Maine Workers Compensation Board Electronic Filing and Forms Overview

Maine Workers’ Compensation Board

Electronic Filing

and

Forms Overview

• AWW - Average Weekly Wage• EDI - Electronic Data Interchange• FROI - First Report of Injury (WCB-1)• MAE - Monitoring, Audit and Enforcement• MOP - Memorandum of Payment (WCB-3)• NOC - Notice of Controversy (WCB-9)• RTW - Return to Work• SOC – Statement of Compensation Paid (WCB-11)• WBR – Weekly Benefit Rate• MWCB – Maine Workers’ Compensation Board

Abbreviations

Form Filing

A complete listing of forms may be obtained by contacting the MWCB, 27 State House Station, Augusta, Maine 04333-0027, telephone 1-888-801-9087 or 207-287-3751 or by visiting the MWCB website at www.Maine.Gov/wcb/

All MWCB forms have a four part distribution as follows:

– COPY 1) Maine Workers Compensation Board

– COPY 2) Employee

– COPY 3) Insurer

– COPY 4) Employer

If COPY 1 is now submitted electronically to the MWCB, all other copies must still be sent to the respective recipients. Copies of forms are available on the MWCB website.

Chapter 3 §2.1 “Except as specifically provided in 39-A M.R.S.A. § 101 et seq. or in these rules, all forms and correspondence, including, but not limited to petitions, shall be filed in the Central Office of the Workers’ Compensation Board.”

http://www.maine.gov/wcb/

Electronic Form Filing

• “Electronic Claims” requirements are available at the MWCB website: www.maine.gov/wcb.

• Claim Administrators must use the IAIABC “Release 3” format.

• It is critical that employers/insurers and their respective EDI vendors understand the MWCB’s EDI requirements.

• To avoid violations/penalties, employers/insurers must maintain routine communication with their respective EDI vendors to ensure that any FROIs/NOCs rejected by the MWCB are addressed in a timely manner.

http://www.maine.gov/wcb

Electronic Form Filing

A sender will receive one of the following application acknowledgement codes after submitting an EDI transaction:

TA = (Transaction accepted). The transaction was accepted and the First Report of Injury or Subsequent Report of Injury is filed.

TE = (Transaction accepted with errors). The error or errors will be identified in the acknowledgement transmission that is sent by the MWCB. All identified errors must be corrected within 14 days after the date the acknowledgement transmission was sent by the MWCB or prior to any subsequent transmission for the same claim, which ever is sooner.

TR = (Transaction rejected) The entire transaction has been rejected and the first Report of Injury or subsequent Report of injury is not filed.

First Report of Occupational Injury or Disease (WCB-1)

• Effective 7/1/05, all claim administrators must submit FROIs to the MWCB via EDI.

• Do not file FROIs with the MWCB in paper format. Doing so may be perceived as a questionable claims-handling technique.

• Don’t forget to send a paper copy of the exact information submitted electronically to the injured employee.


Types of FROI transmissions:

• 00 = (Original) Used to file an original FROI

• 01 = (Cancel) Used to cancel an original FROI that was sent in error

• CO = (Correction) Used to correct a data element or elements when a filing is accepted with errors (“TE”)

• 02 = (Update/Change) Used to update/change a data element

• UR = (Upon request) Submitted in response to a request from the MWCB

• AQ = (Acquired Claim) Used to report that a new claim administrator has acquired the claim


• If there are one or more lost days (hours or wages), the FROI must be sent to the the MWCB within 7 days of the employer’s notice or knowledge.

• If the length of incapacity is 7 days or less, then the updated FROI must be sent to the MWCB with the Return to Work date (Box 47).

• If the length of incapacity is more than 7 days, a MOP or NOC must be filed within 14 days of the employer’s notice or knowledge of incapacity.

