Wyo. Code R. 053-0021-5
Workers' Compensation Division
Chapter 5: Determinations by Division - Coverage & Compensability & Claims
Effective Date: 04/02/2004 to 11/22/2004
Rule Type: Superceded Rules & Regulations
Reference Number: 053.0021.5.04022004
(a) Upon receipt of the injury report, the Division will investigate and review the matter and will address questions of jurisdiction and compensability. The Division may gather additional facts prior to the determination. W.S. §§ 27-14-601(k) and 27-14-801(d). The procedures for review, determination, redetermination and request for hearing shall be as provided in Sections 2 and 3 of this chapter.
The following procedures apply to all determinations by the Division, including coverage/compensability determinations, all benefits claim applications, and all medical bill reviews.
(a) The Division will review the matter within 15 days from the date any completed employer or employee injury report or claim is filed and will issue either a final determination or request for additional information.
(b) At the earliest possible date within 45 days following the request for additional information, the Division will make its final determination as to whether the injury, or death resulting from injury, is compensable and within the jurisdiction of the Act or whether and in what amount a claim or bill is allowed.
(c) Upon mutual consent of the worker, the employer, and the Division, the time limit for the determination by the Division may be extended. Otherwise, upon failure of the Division to make a decision within the time allowed by the Act, at the request of any affected party the matter shall be referred by the Division for hearing.
(d) The final determination shall be mailed to all affected parties at their last known addresses, and, when required by law, shall include a statement of reasons, and a notice of right to request a hearing and right to counsel. An affected party shall immediately notify the Division, in writing, of any change of address or physical residence.
(e) Objection. Any affected party may object to the Division's final determination by filing a written request for hearing with the Division within 15 days following the mailing of the determination. W.S. § 27-14-601. A timely written request for hearing is prerequisite to review by the appropriate hearing authority.
(a) The Division may issue a redetermination within one year following the issuance of a final determination if the Division receives sufficient information to establish the compensability of the case or claim. W.S. § 27-14-601(k)(vi).
(i) The Division will not issue a redetermination, or award benefits to an injured worker, if information substantiating the compensability of a case or claim is submitted more that one year after the Division issued the final determination denying the compensability of the case or claim.
(ii) The redetermination shall be formal written notification sent to the employee, employer, and known treating health care provider(s).
(A) Any affected party may object to the Division's redetermination by filing a written request for hearing within 15 days following the issuance of the redetermination.
(B) A timely request for hearing is prerequisite to review by the appropriate hearing authority.
Section 4. Claims for Benefits. A person seeking an award of benefits under the Act must submit a written application for benefits to the Division, on a form provided by the Division. A report for injury is not a claim for benefits. W.S. § 27-14-503(a). A claim for benefits may be filed by the injured worker, that worker's personal representative, or, in case of an injured worker who is mentally incompetent or a minor, the worker's legal guardian. In order to make an application, a claimant shall submit one of the following:
(a) Claim for Reimbursement. A claim for reimbursement of any expense(s) incurred by an injured worker because of his work-related injury must be submitted on a form provided by the Division according to the procedure outlined in Chapter 7, Section 4(a)(iii) Medical Reimbursement to Injured Worker.
(b) Claim for Temporary Total Disability (TTD) Benefits (Lost Wages).
(i) When Submitted. A claim for TTD must be filed within 60 days after the first day of certified temporary total disability. W.S. § 27-14-404(d).
(ii) Certification. An award of TTD cannot be made without certification from a treating health care provider that the worker is temporarily and totally disabled (that is, incapacitated from performing any gainful employment for which the worker is reasonably suited by experience or training). The certification shall specify the reasons for the total disability and the expected period of disability.
(iii) A physician assistant shall be deemed a health care provider for purposes of examinations and TTD certifications pursuant to W.S. §§ 27-14-404(d)(ii), 404(g) and 501(b), if the TTD certification is accompanied by or the Division has on file, a written statement, signed and dated by the supervising licensed physician, stating 'I [insert name of physician] certify that the physician assistant signing this form has authority to do so and that the certification is provided under my supervision.' W.S. § 33-26-502(b). Both the supervising physician and the physician assistant shall have a continuing duty to notify the Division
immediately if a previously-designated physician assistant is no longer employed by the physician, is no longer licensed as a physician assistant in Wyoming, or is no longer authorized by the physician to certify TTD.
(iv) Where Submitted. A claim for TTD benefits must be filed with the Division. W.S. § 27-14-501(3).
