of documents and communications.
Rule 701
Appeal to the Full Commission
A letter expressing an intent to appeal shall be considered notice of appeal to the Full
Commission within the meaning of N.C. Gen. Stat. §97-85,
provided that it clearly specifies the Order or Opinion and Award from which appeal is
taken.
After receipt of notice of appeal, the Industrial Commission will supply to the
appellant a Form 44
Application for Review upon which appellant must state the grounds for the appeal. The
grounds must be stated with particularity, including the specific errors allegedly
committed by the Commissioner or Deputy Commissioner and, when applicable, the pages in
the transcript on which the alleged errors are recorded. Failure to state with
particularity the grounds for appeal shall result in abandonment of such grounds, as
provided in paragraph (3). Appellants completed Form 44 and brief must
be filed and served within 25 days of appellants receipt of the transcript or
receipt of notice that there will be no transcript, unless the Industrial Commission, in
its discretion, waives the use of the Form 44. The time for filing
a notice of appeal from the decision of a Deputy Commissioner under these rules shall be
tolled until a timely motion to reconsider or to amend the decision has been ruled upon by
the Deputy Commissioner.
Particular grounds for appeal not set forth in the application for
review shall be deemed abandoned, and argument thereon shall not be heard before the Full
Commission.
Appellants Form 44
and brief in
support of his grounds for appeal shall be filed in triplicate with the
Industrial Commission, with a certificate indicating service on appellee by
mail or in person, within 25 days after receipt of the transcript, or
receipt of notice that there will be no transcript. Thereafter, appellee
shall have 25 days from service of appellant’s brief within which to file a
reply brief in triplicate with the Industrial Commission, with written
statement of service of copy by mail or in person on appellant. When an
appellant fails to file a brief, appellee shall file his brief within 25
days after appellant’s time for filing brief has expired. A party who fails
to file a brief will not be allowed oral argument before the Full
Commission. If both parties appeal, they shall each file an appellant’s and
appellee’s brief on the schedule set forth herein.
If the matter has not been calendared for hearing, any party may file with
the Docket Director a written stipulation to a single extension of time not
to exceed 15 days. In no event shall the cumulative extensions of time
exceed 30 days.
After notice of appeal has been given to the Full Commission, any motions
related to the issues before the Full Commission shall be filed in
triplicate with the Full Commission, with service on the other parties.
No new evidence will be presented to or heard by the Full Commission unless the
Commission in its discretion so permits.
Cases should be cited by North Carolina Reports and, preferably, to Southeastern
Reports. Counsel shall not discuss matters outside the record, assert personal opinions or
relate personal experiences, or attribute unworthy acts or motives to opposing counsel.
The Industrial Commission or any one of the parties with permission of the Industrial
Commission may waive oral argument before the Full Commission. In the event of such
waiver, the Full Commission will file a decision, based on the record,
assignments of error and briefs.
A plaintiff appealing the amount of a disfigurement award shall personally appear before
the Full Commission to permit the Full Commission to view the disfigurement.
Briefs to the Full Commission shall not exceed 35 pages, excluding attachments. No page limit shall apply to the length of attachments. Briefs shall be prepared entirely using a 12 point font, shall be double spaced, and shall be prepared with non-justified right margins. Each page of the brief shall be numbered at the bottom right of the page. When quoting or paraphrasing testimony or other evidence in the transcript of the evidence, a parenthetic entry in the text, to include the exact page number location within the transcript of the evidence of the information being referenced shall be placed at the end of the sentence citing the information [Example: (T.p.38)]. When quoting or paraphrasing testimony or other evidence in the transcript of a deposition, a parenthetic entry in the text to include the name of the person deposed and exact page number location within the transcript of the deposition of the information being referenced shall be placed at the end of the sentence citing the information. [Example: (Smith p.15)].
Rule 702
Appeal to the Court of Appeals
Except as otherwise provided in N.C. Gen. Stat. §97-86,
in every case appealed to the North Carolina Court of Appeals, the Rules of Appellate
Procedure shall apply. The running of the time for filing and serving a notice of appeal
is tolled as to all parties by a timely motion filed by any party to amend, to make
additional findings, or to reconsider the decision, and the full time for appeal commences
to run and is to be computed from the entry of an Order upon any of these motions, in
accordance with Rule 3 of the Rules of Appellate Procedure.