1. WCB FILE NUMBER (if known):

EMPLOYER’S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE 1a. OSHA 300 CASE NUMBER (if applicable):

REASON FOR REPORT (check all that apply) 2a. LOST TIME - ONE OR MORE DAYS 2b. WAS EMPLOYEE PAID FOR ½ DAY OR MORE ON DAY OF INJURY? YES NO

3. LOST EARNINGS BUT NO LOST TIME 4. MEDICAL/HEALTH CARE 5. FATALITY DATE OF DEATH: _____/_____/_____ MM DD YYYY 6a. OCCUPATIONAL DISEASE 6b. DATE OF LAST EXPOSURE: _____/_____/_____ 6c. DATE OF DIAGNOSIS AS OCCUPATIONALLY RELATED: ____/_____/_____ MM DD YYYY MM DD YYYY 7a. CORRECT PRIOR REPORT 7b. DATE OF CORRECTION: _____/_____/_____ 7c. DATE CORRECTION SENT TO WCB: _____/_____/_____ MM DD YYYY MM DD YYYY

EMPLOYER 8. STATE EMPLOYER UNEMPLOYMENT INSURANCE ACCOUNT NUMBER (UIAN):

9. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): 10. EMPLOYER NAME:

11. STREET/P.O BOX MAILING ADDRESS: 12. CITY: 13. STATE: 14. ZIP: 15. TELEPHONE NUMBER: ( )

16. PRIMARY BUSINESS PERFORMED BY EMPLOYER WHERE INJURY OCCURRED:

17. EMPLOYER LOCATION IF DIFFERENT FROM MAILING ADDRESS:

18. DID INJURY OR EXPOSURE OCCUR ON EMPLOYER’S PREMISES? YES NO IF NO, THEN GIVE NAME AND PHYSICAL ADDRESS OF THE EMPLOYER WHERE THE EMPLOYEE WAS INJURED OR EXPOSED:

(check one) INSURER THIRD PARTY ADMINISTRATOR (TPA) SELF-ADMINISTERED EMPLOYER 19. INSURANCE / TPA COMPANY NAME: 20. POLICY NUMBER: 21. INSURER FILE NUMBER:

22. STREET/P.O. BOX MAILING ADDRESS: 23. CITY: 24. STATE: 25. ZIP: 26. TELEPHONE NUMBER: ( )

EMPLOYEE 27. LAST NAME: 28. FIRST NAME: 29. MI: 30. TELEPHONE NUMBER:

( ) 31. SOCIAL SECURITY NUMBER: 32. GENDER:

MALE FEMALE

33. STREET/P.O. BOX MAILING ADDRESS: 34. CITY: 35. STATE: 36. ZIP: 37. DATE OF BIRTH: _____/_____/_____ MM DD YYYY

38. OCCUPATION/JOB TITLE:

39. DATE OF HIRE: _____/_____/_____ MM DD YYYY

40. WEEKLY WAGE AT TIME OF INJURY: $

41. DOES EMPLOYEE WORK FOR ANOTHER EMPLOYER? YES NO IF YES, GIVE NAME AND ADDRESS:

CLAIM INFORMATION 44. TIME EMPLOYEE BEGAN WORK (e.g. 7:30 a.m.):

45. DATE EMPLOYER NOTIFIED INSURER/TPA: _____/_____/_____ MM DD YYYY

42. DATE OF INJURY OR ILLNESS: _____/_____/_____ MM DD YYYY DATE EMPLOYER NOTIFIED: _____/_____/_____ MM DD YYYY

43. DATE OF INCAPACITY: _____/_____/_____ MM DD YYYY DATE EMPLOYER NOTIFIED: _____/_____/_____ MM DD YYYY

46. TIME OF INJURY (e.g. 1:10 p.m.): 47. HAS EMPLOYEE RETURNED TO WORK? YES NO IF YES, GIVE DATE: _____/_____/_____ MM DD YYYY

48. SPECIFIC INJURY OR ILLNESS (e.g. second degree burn or toxic hepatitis):

49. BODY PART(s) AFFECTED (e.g. lower right forearm): 50. ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN THE EVENT OCCURRED (e.g. acetylene torch, metal plate):

51. SPECIFY ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE EVENT OCCURRED (e.g. cutting metal plate for flooring.):

WAS ACTIVITY PART OF NORMAL JOB DUTIES? YES NO

52. HOW INJURY OR ILLNESS OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED OR MADE THE EMPLOYEE ILL. (e.g. worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against hot metal.):

53. HOSPITALIZED OVERNIGHT AS INPATIENT?

YES NO

54. WAS THE EMPLOYEE TREATED IN AN EMERGENCY ROOM?

YES NO:

55. HEALTH CARE PROVICER NAME: 56. MAILING ADDRESS: 57. TELEPHONE NUMBER: ( )

PREPARER INFORMATION 58. PREPARER NAME AND TITLE (TYPE OR PRINT): 59. TELEPHONE NUMBER:

( ) 60. DATE SENT TO WCB: _____/_____/_____ MM DD YYYY

WCB-1 (01/02) The State of Maine does not discriminate on the basis of disability in admission to, access to, or operation of its programs, services or activities. This material can be made available in alternate formats by contacting your Department ADA Coordinator. DISTRIBUTION: COPY (1) MAINE WORKERS’ COMPENSATION BOARD, 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027, (2) EMPLOYEE, (3) INSURER, (4) EMPLOYER.

