D.C. Mun. Regs. tit. 7, r. 7-3502

Current through Register Vol. 72, No. 2, January 10, 2025
Rule 7-3502 - PROCESSING CLAIMS FOR PAID LEAVE
3502.1

Within ten (10) business days after the filing of a claim for paid-leave benefits, a DOES claims examiner shall:

(a) Notify the applicant of DOES's determination of eligibility or ineligibility for the type of paid-leave benefits sought; or
(b) Issue a provisional denial of the claim and provide an explanation of the need to submit additional information for DOES to process the claim.
3502.2

Within three (3) business days after the filing of a claim for paid-leave benefits, a DOES claims examiner shall:

(a) Notify the current covered employer of the filing of a claim by the applicant; and
(b) Request from the employer:
(1) The employment status of the applicant;
(2) The last day worked by the applicant;
(3) Which type of leave from among the options described in subsection 3501.2 that the employee requested from the employer pursuant to the notice described in section 3509; and
(4) If applicable, whether the employer agrees with the employee's self-described workweek provided pursuant to Subsection 3506.5(b)(1).
3502.3

The covered employer shall submit the requested information, or an attestation that the applicant was or is not an employee of the employer, within four (4) business days after receipt of the request from the claims examiner. If the covered employer fails to provide the requested information within four (4) business days, the claim for paid leave shall be processed using the available information; provided that if the covered employer later files additional information, DOES may re-process the claim, taking into account the additional information.

3502.4
(a) If DOES requires additional information from an applicant to process a claim, and the information cannot be obtained within the ten (10)-day processing period provided in Subsection 3502.1, DOES shall issue a provisional denial of the claim and provide a description of the missing information to the applicant.
(b) If the applicant provides the additional information in response to DOES' request for additional information within ten (10) business days of the date of the provisional denial, DOES shall reprocess the claim taking into account the additional information.
(c) If the applicant does not provide additional information in response to DOES' request for additional information within ten (10) business days of the date of the request, the determination of denial shall be final.
(d) A provisional denial pursuant to this subsection shall be considered an official determination for the purposes of appeals pursuant to Sections 3511 and 3512.
3502.5

For qualifying family leave, qualifying medical leave, and qualifying pre-natal leave, the claims examiner shall first determine an applicant's tentative eligibility based on non-medical factors supported by documentation submitted to establish the applicant's identity, employment history, and, if applicable, familial relationship.

3502.6

After establishing tentative eligibility for qualifying family leave or qualifying medical leave, the claims examiner shall review the medical evidence for eligibility. The medical evidence shall take the form of proof of a qualifying event provided by the eligible individual, health care provider, and the qualified family member, if applicable. This evidence shall be reviewed by the claims examiner in accordance with the International Classification of Diseases, Tenth Revision (ICD-10), or subsequent revisions by the World Health Organization to the International Classification of Diseases.

3502.7

If DOES determines that additional information is not required and makes an initial determination on eligibility for paid-leave benefits, DOES shall issue a notification of the initial determination:

(a) To both the eligible individual and the covered employer that includes:
(1) A statement as to whether the claim for paid-leave benefits has been approved or denied;
(2) If the claim was approved:
(A) The start date for the payment of paid-leave benefits;
(B) Whether the leave will initially be taken continuously or intermittently, and, if intermittently, the scheduled days on which benefits will be payable;
(C) The expected end date for paid-leave benefits, given the current payment schedule elected by the eligible individual; and
(D) If the individual opted to instruct DOES to disclose the weekly benefit amount, and, if applicable, the equivalent daily benefit amount, the notification shall include the individual's approved weekly benefit amount, and, if applicable, the equivalent daily benefit amount.
(b) To the eligible individual in private communication:
(1) If the claim was approved, the approved weekly benefit amount, and, if applicable, the equivalent daily benefit amount;
(2) If the claim was denied, the reason(s) for the denial; and
(3) Regardless of whether the claim was approved or denied, a description of the process to file an appeal with the DOES Administrative Appeals Division or the Office of Administrative Hearings.
3502.8

By default, DOES will not include in the notification described in Subsection 3502.7(a) the eligible individual's approved weekly benefit amount, or, if applicable, the equivalent daily benefit amount. An eligible individual may choose to instruct DOES to disclose the benefit amount to the employer in the initial determination. However, regardless of whether the individual makes such an election, any information described in Subsection 3502.7(b) provided by DOES to the individual may be shared by the individual with the covered employer or other entities for any purpose, including allowing the covered employer or other entities to coordinate their paid-leave benefits with the benefits provided by this chapter. Covered employers or other entities may require that such information be shared by the individual in order for benefits provided by the covered employer or other entity to be paid to the individual.

D.C. Mun. Regs. tit. 7, r. 7-3502

Final Rulemaking published at 67 DCR 4001 (4/10/2020); amended by Final Rulemaking published at 68 DCR 1141 (2/11/2022)