MUS SELF-FUNDED WORKERS'
Explanation of the Work Comp Claim Process
- The employee and supervisor completes and 2-step process to complete and submit a First Report of Injury (FROI) to the campus claim coordinator.
Step 1: Employee completes his/her portion of the electronic FROI and submits it through the encrypted electronic system. The FROI is delivered to the employee’s supervisor for completion by the supervisor.
Step 2: The Supervisor receives an email with a secure link to the FROI, reviews the FROI, completes the Supervisor’s section and submits the form electronically. The employee’s signature authorizes medical providers to provide relevant health information to the workers’ compensation claim adjuster.
Both the employee and employer should complete each section of the FROI as thoroughly as possible with information available, including details on when, where and how the injury or illness occurred and who was involved. However, the FROI should be completed and submitted as soon as possible for best possible outcomes; additional information not immediately available may be reported later.
Each campus has a claim coordinator who will review the claim and may contact you and possibly your supervisor for more or clarifying information. The claim coordinator does not make any determinations regarding the claim. When finalized, the campus claim coordinator submits the claim to a professional claim adjuster.
- Campus claim coordinator finalizes FROI and submits it to a professional claim adjuster.
The claim adjuster will make initial contacts and provide a claim number to the employee. The claim adjuster is responsible for investigating the claim, determining compensability, authorizing treatment, and working with the workers’ compensation team to ensure the entire process is well managed. The workers’ compensation team includes the employee and employee’s supervisor, medical provider(s), campus claim coordinator, and claim adjuster. More complex claims may involve additional specialists.
- Incident and Injury Investigation is conducted
The claim adjuster conducts a claims investigation to determine whether the injury/illness is compensable under the Montana Workers’ Compensation Rules and Regulations. The claim adjuster gathers information from the employee, the employee’s supervisor, witnesses to the injury incident, and also gathers appropriate medical information related to the claim from the medical provider(s).
MUS is interested in preventing similar incidents and may conduct additional incident investigation in order to identify and correct any hazards.
As part of the claim investigation process, it may be necessary to exchange information with the MUS Benefit Plan. Health information related to a workers’ compensation claim can only be provided to the MUS Benefit Plan if the employee signs a release.
- Compensability is determined by the professional claim adjuster.
The claim adjuster reviews the information and determines if the injury or illness is compensable under Montana’s workers' compensation rules and regulations. Very generally, compensable work comp claims are for work-related injuries and diseases that are incurred accidentally through the course and scope of employment and that are verified by medically objective findings.
Each claim must be independently evaluated based on the specific facts of the claim. Montana statute allows 30 days for a determination to accept or deny a claim, with some exceptions if a determination cannot reasonably be made within 30 days.
For links to additional information about workers' compensation rules and regulations, go to Who makes Workers' Compensation Rules.
- Claim determination letter is sent to the employee.
When the claim adjuster completes the investigation, a letter is sent to the employee describing the status of the work comp claim.
When a claim is accepted:
The MUS Self-Funded Workers’ Compensation Program pays expenses related to the injury or illness for:
- Approved medical, hospital and related services;
- Wage compensation for those who are temporarily unable to work. Under current rules, replacement wages equal to 2/3 of the employee’s average weekly wages, calculated using the previous 4 pay periods, up to a maximum weekly amount established annually by the State Department of Labor;
- Stay-at-work/Return-to-work (SAW/RTW) assistance to facilitate an employee's return to productive work as soon as medically feasible using temporary transitional work opportunities when necessary;
- Vocational Rehabilitation opportunities and Disability Compensation in cases of permanent impairment.
The claim adjuster and employee work closely together with the medical providers to coordinate care.
For a more comprehensive explanation of benefits available to an injured worker please see the DLI Explanation of Workers' Compensation Benefits.
Best outcomes are achieved when the employee and employee’s supervisor, medical providers, campus claim coordinator, claim adjuster, and specialists if needed, work as a team. The goal of the team is to maximize the employee’s healing and to facilitate the employee’s appropriate return to productive work.
In most cases, an employee returns to work shortly after receiving the necessary medical care and contact with the workers' compensation team is minimal. MUS also provides Stay-at-Work/Return-to-Work Assistance to facilitate the restoration of health and minimize disruption by reintegrating the worker to the same position or to a temporary modified position within the employee’s current physical capabilities as soon as possible.
In rare events, employees require ongoing medical care and may require time away from work. Regular communication throughout the team is especially important in these more complex cases. Indemnity benefits may be available to employees medically required to take time off work.
If a claim is denied:
When a claim is denied the claim adjuster sends a letter indicating the denial along with the reason for the denial to the employee.
The MUS Self-Funded Workers' Compensation Program is committed to providing all the work comp benefits necessary to the employee’s recovery and return to work that an employee is legally entitled to receive. The Program is also committed to ensuring that the Program is a good steward of MUS funds and that it pay only those costs that are the statutory responsibility of the workers' compensation program.
If an employee thinks that a claim was denied in error, the employee may utilize the MUS Work Comp Program’s internal appeal process or may appeal a denied claim to the Montana Department of Labor (MT DLI). To utilize the MUS Self-Funded Workers’ Compensation internal appeal process, contact your campus claim coordinator or the claim adjuster. To appeal to MT DLI, contact the Workers’ Compensation Claim Assistance Bureau at 406-444-1574.
The Administrative Rules or Montana stipulate that parties having a dispute about workers’ compensation benefits must bring the dispute before a DLI mediator prior to petitioning the workers' compensation court. The mediator is a neutral third person who listens to the concerns of both parties and assists them in resolving the dispute. The non-binding conferences are informal and confidential.
If a claim is delayed:
Rarely, the 30 days allowed by Montana statute does not provide adequate time to make a determination to accept or deny a claim. Such claims usually involve circumstances where the employee’s medical records have not been provided or are inconclusive or the employee’s work status has not been substantiated. The claim adjuster will aggressively pursue information necessary for an appropriate determination and will provide updates to the employee at least every 30 days. If such a case involves wage loss, payment of indemnity benefits may be made under a reservation of rights consistent with Montana workers’ compensation statutes.