(c) Claim for Temporary Partial (Light Duty) Disability (TPD).
(i) When Submitted. A claim for TPD may be filed after a written offer of light duty work, made by an employer to a claimant receiving TTD, is approved by the claimant's treating physician, and accepted by the claimant.
(ii) Light Duty Agreement. The offer must be in writing, on an agreement form supplied by the Division. Whenever terms of the agreement change, a new agreement form must be completed and submitted to the Division. Each agreement form must include the following information:
(I) Light duty wages equivalent to 2/3 of the pre-injury wage are recommended, but not required. Wages may be offered at what is determined by the employer to be a reasonable rate of pay for the work to be performed.
(II) Wages offered at 95% or more of the claimant's pre-injury wage shall be considered substantial restoration of pre-injury wage. TPD will not be awarded and TTD will be terminated.
(I) If the employer does not request a final determination, TPD will not be awarded; the claimant remains on full TTD, chargeable to the employer.
(iii) Payment of TPD will commence on the first day of light duty work when a valid written offer is accepted and the employer requests a final determination letter.
(iv) When a written offer of light duty work is refused by the worker, TPD will not be awarded and TTD will be reduced to 1/3 (0.3333) of the TTD rate, effective the 15th day following the refusal, if the employer has met all the conditions required in W.S. § 27-14-404(j).
(v) Non-Chargeable. An employer's account will not be charged for TPD paid to the claimant when either of the following occurs:
(A) A valid written offer is accepted and the employer requests a final determination letter;
(B) The claimant refuses a written offer and the terms of the agreement meet all the conditions required in W.S. § 27-14-404(j).
(vi) It is not considered a refusal of light duty work if the claimant submits proof of enrollment in a valid retraining program approved by the Division.
(d) Initial Claim for Permanent Partial Impairment (PPI) Benefits.
(i) When Submitted. An application for PPI benefits may be filed when a worker has suffered an ascertainable loss as defined in W.S. § 27-14-102(a)(ii).
(ii) Applications For PPI Award. If a physician determines that the injury has resulted in a permanent impairment according to the American Medical Association's Guide to the Evaluation of Permanent Impairment or its successor, the physician shall notify the Division in writing. The Division shall file the written documentation of permanent impairment, copying all parties. Based upon the rating given by the physician, the worker may apply with the Division for the appropriate award, pursuant to W.S. §§ 27-14-405 or 406.
(e) Claim for Vocational Rehabilitation Benefits.
(i) At any time after the injury when medical evidence indicates that an injured worker cannot return to employment as outlined in W.S. § 27-14-408(a)(ii) the worker may submit an application to the Division on a form provided by the Division for vocational rehabilitation benefits.
(ii) The Division may extend or increase a rehabilitation program's limits defined in W.S. § 27-14-408(e)(ii) upon consideration of one of the following extenuating circumstances:
(A) The injured worker's disability is so severe as to limit his ability to complete his vocational rehabilitation plan within specified time frames;
(B) Medical services or complications prevent the injured worker from completing his vocational rehabilitation program on time;
(C) The educational institution's scheduled course offerings prevent the injured worker from completing the vocational rehabilitation program on time; or
(D) Any other circumstance mutually agreed upon by the Division, Division of Vocational Rehabilitation and the injured worker.
(iii) The application for vocational rehabilitation shall include a statement that the applicant elects to accept vocational rehabilitation instead of any PPD award under W.S. § 27-14-405(h) and (j) arising from the same physical injury.
(f) Application for Permanent Partial Disability (PPD) Benefit. An application for PPD may be filed no sooner than three months after the date of ascertainable loss or three months before the last scheduled PPI payment, whichever date is later, and must be filed within one year of the later date. W.S. § 27-14-405(h)(ii).
(g) Miscellaneous Benefit Application.
(i) Applications for other benefits, including death benefits, permanent total disability, benefits for dependents or survivors, and extended benefits shall be made to the Division as soon as practical after the applicant becomes aware of entitlement to such benefits and within applicable statutes of limitations.
(ii) Where death results from an injury, the claim for death benefits shall be filed by the surviving spouse, by the guardian of a surviving spouse who is incompetent, by the guardian of dependent minor children, by the worker's dependent parent(s), or by the guardian of the worker's incompetent dependent parent(s).
Section 5. Waiver and Settlement - Benefits. Upon good and sufficient cause the Administrator or designee(s) of the Workers' Safety and Compensation Division may waive, compromise or otherwise settle any claim for benefits.