If the
parties cannot agree on the record on appeal, appellant shall furnish the
Chair of the Industrial Commission, or his designee, one copy of the
proposed record on appeal, objections and/or proposed alternative record on
appeal along with a timely request to settle the record on appeal. The
hearing to settle the record on appeal shall be held at the offices of the
Industrial Commission or by telephone conference.
The record on appeal shall be settled in accordance with the provisions of
Rule 18(d) of the North Carolina Rules of Appellate Procedure.
The amount of the appeal bond shall be set by the Chair or his designee, and may be waived in accordance with N.C. Gen. Stat. §97-86.
Rule 702A
Remand from the Appellate Courts
When a case is remanded to the Commission from the appellate courts, each party may file a statement with the Full Commission, supported by a brief if appropriate, setting forth its position on the actions or proceedings, including evidentiary hearings or depositions, required to comply with the court’s decision. This statement shall be filed within 30 days of the issuance of the court’s mandate and shall be filed with the Commissioner who authored the Full Commission decision or the Chairman of the Industrial Commission if the Commissioner who authored the decision is no longer a member of the Industrial Commission.
Rule 703
Review of Administrative Decisions
Orders, Decisions, and Awards made in a summary manner, without detailed findings of
fact, including Decisions on applications to approve agreements to pay compensation and
medical bills, applications to approve the termination or suspension of compensation,
applications for change in treatment or providers of medical compensation, applications to
change the interval of payments, and applications for lump sum payments of compensation
may be reviewed by filing a Motion for Reconsideration with the Industrial
Commission and addressed to the Administrative Officer who made the Decision or may be
appealed by requesting a hearing within 15 days of receipt of the Decision or receipt of
the ruling on a Motion to Reconsider. These issues may also be raised and determined at a
subsequent hearing.
Motions for Reconsideration shall not stay the effect of the Order, Decision or Award;
provided, that the Administrative Officer making the Decision or a Commissioner may enter
an Order staying its effect pending the ruling on the Motion for Reconsideration or
pending a Decision by a Commissioner or Deputy Commissioner following a formal hearing. In
determining whether or not to grant a stay, the Commissioner or Administrative Officer
will consider whether granting the stay will frustrate the purposes of the Order,
Decision, or Award.
Any review made by requesting a hearing shall be made to the Industrial Commission and
filed with the Industrial Commissions Docket Director. The Industrial Commission
shall designate a Commissioner or Deputy Commissioner to hear the review. The Commissioner
or Deputy Commissioner hearing the matter shall consider all issues de novo, and no
issue shall be considered moot solely because the Order has been fully executed during the
pendency of the hearing.
Orders filed by a single Commissioner, including Orders dismissing appeals to the Full Commission or denying the right of immediate appeal to the Full Commission, are administrative orders and are not final determinations of the Industrial Commission. As such, an Order filed by a single Commissioner is not immediately appealable to the North Carolina Court of Appeals. A one-signature Order filed by a single Commissioner may be reviewed by filing a Motion for Reconsideration addressed to the Commissioner who filed the Order or may be appealed to a Full Commission panel by requesting a hearing within 15 days of receipt of the Order or receipt of the ruling on a Motion for Reconsideration.
ARTICLE VIII. RULES OF THE COMMISSION
Rule 801
Waiver of the Rules
In the interest of justice, these rules may be waived by the Industrial Commission. The rights of any unrepresented plaintiff will be given special consideration in this regard, to the end that a plaintiff without an attorney shall not be prejudiced by mere failure to strictly comply with any one of these rules.
Rule 802
Sanctions
Upon failure to comply with any of the aforementioned rules, the Industrial Commission
may subject the violator to any of the sanctions outlined in Rule 37
of the North Carolina Rules of Civil Procedure, including reasonable attorney fees to be
taxed against the party or his counsel whose conduct necessitates the order.
