MEDICAL - contact an employee of the Medical Section for additional information.
- What is recommended for getting the correct and proper treating medical provider from the beginning of the claim?
Alabama Department of Labor Administrative Code 480-5-5-.12 - The employer/carrier directs care. Except in the case of an emergency, claimant should be sent to the employer/carrier’s chosen primary care provider who will treat and recommend referral to a specialist, when necessary. The employer/carrier directs the care from the moment the injury notice has been given, not after treatment has been ongoing.
- If the approved treating physician refers the employee to another physician, is the employer obligated to approve that particular physician?
- Who controls medical treatment?
The employer or carrier.
- When is an IME (independent medical exam) needed?
Code of Alabama, 1975 §25-5-77(b) - An IME is an independent assessment of the claimant’s physical condition and/or bodily functions performed by a non-treating physician with written report of findings. Generally occurs prior to return-to-work status. May be requested by employer or employee. It does not equate to utilization review. It is not a second opinion in that it is not a confirmatory evaluation. It is not an impairment rating in that no impairment rating is given. The examination is done by someone other than the individuals’ family physician or a physician who is currently treating or has previously treated the claimant for the same complaint.
- Can the employer or agent conduct utilization review?
Yes, any entity involved in the administration or payment of workers’ compensation claims may, but are not required to implement utilization review.
- Does medical treatment require pre-certification?
Alabama Department of Labor Administrative Code 480-5-5-.08 lists those services that require certification. The list is not all-inclusive. From a practical standpoint all medical treatment can be pre-certified. The carrier and provider may mutually agree to procedures that will not require pre-certification.
- Is my employer responsible for paying my medical bills?
Code of Alabama, 1975 § 25-5-77(a) Upon approval of the workers’ compensation claim, the employer is responsible for paying only medical bills associated with the injury in question.
- Do I receive mileage reimbursement for my doctor visits?
Yes. Refer to /docs/guides/wc_mileage_rate.pdf for specific amounts. Contact your adjuster regarding how to submit for reimbursement.
- How long should a medical provider have to wait for reimbursement?
Code of Alabama, 1975, §25-5-77(h) & Alabama Department of Labor Administrative Code 480-5-5-.04
Twenty-five (25) working days from the date of receipt.
- How long does a medical provider have to submit a bill?
Alabama Department of Labor Administrative Code 480-5-5-.33 - One year from date of service.
- Do HIPAA regulations change the procedure of providing medical records within the worker’s compensation law?
No, HIPAA law does not preempt state law on workers’ compensation and should not impede the process.
- Can a medical provider bill a workers’ compensation claimant for medical services?
Code of Alabama, 1975 §§25-5-77(g) & 25-5-293 (g) - Not if the treatment was authorized; however, the employer is not liable for medial or surgical treatment obtained by the employee without justification or notice to the employer.
- Must I submit to medical examinations arranged by my employer?
Code of Alabama, 1975, §§25-5-77(a)(b) - Yes, the injured employee shall submit to examination by the employer’s physician at all reasonable times.
- Can a medical provider charge for copying medical records in a workers’ compensation case?
Code of Alabama, 1975, §§25-5-77(b) & 12-21-6.1 - Yes, however, no charge is allowed for the initial bills sent by institutional and non-institutional providers for reimbursement.
CLAIMS - contact an employee of the Examiners Section for additional information.
- The insurance company has denied my claim. What can the Alabama Workers’ Compensation Division do to help me?
Contact our examiners for assistance or hire and attorney. The injured worker should contact the Alabama State Bar Association and ask for a referral to an attorney who specializes in workers’ compensation.
- What is the Statute of Limitation of a workers’ compensation claim?
Two years from the date of injury or two years from the date of last compensation payment.
- My employer does not have light duty. Will I receive benefits, and if so, for how long?
If the employer does not have light duty, the injured worker will receive benefits until he reaches MMI or until the employer can accommodate restrictions and possibly return the injured worker in a light duty capacity. If in the light duty capacity, the injured worker received post injury earnings less than pre-injury earnings, the injured worker will receive 66 2/3% of the difference between post injury earnings and pre-injury earnings, subject to the state maximum.
- How much am I going to get paid under workers’ compensation?
Based upon an approved claim, and after the 3-day waiting period, payment will be 66 2/3% of the employee’s average weekly wage subject to the maximum and minimum. This is also depending on the authorized treating physician’s approval of the missed days from work.
- How is an injured workers’ average weekly wage (AWW) determined?
AWW is calculated using your earnings for the 52 weeks prior to the injury and reportable on a Federal W-2 form. If an employee has not been employed for 52 weeks, the employer may base the AWW on a similarly situated employee. AWW is subject to the State maximum at the time of injury.