• When lost time benefits are paid voluntarily, a Wage Statement must be filed within 30 days of the first day of compensability (8th day of incapacity).

• When lost time benefits are controverted, a Wage Statement must be filed within 30 days of the employer’s notice or knowledge of the incapacity.

• If the employer completes the Wage Statement, the adjuster should review it for accuracy and ensure the correct AWW is reflected on the MOP.

Wage Statement (WCB-2)

WAGE STATEMENTSTATE OF MAINE

WORKERS' COMPENSATION BOARDSTATION 27, AUGUSTA, MAINE 04333-0027

1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER 7. WCB FILE NUMBER:

2. EMPLOYER NAME: 8. EMPLOYEE LAST NAME: 9. FIRST NAME: 10. M.I.:

3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 11. ADDRESS-NUMBER AND STREET:

4. INSURER NAME: 12. CITY: 13. STATE: 14. ZIP: 15. HOME PHONE:

5. INSURER MAILING ADDRESS: 16. DATE OF INJURY: 17. DESCRIPTION OF INJURY:

18. DOES EMPLOYEE WORK FOR ANOTHER EMPLOYER? IF YES, THE EMPLOYER SHALL SUBMIT A WAGE STATEMENT FROM EACH ADDITIONAL EMPLOYER.

YES

NO

19. DOES EMPLOYEE RECEIVE FRINGE BENEFITS THAT MAY STOP WHILE ON WORKERS; COMPENSATION?.

YES

NO

20. WEEK 52 IS THE WEEK BEFORE THE INJURYWK1

WEEK ENDING GROSS EARNINGS WK19

WK37

2 20 38

3 21 39

4 22 40

5 23 41

6 24 42

7 25 43

8 26 44

9 27 45

10 28 46

11 29 47

12 30 48

13 31 49

14 32 50

15 33 51

16 34 52

17 35 21. TOTAL EARNINGS $

18 36 22. GROSS AVERAGE WEEKLY WAGE $

23. PREPARER NAME AND TITLE (TYPE OR PRINT): 24. TELEPHONE NUMBER: 25. DATE MAILED:

THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIOTAPE.

WCB 2 (8/94)

• When lost time benefits are paid voluntarily, a Schedule of Dependent(s) and Filing Status Statement must be filed within 30 days of the first day of compensability (8th day of incapacity).

• When lost time benefits are controverted, a Schedule of Dependent(s) and Filing Status Statement must be filed within 30 days of the employer’s notice or knowledge of the incapacity.

• If the employee completes the Schedule of Dependent(s) and Filing Status Statement, the adjuster should review it for accuracy and ensure the correct WBR is reflected on the MOP.

Schedule of Dependent(s) and Filing Status Statement (WCB-2A)

SCHEDULE OF DEPENDENT(S) AND FILING STATUS STATEMENT

STATE OF MAINE WORKERS' COMPENSATION BOARD

STATION 27, AUGUSTA, MAINE 04333-0027

EMPLOYER/INSURER COMPLETES BOXES 1 TO 17



3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:

11. ADDRESS-NUMBER AND STREET:



EMPLOYEE COMPLETES BOXES 18 TO 21

18. FEDERAL TAX FILING STATUS

SINGLE MARRIED/JOINT SINGLE/HEAD OF HOUSEHOLD MARRIED/SEPARATE

.19.

DEPENDENT(S)

DEPENDENT NAMES(S)

(IF NONE, SO STATE)

RELATHIONSHIP

(I.E., SPOUSE, DAUGHTER, SON)

DATE OF

BIRTH

SOCIAL SECURITY

NUMBER (IF NONE, SO STATE)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIOTAPE. WCB 2A (8/94)

WCB-2 and WCB-2A Recap

• Wage Statements and Schedule of Dependent(s) and Filing Status Statement forms (WCB-2 and WCB-2A) must be filed for all claims where lost time exceeds seven days (waiting period).