Failure to timely file forms as required by either these Rules or pursuant to the Act may result in fines or other appropriate sanctions.
Rule 803
Procedure for Workers Compensation Rule Making by the Industrial Commission
Prior to adopting, deleting, or amending any Workers Compensation Rule of the Industrial Commission which affects the substantive rights of parties, the Industrial Commission will give at least 30 days notice of the proposed change in rules. Such notice will be given by publishing, in a newspaper or newspapers of general circulation in North Carolina, notice of such proposed change. Such notice will include an invitation to any interested party to submit in writing any objection, suggestion or other comment with respect to the proposed rule change or to appear before the Full Commission at a time and place designated in the notice for the purpose of being heard with respect to the proposed rule change.
ARTICLE IX. REPORT OF EARNINGS
Rule 901
Check Endorsement
If a self-insured employer, carrier or third party administrator places "check endorsement" language on the back of an employee's check, the following language (or similar language approved by the Industrial Commission) shall be used:
By endorsing this check, I certify that I have not worked for or earned wages from any business or individual during the period covered by this check, or that I have reported any earnings to the employer/carrier paying me workers' compensation benefits. I understand that making a false statement by endorsing this benefit check may result in civil or criminal penalties.
Rule 902
Notice
A self-insured employer, carrier or third party administrator shall not use check endorsement language on the back of an employee's workers' compensation benefit check unless the employee has been provided the following Notice sent by certified mail return receipt requested:
Notice to Employee Receiving Workers' Compensation Benefits
This NOTICE is intended to advise you of important information you need to know if you are receiving workers' compensation benefits.
Please TAKE NOTICE of the following:
(1) When you are receiving weekly workers' compensation benefits, you must report any earnings you receive to the insurance company (or employer if the employer is self-insured) that is paying you the benefits. "Earnings" include any cash, wages or salary received from self-employment or from any employment other than the employment where you were injured. Earnings also include commissions, bonuses, and the cash value for all payments received in any form other than cash (e.g., a building custodian receiving a rent-free apartment). Commission bonuses, etc., earned before disability but received during the time you are also receiving workers' compensation benefits do not constitute earnings that must be reported.
(2) You must report any work in any business, even if the business lost money or if profits or income were reinvested or paid to others.
(3) Your endorsement on a benefit check or deposit of the check into an account is your statement that you believe that you are entitled to receive workers' compensation benefits. Your signature on a benefit check is a further affirmation that you have made no material false statement or concealed any material fact regarding your right to receive the benefit check.
(4) Making false statements for purpose of obtaining workers' compensation benefits may result in civil and criminal penalties.
Rule 903
Employees Obligation to Report Earnings
A self-insured employer, carrier or third-party administrator may require the employee to complete a Form 90 Report of Earnings when reasonably necessary but not more than once every six months.
The Form 90 must be sent to the employee by certified mail, return receipt requested, and include a self-addressed stamped envelope for the return of the Form. When the employee is represented by an attorney, the Form 90 shall be sent to the attorney for the employee and not to the employee.
The employee shall complete and return the Form 90 Report of Earnings within 15 days after receipt of a Form 90. If the employee fails to complete and return the Report of Earnings within 30 days of receipt of the form, the self-insured employer, carrier or third-party administrator may seek an order from the Executive Secretary allowing the suspension of benefits. The self-insured employer, carrier or third-party administrator shall not suspend benefits without Commission approval. If the Commission suspends benefits for failure to complete and return a Form 90 Report of Earnings, the self-insured employer, carrier or third-party administrator shall immediately reinstate benefits to the employee with back payment as soon as the Report of Earnings is submitted by the employee. If benefits are not immediately reinstated, the employee should submit a written request for an Order from the Executive Secretary instructing the self-insured employer, carrier or third-party administrator to reinstate benefits. If the employee’s earnings report does not indicate continuing eligibility for partial or total disability compensation, then the self-insured employer, carrier or third-party administrator may apply to the Commission to terminate or modify benefits pursuant to Commission procedure, including filing a Form 24, 36, and 33.