Section 031-440-IV-2 - Disability ManagementA. Disability Control (1) Maximum medical improvement (MMI): The servicing carrier shall take appropriate steps to establish and document MMI in each case file for partial incapacity cases with dates of injury before October 17, 1991. (i) MMI shall be established by decree, by formal agreement, by the payment of a permanent impairment award, or by strong medical evidence.(ii) If MMI has not been established for a partial incapacity case, the case file shall contain a documented plan including discussion of specific measures by which the servicing carrier intends to establish MMI with the Workers' Compensation Board.(2) The servicing carrier shall establish disability control and track weeks of disability in accordance with 39 M.R.S.A. §§55-A or 55-B, and 39-A M.R.S.A. §§ 211 -214, as appropriate. (i) The case file shall clearly indicate whether disability payments are being made under § 54-B, total incapacity, or under § 55-B (or 39-A M.R.S.A. §213) , partial incapacity.(ii) If payments are being made under 39 M.R.S.A. § 55-B or 39-A M.R.S.A. § 213, the servicing carrier shall track payments and/or weeks of disability against the statutory maximum duration of 400 weeks after MMI for dates of injury before October 17, 1991; 520 weeks of compensation for dates of injury from October 17, 1991 through December 31, 1992; 260 weeks of compensation for dates of injury on or after January 1, 1993.(iii) Every case file shall be reviewed at least every 6 months.B. Claimant Contact (1) Continuing contact with the unrepresented injured worker at least every 6 months, and with the physician at intervals consistent with the injury and estimated length of disability and with obtaining an estimated return to work date.(2) Medical examinations under 39-A M.R.S.A. §§207 or 312 where questions of disability, causal relationships, and treatment exist or where reports of treating physicians are not forthcoming(3) Activity checks consistent with length of disability and/or suspected fraud, at least every 6 months. Activity checks may include but are not limited to phone calls to the claimant and/or his/her employer, in-person contact, surveillance, or contact with a designated representative.(4) Availability of return to modified or light work duties consistent with medical restrictions, if return to regular job does not appear medically feasible or is unavailable.(5) Vocational rehabilitation, in the form of alternative work, modified work, job placement, on the job training, and/or schooling, ensuring strict compliance with statutory standards.C. Coordination of benefits. The servicing carrier shall maintain an ongoing review of open cases with regard to each of the following factors, as may be appropriate in a particular case:(1) Employment Rehabilitation Fund possibilities;(2) Social Security and unemployment benefits;(3) Third party recovery;(4) Progress of claimant's medical condition toward maximum medical improvement;(5) Potential propriety of vocational rehabilitation. Claimant activity and dependency checks shall be made at least every 6 months.
D. Timely indemnity benefit payments. All indemnity benefit payments will be made promptly, in accordance with statutory provisions.E. Medical Cost Management (1) Review all medical bills or medical abstracts/documentation generated from the actual bills to verify reasonableness of charges and necessity of services. Appropriate reference to standards, scales, or schedules of appropriate charges adopted to the Workers' Compensation Board pursuant to 39-A M.R.S.A. §209 is required.(2) Where no questions of liability or reasonableness exist and physician reports have been received, pay all bills within 30 calendar days.(3) Where questions of liability or reasonableness exist, promptly investigate and obtain such further information as is necessary to resolve questions.F. Settlements. Where appropriate, carriers shall identify and pursue settlement opportunities. Any settlement shall be based on sound claims judgment consistent with liability and medical evidence developed, in accordance with the law and benefit structure.G. Claim Reopenings. Carriers shall record and document all reopenings of claims previously thought to be closed, including reason for the reopening and action taken or plan of action required to manage/close the case.02-031 C.M.R. ch. 440, § IV-2