MUS SELF-FUNDED WORKERS' COMPENSATION PROGRAM

Explanation of the Work Comp Claim Process  (MT Employees)

MUS employees who work and reside outside Montana on a more than temporary basis  must follow the Non-Montana Claim Process, not the process described below.  Workers’ compensation is regulated state-by-state, MUS purchases a workers’ compensation insurance policy to ensure its non-Montana employees have appropriate state-specific coverage.

1. 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 their portion of the encrypted electronic FROI. The employee’s signature authorizes medical providers to provide relevant health information to the workers’ compensation claim examiner.
   

   
   MUS employees should report injuries and complete a FROI immediately following a work-related injury or becoming aware of an occupational illness. Prompt reporting leads to best injury recoveries, allows workplace hazards to be eliminated, and helps protect your eligibility for workers’ compensation benefits.  Delayed reporting an injury or occupational disease (OD) to your employer can result in lost injury prevention opportunities, slower recovery,  and may complicate your ability to prove  work-relatedness.   Employees who report or file a FROI for occupational injuries or illnesses beyond statutory timelines, 30 Days for injuries or 1 year from knowing or should-have-known of an occupational disease (OD),  may  be ineligible for workers’ compensation benefits.

   
   Step 2: The Supervisor reviews the FROI, completes the Supervisor’s section and submits the form electronically.
   
   
   • a) If the Supervisor is present with the employee, they respond to the questions that follow immediately after the employee's section of the FROI.
     
     
   • b) If the Supervisor is not immediately present, they will receive the FROI through a secure email.
   
   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 examiner.  The claim coordinator and claim examiner will remain an important part of your recovery team. 
   
   MUS employees who work and reside outside Montana on a more than temporary basis  must follow a specific non-Montana claim process. Workers’ compensation is regulated state-by-state, MUS purchases a workers’ compensation insurance policy to ensure its non-Montana employees have appropriate state-specific coverage. 

    

2. Campus claim coordinator finalizes FROI and submits it to a professional claim examiner.
   

   The claim examiner has primary responsibility for managing the claim and recovery process.  The claim examiner will make initial contacts and provide a claim number to the employee – for minor claims, initial contact may be by mail.  The claim examiner is responsible for evaluating the circumstances of the  claim, determining compensability, authorizing medical care, and working with the workers’ recovery team to ensure the entire treatment and recovery process is well managed.  The workers’ recovery team includes the employee and employee’s supervisor, medical provider(s), campus claim coordinator, and claim examiner.  More complex claims may involve additional specialists.   

   It is important for employees to recognize the importance of the claim examiner’s role in navigating the employee through treatment and recovery within the workers’ compensation system.  A claims examiner shares the employee and employer interests in getting timely, medical treatment necessary to optimize recovery and return to work.  Those shared goals, together with the legal obligations and constraints established by the MT Workers' Compensation Act and MT Rules of Administrative Procedure (ARM), require the claims examiner to take a more active role than what an employee may be familiar with through their experience utilizing group health insurance (such as https://choices.mus.edu/).  The key to getting the best, timely care is establishing and maintaining good communication with your claim examiner.  A few key items to remember:

   • Other than emergencies, medical appointments must be pre-approved by your claim examiner
   • Attend all approved medical appointments or notify the provider and the claim examiner in advance if you must reschedule
   • If you have any concerns about your treatment plan, your medical provider, or  your recovery process, share them with your claim examiner
   • Utilize Stay-at-Work/Return-to-Work opportunities with your employer and keep the claim examiner informed on progress or any concerns
   • Notify your claim examiner immediately if you do not receive wage replacement or other benefits on time
   • Your work comp claim examiner can be a powerful ally in getting timely medical and therapy appointments, accessing specialists, ensuring your payments are timely, and helping you stay on track to heal and recover.
     
     
3. Claim Acknowledgement letter is sent to the employee.
   

   Watch for this letter in the mail.  Keep all claim-related documents you receive.  If you haven’t already, now is a good time to review more information about workers’ compensation in Montana:

   • MT University System Workers’ Compensation Program website
   • Your Campus Workers’ Compensation website
   • MT DLI Workers Compensation website and benefits brochure
     
     
4. Compensability is determined by the professional claim examiner and a determination letter sent to the employee.
   The claim examiner reviews all the information and determines if the injury or illness is eligible for workers’ compensation coverage.  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 objective medical 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.
   
   

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
  MUS WC has an extensive list of Pharmacies located throughout Montana that accept the work comp Pharmacy Card;
• 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 Montana Department of Labor (DLI);
• 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 examiner and employee work closely together with the medical providers to coordinate care.  

For a further explanation of benefits available to an injured worker please see the DLI Work Comp Benefits Summary.

Best outcomes are achieved when the employee and employee’s supervisor, medical providers, campus claim coordinator, claim examiner, 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 transitional 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.  Partial Wage Loss 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 examiner 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 DLI.  To utilize the MUS Self-Funded Workers’ Compensation internal appeal process, contact your campus claim coordinator or the claim examiner.  To appeal to Montana 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 Montana 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 at the time of the injury has not been substantiated.  The claim examiner 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.