3132

PROCEDURES FOR EXISTING CLAIMS

3132.1 The Program shall review EDs for compensation benefits, including decisions to terminate, suspend, or modify benefits.

3132.2 The Program shall adjust a claim using information from the treating physician who provides medical treatment to the employee for an injury or disability and from any Additional Medical Examination (AME) report. An AME shall consist of a case file review, and/or an in-person assessment or examination, by a qualified health professional other than the treating physician.

3132.3 An AME report shall be conclusive and responsive to the requests from the Program as part of a complete professional evaluation. Prior to any determination of coverage based upon the recommendation(s) of an AME, the injured employee's treating physician shall have thirty (30) days from receipt of a copy of the AME to submit written comments to the Program regarding the AME finding(s).

3132.4 Upon a request from the Program, the employee and the treating physician shall provide copies of all the employee's medical records regardless of the source of the record(s) or the medical condition(s) addressed in the records. The Program shall take appropriate steps to ensure that the medical records provided to it are maintained in a confidential manner.

3132.5 An employee who is receiving benefits under the Program shall not be the subject of an ED unless and until there is sufficient evidence to support the issuance of an ED pursuant to the Act and this section.

3132.6 An ED may be based, in whole or in part, upon the following factors:

(a) The death of the employee;

(b) The clear evidence that employee has returned to work;

(c) The employee's conviction of fraud in connection with the claim;

(d) The employee's failure to participate in vocational rehabilitation or to cooperate with the Program's request for a physical examination;

(e) The cessation or lessening of a compensable injury;

(f) The condition is no longer causally related to the employment;

(g) The condition has changed from a total disability to a partial disability;

(h) The employee has returned to work on a full-time or part-time basis notwithstanding individuals directed to undergo vocational rehabilitation under section 2304 of the Act;

(i) The Program determines based upon strong compelling evidence that the ID was in error; and

(j) Any other ground demonstrating that the Act requires the employee's benefits to be modified, such as abandonment of the claim, retirement of the employee, or clear evidence that the employee has knowingly and willfully received benefits to which he or she was not entitled under the Act.

3132.7 With the exception of the factors set forth in subsection 3132.6 (a)--(d), compensation benefits subject to an ED shall not be modified until the period for requesting reconsideration set forth in section 3134 has elapsed with no Request for Reconsideration being received by the ORM, or until a timely Request for Reconsideration has been decided by the ORM, whichever is earlier.

3132.8 A claim shall be deemed abandoned or subject to modification for non-cooperation when the employee fails to return required forms for an existing claim, the Program has made at least two (2) attempts to contact the employee and request such forms, and at least fourteen (14) calendar days prior to the issuance of the notice, the Program sends the employee a warning letter explaining why the Program believes the employee is not cooperating or has abandoned the claim, what the employee must do in order to comply, and describing the consequences of failing to cooperate or abandonment.

3132.9 In making its determinations regarding whether a claim should be the subject of an ED, the Program shall consider all relevant evidence in the claim file, including all relevant medical evidence.

3132.10 The ED is effective unless the employee succeeds on a request for reconsideration under section 3134 or the Program revises the ED.

3132.11 Medical reports used in connection with an ED shall meet the requirements of section 3160.

SOURCE: Notice of Emergency and Proposed Rulemaking published at 52 DCR 5481(June 10, 2005) [Expired]; and Notice of Emergency and Proposed Rulemaking published at 52 DCR 5771(June 17, 2005) [Expired]; and Notice of Emergency and Proposed Rulemaking published at 52 DCR 8964(October 7, 2005) [Expired]; and Notice of Emergency and Proposed Rulemaking published at 53 DCR 940(February 10, 2006) [Expired];Final Rulemaking published at 53 DCR 4290 (May 26, 2006); as amended by Final Rulemaking published at 53 DCR 6578 (August 11, 2006); as amended by Notice of Emergency and Proposed Rulemaking published at 57 DCR

9540 (October 8, 2010)[EXPIRED]; as amended by Notice of Final Rulemaking published at 57 DCR 12224, 12236 (December 24, 2010).