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The Initial Adjudication Unit
The Initial Adjudication Unit makes formal decisions on claims not previously reviewed by Claims Examiners and determines whether the evidence submitted with the claim is sufficient to establish that the claimant has sustained a job-related injury. Where the evidence submitted is sufficient to establish that the claimant has sustained an injury, the computer is coded with an acceptance code, a notice is forwarded to the claimant in most cases, immediate tests or physical therapy is authorized, payments are initiated if claimed, and the claim is then forwarded to another unit for medical management. Where the evidence submitted is insufficient to establish the validity of the claim, the claimant is notified of the deficiencies of the claim and is given the opportunity to submit factual or medical evidence necessary to perfect the claim.
The unit adjudicates approximately 90% of claims for injuries suffered over one work shift (traumatic injuries) within 45 days.
The unit adjudicates more than 90% of claims for injuries that developed over a period of time, that is during more than one work shift, (occupational disease claims) within the prescribed times. The time is 90 days for "basic" injuries, such as diseases affecting the skin, diseases of infectious nature, and diseases affecting the musculoskeletal structure of the body. The time becomes 180 days for complex occupational disease claims such as claims for job-related stress, hearing loss, and heart and respiratory conditions.
QCM Unit
The objective of the QCM unit is to medically manage the injured worker's claim thereby necessitating the fullest recovery possible. To ensure that proper medical treatment/services are provided, the claims examiner in conjunction with a contract nurse, if warranted, monitors this process. Once partial or full recovery occurs, the claims examiner takes steps to enable the injured worker to return to work in a suitable position. When partial recovery occurs, and the employer is not able to provide a suitable position, vocational rehabilitation services are provided. In addition, when it is determined that the injured worker is capable of returning to his/her regular position, or a position commensurate with his/her medical restrictions, and fails to do so, compensation benefits are terminated.
Rehabilitation under the Federal Employees' Compensation Act
The purpose of the FECA rehabilitation program is to assist disabled employees who are covered by the Federal Employees' Compensation Act (FECA) to minimize their disabilities and return to gainful work. Rehabilitation helps injured workers to become self-supporting and productive, and saves money by eliminating or reducing workers' compensation payments.
Rehabilitation Specialists and Claims Examiners carry out the program with the assistance of private and public agency rehabilitation counselors, physicians, and employers, making sure that eligible workers receive the rehabilitation services best designed to return them to suitable work, preferably with little or no loss of earnings.
Some of the services provided are:
Medical Rehabilitation Services
Counseling and Guidance
Selective Placement
Vocational Testing or Work Evaluation
Training
Self-Employment
Follow-Up Services
Payments for Loss of Wage Earning Capacity
If an injured worker refuses to begin participation in the rehabilitation process, 20 CFR 10.519 provides that the Office may assume that rehabilitation would have resulted in reemployment with no loss of earnings, and compensation may be adjusted to zero.
Post Entitlement Modules I & II
The Post Entitlement Modules are the glue that holds the other Modules together. While all the Modules are specialized to some degree, the Post Entitlement or PE Mods handle any and all work not handled by another Mod. They ensure that no claims or workloads "fall between the cracks." Their main responsibility is the handling of cases after an initial decision is made. In the case of acceptances, this may entail authorizations for medical procedures, the initiating of the person's first compensation payments, and, in lost time cases, preparation of the claim file for transfer to the Quality Case Management or Rehabilitation Module. Claims are no longer assigned permanently to a single Claims Examiner, based on the File Number. Now, any examiner in the the unit can take action or assist a caller.
The Periodic Roll Management Project Unit
The Periodic Roll Management Project (PRMP) Unit is aimed at focusing on the quality management of the longer term disability claims, improvement in service to disabled beneficiaries, and working towards restoring a worker to fuller activity and employment. The unit provides rehabilitation and reemployment of the partially disabled and the adjustment of benefits to reflect eligibility more accurately.
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