• Wage Statements and Schedules of Dependent(s) and Filing Status Statement forms (WCB-2 and WCB-2A) must be filed for all controverted lost time claims.

Weekly Benefit Tables

ZERO ONE TWO THREE FOUR FIVE 561 Single 355.76 367.14 378.06 388.97 399.12 406.38 Married Joint 390.08 397.28 404.24 410.35 413.49 Head of Household 370.05 380.96 391.26 398.47 405.64 411.75 Married Separate 354.58 366.16 377.09 388.00 398.15 405.75

562 Single 356.31 367.71 378.62 389.54 399.72 407.00 Married Joint 390.70 397.90 404.88 410.99 414.21 Head of Household 370.61 381.52 391.89 399.09 406.28 412.39 Married Separate 355.13 366.71 377.65 388.57 398.75 406.38

563 Single 356.86 368.27 379.18 390.10 400.32 407.62 Married Joint 391.32 398.52 405.53 411.63 414.94 Head of Household 371.17 382.09 392.49 399.71 406.92 413.03 Married Separate 355.69 367.26 378.21 389.13 399.35 407.00

• Find the AWW within the tables.

• Select the line that correctly matches the filing status information.

• Select the column that correctly matches the number of dependents.

• The “ZERO” column includes only the injured employee.

Memorandum of Payment (WCB-3)

A MOP must be filed:• Within 14 days of the employer’s

notice or knowledge of an undisputed claim for compensation.

• When a claim for compensation is controverted later than 14 days from the employer’s notice or knowledge of a claim for compensation (“mandatory MOP”)

• When compensation is paid pursuant to a decision or approved agreement.

• Box 24 must accurately reflect the date the first indemnity payment was mailed to the claimant for the incapacity reported in Box 23.

• Box 28 must accurately reflect the first date of incapacity after the 7-day waiting period.

1. REVISION DATE: _____/_____/_____ MM DD YYYY MEMORANDUM OF PAYMENT

2. WCB FILE NUMBER (if known):

EMPLOYEE3. EMPLOYEE LAST NAME: 4. FIRST NAME: 5. MI.: 6. SOCIAL SECURITY NUMBER:

7. STREET/P.O. BOX MAILING ADDRESS: 8. CITY: 9. STATE: 10. ZIP: 11. HOME PHONE NUMBER:

( )

12. DATE OF INJURY: _____/_____/_____ MM DD YYYY

13. SPECIFIC INJURY OR ILLNESS: 14. BODY PARTS (S) AFFECTED:

EMPLOYER15. INSURER FILE NUMBER: 16. EMPLOYER NAME: 17. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:

18. INSURER/TPA NAME: 19.INSURER/TPA MAILING ADDRESS:

NOTICE TO EMPLOYEE20. YOUR EMPLOYER/INSURER IS REQUIRED TO FILE THIS WORKERS’ COMPENSATION FORM UPON PAYMENT OF A LOST TIME WORK-RELATED INJURY. PAYMENTIS MADE FOR THE FOLLOWING REASON:

A. YOUR CLAIM IS ACCEPTED.

B. THIS IS A VOLUNTARY PAYMENT PENDING INVESTIGATION.

C. THIS IS A MANDATORY PAYMENT BECAUSE A NOTICE OF CONTROVERSY WAS NOT TIMELY FILED PURSUANT TO RULE 1.1.PERIOD COVERED BY MANDATORY PAYMENT: FROM (DATE) _____/_____/_____ THROUGH (DATE) ______/_____/_____ AMOUNT PAID $ ________

MM DD YYYY MM DD YYYY

21. TYPE OF PAYMENT:

A. WEEKLY COMPENSATION B. SPECIFIC LOSS _________________WEEKS AMOUNT PAID $ ___________

C. PERMANENT IMPAIRMENT AMOUNT PAID $ _____________ D. OTHER (EXPLAIN) ________________________________________________________