Earnings during last 52 weeks ÷ 52 weeks = AWW
- How long do I have to wait before my first check?
Code of Alabama, 1975 §25-5-59 (b) - After the 3-day waiting period, the indemnity period or disability period starts on the 4th day you are out of work. Payment of compensation benefits should be paid within 30 days after it becomes due unless there is a sufficient reason it has not been paid.
- Is there a waiting period before I start receiving pay? Will I get the 3-days’ back or do I lose them?
Code of Alabama, 1975 §25-5-59 - There is a 3-day waiting period. You will receive the 3-days back only if you are out of work for a period of time exceeding 21 days.
- Can a workers’ compensation claim be denied if the injured worker refuses to submit to a drug/alcohol screen?
Code of Alabama, 1975 §25-5-51 - Yes, no compensation shall be allowed if the employee refuses to submit to or cooperate with a blood or urine test.
- Can an employer refuse to file a workers’ compensation claim because there was no witness to the accident?
No. Just because an accident wasn’t witnessed doesn’t mean it didn’t happen. A first report of injury must be filed with our Department.
- Can an employer continue an employee’s salary in lieu of workers’ compensation benefits?
Yes, an employer can continue your salary in lieu of workers’ compensation benefits but the insurance company still has to file a WC 3/4 form with Workers’ Compensation Division showing monies paid. It is necessary to report to the Division that the employer is paying salary in lieu of workers’ compensation benefits.
- Is the insurance company required to notify the injured worker of cessation of TTD benefits before they are actually stopped?
Code of Alabama, 1975 §25-5-57 - No, the law does not require notice of the termination of temporary total benefits before they can be stopped.
COMPLIANCE - contact an employee of the Compliance Section for additional information.
- How many employees must you have before coverage is mandatory?
Any business that has five (5) or more employees, other than contractors, is required by law to have workers’ compensation coverage. The term employee includes all full or part-time employees, officers of a corporation or members of an LLC. Once the coverage is secured, the employer may choose to exclude the officers or members by filing with the Division an officer exemption form.
- Where can an employer purchase a workers’ compensation insurance policy?
You may obtain workers’ compensation coverage from your local insurance agency. The State of Alabama does not sell workers’ compensation insurance.
- Can a general contractor charge a sub-contractor for workers’ compensation insurance?
Yes, but an employer cannot charge an employee for workers’ compensation.
SELF-INSURANCE - contact an employee of the Self-Insurance Section for additional information.
- What are the requirements for self insurance?
Net worth of $5 million
Current assets to currents liabilities ratio of 1 or greater
Positive net income for the past three years
- What are the security requirements for self insured employers?
There’s no security required except that the self insured employer must belong to the Alabama Workers’ Compensation Self Insurers Guaranty Association.
- How is the security amount for the Guaranty Association determined?
The security amount cannot be less than the greater of the following:
- The sum total of the two highest years of workers’ compensation insurance premiums paid by the applicant during the preceding three years.
- The sum total of the two highest years of incurred workers’ compensation claims losses during the preceding three years.
- The excess insurance retention amount.
- How is the security assessment for the Guaranty Association calculated?
Security amount is paid at a rate of $15 per thousand. This amount is paid for four years, at that point the employer is deemed to have reached parity.
Example: $500,000 security amount $500 x $15 = $7,500
$7,500 x 4 years = $30,000
- Does the self insured employer have to have excess insurance?
A self insurer must have and maintain specific excess insurance coverage with a retention amount of $250,000 or greater.
MEDICAL DISPUTES - contact an employee of the Medical (Mediations) section for additional information.
- How can I get a file review for medical issues?
Pursuant to the Code of Alabama, 1975, §25-5-77(i)(5) we offer medical dispute resolution. Please contact Sally Thames prior to submission of the disputed claim. Once we receive an opinion from one of our independent medical experts on the disputed issue or issues, we will prepare a non-binding recommendation in writing.
- What are the options for the injured employee if he or she gets an adverse determination pursuant to medical dispute resolution? For the employer if determination is in employee’s favor?
Employees may request a medical mediation through this Division, or the employee or his attorney may petition the court. The employer/carrier may act on our recommendation or petition the court.
- How can abuse of prescription pain medications be controlled?
All medication can be pre-certified to insure medical necessity is met. The employer can initiate background checks and surveillance if the situation warrants it. The physician may be contacted concerning possible addiction or asked to perform random unannounced drug screens.
- What is the purpose of a medical mediation and how is it conducted?
A medical mediation is handled the same as our compensation mediations, except the issues to be mediated are medical issues and not settlement of compensation. Contact Sally Thames for scheduling. If the parties agree to a resolution of the medical issues in question, the parties shall sign a binding mediation agreement.