22 A. IS THERE ANY INDICATION THAT THE INJURY IS PERMANENT? YES NO

B. IF THE ANSWER IS YES, WHAT IS THE PERMANENT IMPAIRMENT RATING? % NOT YET AVAILABLE

23. DATE OF INCAPACITY: _____/_____/_____ MM DD YYYY

DATE EMPLOYER NOTIFIED: _____/_____/_____ MM DD YYYY

24. DATE CHECK MAILED:

_____/_____/_____ MM DD YYYY

25. AVERAGE WEEKLY WAGE:

$

26. CURRENT WEEKLY COMPENSATION RATE: TOTAL PARTIAL $

27. DOES EMPLOYEE WORK FOR ANOTHER EMPLOYER? YES NOIF YES, GIVE NAME:

28. FIRST DAY OF COMPENSABILITY AFTER WAITING PERIOD IS MET:

_____/_____/_____ MM DD YYYY

29. IS THIS AN APPORTIONMENT CLAIM? YES NO IF YES, ANSWER THE FOLLOWING:

OTHER DATE(S) OF INJURY INVOLVED: ______________________________________________________________________________________________________

OTHER CARRIER(S) INVOLVED: ____________________________________________________________________________________________________________

WHO IS THE “LEAD” CARRIER? _____________________________________________________________________________________________________________

EXPLAIN THE TERMS OF THE APPORTIONMENT: _____________________________________________________________________________________________

30. COMMENTS:

ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS’ COMPENSATION BOARD’S REGIONAL OFFICES

AUGUSTA BANGOR CARIBOU LEWISTON PORTLAND 24 STONE ST. 106 HOGAN ROAD 43 HATCH DRIVE 140 CANAL ST. 62 ELM ST. AUGUSTA, ME BANGOR, ME CARIBOU, ME LEWISTON, ME PORTLAND, ME 04330-5220 04401-5638 04736-2347 04240-7777 04101-3061 (207)287-2308 (Voice) (207)941-4550 (207)498-6428 (207)783-5490 (207)822-0840 (207)287-6119 (TTY) 1-800-400-6856 1-800-400-6855 1-800-400-6857 1-800-400-6858 1-800-400-6854 (Voice)

31. CLAIM HANDLER NAME (TYPE OR PRINT):

E-MAIL ADDRESS:

32. TELEPHONE NUMBER:( )TOLL FREE NUMBER:( )

33. DATE SENT TO WCB:

_____/_____/_____ MM DD YYYY

WCB-3 (10/98) The State of Maine does not discriminate on the basis of disability in admission to, access to, or operation of its programs, services or activities. This material can be made available in alternate

formats by contacting your Department’s ADA Coordinator.

DISTRIBUTION: COPY (1) MAINE WORKERS’ COMPENSATION BOARD, 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027, (2) EMPLOYEE, (3) INSURER, (4) EMPLOYER

Discontinuance or Modificationof Compensation (WCB-4)

A Discontinuance or Modification of Compensation must be filed:

• When an employee returns to pre-injury earning status with the insured (as a discontinuance).

• When an employee returns to work part-time for the insured (as a modification).

• When an employee’s post-injury wages with the insured fluctuate (TP to TT and vice versa).

• When statutory offsets are applied.• When compensation is modified or

discontinued pursuant to a decision or approved agreement.

DISCONTINUANCE ORMODIFICATION OF COMPENSATION

STATE OF MAINEWORKERS' COMPENSATION BOARD







DISCONTINUANCE18 REASON FOR DISCONTINUANCE:

RETURNED TO WORK FOR SAME EMPLOYER INCREASED EARNINGS 205 (9) (A) 205 (9) (A)

BOARD DECISION OTHER (EXPLAIN) ___________________________________________ ___________________________________________________________19. PERIOD OF INCAPACITY:FROM (DATE): TO: (RETURN DATE):

20. WEEKLY COMPENSATION RATE:

21. AMOUNT PAID:

22. DATE OF FINAL PAYMENT:

MODIFICATION23. REASON FOR MODIFICATION:

RETURNED TO WORK FOR SAME DECREASED EARNINGS AVERAGE WEEKLY WAGE 205 (9) (A) ESTABLISHED

INCREASED EARNINGS COST OF LIVING ADJUSTMENTS OTHER ____________________________________ 205 (9) (A OTHER (EXPLAIN) ___________________________________________

24. OLD COMPENSATION RATE:

25. NEW COMPENSATION RATE:

24. EFFECTIVE DATE OF MODIFICATION:

27. COMMENTS:

ASSISTANCE IS AVALABLE AT THE BOARD'S REGIONAL OFFICES:

AUGUSTA24 STONE STAUGUSTA, ME 04330-5220287-21681-800-400-6854

BANGOR106 HOGAN RD.BANGOR, ME 04401-5640941-45501-800-400-6856

CARIBOUONE VAUGHN PLACE43 HATCH DR, STE 305CARIBOU, ME 04736498-64281-800-400-6855

LEWISTON36 MOLLISON WAYLEWISTON, ME 04240-5811753-77001-800-400-6857

PORTLAND62 ELM STPORTLAND, ME 04101-6858822-08401-800-400-6858



WCB 4 (8/94)

21-day Certificate of Discontinuance (WCB-8)

• If the employee’s benefits were discontinued or reduced for any reason other than those stated on the previous slide, then a 21-day Certificate of Discontinuance must be filed unless indemnity is being paid pursuant to an order, award, or compensation scheme.

• DO NOT file this form if indemnity is being paid pursuant to an order, award, or compensation scheme.

• Benefits may be discontinued or reduced no earlier than 21 days after the form is mailed via certified mail (Box 29) to the claimant.

• Box 29 must accurately reflect the date the WCB-8 is mailed to the injured employee.

• Benefits must be paid through the effective date (Box 19) of the discontinuance or (box 25) of the reduction.

• Form must be sent by certified mail to the employee and to the MWCB.

CERTIFICATE OFDISCONTINUANCE OR REDUCTION OF COMPENSATION

STATE OF MAINEWORKERS' COMPENSATION BOARD







NOTICE TO EMPLOYEEYOUR WEEKLY COMPENSATION BENEFITS WILL BE DISCONTINUED OR REDUCED 21 DAYS FROM THE DATE THIS CERTIFICATE WAS MAILEDBASED ON THE ATTACHED INFORMATION. IF YOU DISAGREE WITH THIS ACTION, YOU ARE ENTITLED TO FILE A PETITION FOR REVIEW AND TOREQUEST THE PROVISIONAL REINSTATEMENT OF YOUR BENEFITS. YOUR PETITION AND REQUEST SHOULD BE MAILED TO THE ABOVEWORKERS' COMPENSATION BOARD ADDRESS.

18 REASON FOR DISCONTINUANCE:

DISCONTINUANCE19. PERIOD OF INCAPACITY:FROM (DATE): TO (EFFECTIVE DATE OF DISCONTINUANCE):

20. WEEKLY COMPENSATION RATE:

21. COMPENSATION PAYMENT TO DATE OFCERTIFICATE:

22. COMPENSATION TO BE PAIDFOR 21 DAY PERIOD:

REDUCTION23. OLD COMPENSATION RATE:

24. NEW COMPENSATION RATE:

25. EFFECTIVE DATE OF REDUCTION:

26. COMMENTS:

ASSISTANCE IS AVALABLE AT THE BOARD'S REGIONAL OFFICES:

AUGUSTA24 STONE STAUGUSTA, ME 04330-5220287-21681-800-400-6854







WCB -8 (8/94) DISTRIBUTION: COPY (1) WORKERS' COMPENSATION BOARD, (2) EMPLOYEE, (3) INSURER, (4) EMPLOYER

21-day Certificate of Discontinuance (WCB-8)

Certified Mailing Reminder

• Claim administrators should have this sender’s receipt postmarked to prove when they sent the WCB-8.

Postmark

Here

• Effective 7/1/06, all claim administrators must submit original NOCs to the MWCB via EDI.

• While claim administrators may post corrections to NOCs via EDI in response to a “TE” error in their transmission reports, any changes to NOCs not specifically related to an EDI “TE” error must be submitted via paper.

• Do not file NOCs with the MWCB in paper format. Doing so may be perceived as a questionable claims-handling technique.

• Don’t forget to send a paper copy of the exact information submitted electronically to the injured employee.

Notice of Controversy (WCB-9)

Notice of Controversy (Denial) (WCB-9)

A NOC must be filed:1. To dispute indemnity.

– The NOC must be filed within 14 days of the employer’s notice or knowledge of incapacity

– If the NOC is not filed within 14 days of the employer’s notice or knowledge of incapacity:– A mandatory payment must be

issued for total incapacity benefits from the first day of incapacity until the NOC is filed and accrued benefits are paid..

– A MOP must be filed

2. To dispute medical bill(s) and/or treatment.– The NOC must be filed within 30 days of

the receipt of a disputed bill.

3. To dispute jurisdiction.

4. To dispute coverage.

5. To dispute for any other reason as described in the Full or Partial Denial Codes.

NOTICE OF CONTROVERSY

THIS IS A DENIAL OF YOUR BENEFITS

1. WCB FILE # (if known):

EMPLOYEE 2. EMPLOYEE LAST NAME: 3. FIRST NAME: 4. MI: 5. EMPLOYEE ID:

TYPE: #:

6. STREET/P.O. BOX MAILING ADDRESS: 7. CITY: 8. STATE: 9. ZIP: 10. HOME PHONE #: ( )

11. DATE OF INJURY: _____/_____/_____

12. SPECIFIC INJURY OR ILLNESS: 13. BODY PART(S) AFFECTED:

EMPLOYER 14. INSURER/CLAIM ADMIN FILE #: 15. EMPLOYER NAME: 16. EMPLOYER MAILING ADDRESS AND PHONE #:

17. INSURER/CLAIM ADMIN NAME AND ADDRESS: 18. INSURER/CLAIM ADMIN FEIN:

19. NOTICE TO EMPLOYEE YOUR EMPLOYER/INSURER IS DENYING YOUR WORKERS’ COMPENSATION CLAIM OR PART OF IT. THE REASON FOR THE DENIAL IS CHECKED BELOW.

IF YOU DISAGREE WITH THIS DENIAL, CONTACT A CLAIMS RESOLUTION SPECIALIST AT THE NEAREST REGIONAL OFFICE LISTED BELOW. 19b.

PARTIAL DENIAL REASON

20a.

DATE OF INITIAL INCAPACITY ____/____/____ CURRENT CURREND CURRENT DTE OF INCAPACITY ____/_____/_____

19a. FULL DENIAL REASON

FULL DENIAL EFFECTIVE DATE _____/_____/_____ *NOTE: Reasons identified in boxes 19a or 19b will not preclude a party from raising additional issues at a later date.

20b. DATE EMPLOYER NOTIFIED _____/_____/_____

21. COMMENTS:

22. IF THIS DENIAL NOTICE IS NOT TIMELY PURSUANT TO RULE 1.1, the employee must be paid total benefits, with credit for earnings and other statutory offsets, from the date of incapacity in accordance with 39-A M.R.S.A. § 205(2) and in compliance with 39-A M.R.S.A. § 204. The requirement for payment of benefits under this subsection automatically ceases upon the filing of a Notice of Controversy and the payment of any accrued benefits. Payment under Rule 1.1 requires filing of a Memorandum of Payment.

ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS’ COMPENSATION BOARD’S REGIONAL OFFICES

AUGUSTA BANGOR CARIBOU LEWISTON PORTLAND 24 STONE ST. SUITE 2 106 HOGAN ROAD 43 HATCH DRIVE SUITE 110 36 MOLLISON WAY 62 ELM ST. AUGUSTA, ME BANGOR, ME CARIBOU, ME LEWISTON, ME PORTLAND, ME 04330-5220 04401-5638 04736-2347 04240-5811 04101-3061 (207)287-2308 (Voice) (207)941-4550 (207)498-6428 (207)753-7700 (207)822-0840 1-800-400-6854 (Voice) 1-800-400-6856 1-800-400-6855 1-800-400-6857 1-800-400-6858 TTY 1-877-832-5525

25. DATE SENT TO WCB:

_____/_____/_____

23. NAME (TYPE OR PRINT): E-MAIL ADDRESS:

24. TELEPHONE #: ( )

26. DATE RCVD AT THE WCB (WCB use only):

_____/_____/_____

WCB-9 (1/12/06) The State of Maine does not discriminate on the basis of disability in admission to, access to, or operation of its programs, services, or activities. This form is available in alternative format. For further assistance, contact the Maine Workers' Compensation Board, ADA Coordinator, telephone: 1-888-801-9087 or TTY (877) 832-5525. DISTRIBUTION: COPY (1) EMPLOYEE, (2) EMPLOYER

Statement of Compensation Paid (WCB-11)

• The filing requirement for the Statement of Compensation Paid is triggered by indemnity payment(s).

• If it has been 195 days since the date of injury, then the WCB-11 must be filed if indemnity has been paid. (Interims must be filed within 195 days after the date of injury.)

• If it has been one year or more since the date of the injury, are payments of any type expected to continue? If yes, an “Interim” WCB-11 must be filed. (Subsequent “Interims” must be filed annually within 15 days of the anniversary date of injury if payments of any type are expected to continue.)

• If no, then a “Final” WCB-11 must be filed. (“Finals” must be filed when no further payments of any type are anticipated. The amount of Weekly Compensation listed in Box 20 must equal the total of the Amounts Paid reported on all Discontinuances [WCB-4, WCB-4A, and/or WCB-8] previously filed.)

STATEMENT OF COMPENSATION PAIDSTATE OF MAINE

WORKERS' COMPENSATION BOARDSTATION 27, AUGUSTA, MAINE 04333-0027






NOTICE TO EMPLOYEETHIS REPORT IS A PAYMENT SUMMARY OF YOUR CLAIM. PLEASE KEEP FOR YOUR RECORDS .

18. INTERIM REPORT (ONGOING PAYMENTS) FINAL REPORT

19. A. IS THERE ANY INDICATION THAT THE INJURY IS PERMANENT? YES NO

B. IF THE ANSWER IS YES, WHAT IS THE PERMANENT IMPAIRMENT RATING? % NOT YET AVAILABLE.

PAYMENT SUMMARY

20. LISST CUMULATIVE TOTALS:

MEDICAL $ DEATH BENEFIT/FUNERAL EXPENSE $

WEEKLY COMPENSATION $ LEGAL EXPENSE (EMPLOYEE RELATED) $

PERMANENT IMPAIRMENT $ LEGAL EXPENSE (EMPLOYER RELATED) $

REHABILITATION EXPENSE $ OTHER PAYMENTS $

LUMP SUM SETTLEMENT $

TOTAL PAID $

ASSISTANCE IS AVALABLE AT THE BOARD'S REGIONAL OFFICES:AUGUSTA24 STONE STAUGUSTA, ME 04330-5220287-21681-800-400-6854





21. PREPARER NAME AND TITLE (TYPE OR PRINT): 22. TELEPHONE NUMBER: 23. DATE:

THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIOTAPE.WCB 11 (3/98)

Maine Claims Scenarios - Review

Scenario 2 – No Lost Time - medicals denied

• File NOC within 30 days of receipt of a medical bill (See Rule 5.7).

• File FROI (See Rule 8.13).

Scenario 1 – No Lost Time - medicals accepted

• FROI not required to be filed.


Scenario 4 – Lost Time; Return To Work within 7 days – medicals denied

• File FROI within 7 days of employer’s notice or knowledge of a lost day.

• File updated FROI within 7 days of RTW.

• File NOC within 30 days of receipt of a medical bill.

Scenario 3 – Lost Time Return To Work within 7 days-medicals accepted

• File FROI within 7 days of employer’s notice or knowledge of a lost day (See Section 303, Rule 3.1).

• File updated FROI within 7 days of RTW (See Rule 8.16).


• File WCB-4, WCB-4A, or WCB-8 (as applicable) when indemnity is discontinued, reduced or otherwise modified.

• File (Interim) SOC within 195 days of injury date, and then annually within 15 days of the anniversary date of the injury while payments (of any type) are ongoing.

• File (Final) SOC when no further payments are anticipated.

Scenario 5 Lost Time – Greater Than 7 days – Lost Time accepted


• File MOP within 14 days of employer’s notice or knowledge of incapacity or within 6 calendar days after 1st day of compensability (Box 28 of MOP).

• File WCB-2 and WCB-2A within 30 days of 1st day of compensability (Box 28 of MOP).

• File amended MOP (or WCB-4, modification) to establish AWW and WBR.


• File amended mandatory MOP to establish AWW and WBR, and to revise the “Amount Paid” (Box 20C), if applicable.

• File (Interim) SOC within 195 days of injury date, and then annually within 15 days of the anniversary date of the injury while payments (of any type) are ongoing.

• File (Final) SOC when no further payments are anticipated.

Scenario 6 – Lost Time greater than 7 days – Lost Time denied


• File NOC within 14 days of employer’s notice or knowledge of incapacity.

• If NOC was filed late, you must issue a mandatory payment and file a mandatory MOP (See Rule 1.1).

• File WCB-2 and WCB-2A within 30 days of employer’s notice or knowledge of incapacity.

• Any questions?

MWCB Contacts

Claims Department, • Phone (207) 287-• @maine.gov

MAE Program, • Phone (207) 287-• @maine.gov

Documents

Maine Workers Compensation Board Electronic Filing and Forms Overview