DI 52155: Initial Claims with Workers' Compensation/Public Disability Benefit (WC/PDB)
WC/PDB notices are initial determinations of actions that may contain crucial information if an appeal is filed. The notices may also be used to determine if a reopening is appropriate.
A WC/PDB notice must include complete and accurate information that explains the current action and the reporting responsibilities for changes or events which may affect benefits. Notices should explain all of the following:
What the initial determination is;
The reason(s) for the determination;
The appeals rights; and
The waiver provisions, if an overpayment is involved.
A. Locating notice paragraphs
Notice paragraphs are numbered based on the system that processes the action. Dictated paragraphs may be necessary if no numbered paragraphs are available to explain the situation.
Modernized Claims System (MCS) Earnings Computation (EC) System paragraphs are in NL 00725.005.
Manual Adjustment, Credit and Award Process (MADCAP) WC/PDB paragraphs are in NL 00720.395.
Numbered paragraphs that may be used in dictated notices and may apply to other aspects of the WC/PDB case are in NL 00708.100.
B. Processing initial notices
1. MCS EC System
The MCS EC system automatically generates most WC/PDB paragraphs based on the information coded on the application screens. There are a limited number of WC/PDB paragraphs (known as universal text identifiers (UTIs)) that can be requested. UTIs are NL 00725.005 – MCS Universal Text Identifiers (UTIs). Instructions for completing MCS notices are in MSOM MCS 009.010 – Notice 3 (NOT 3) and MSOM ORS 002.003 – FO/PC Requested and Dictated Paragraphs.
a. Systems generated UTIs - WCP
Paragraphs that begin with the prefix “WCP” are automatically systems generated based on offset data entered into MCS. See NL 00725.005 – MCS Universal Text Identifiers (UTIs).
b. Requested UTIs - WCPR
In MCS, UTIs that must be requested are identified with an “R” in the 4th position of the UTI (e.g., WCPR15). If an MCS EC claim requires additional notice information, select the Notice 3 (NOT 3) screen per MSOM MCS 009.010. Since these paragraphs are only generated upon request, fill-ins are required.
NOTE: See MSOM ORS 002.003 – FO/PC Requested and Dictated Paragraphs for a list of requested UTI paragraphs and formatting rules. See NL 00725.005 for a list of generated UTIs to determine if a UTI must be requested.
c. Dictated Language
If the available UTIs do not fully explain the situation, use UTI COPD01 for MCS notice with the appropriate dictated language added on the NOT3 screen. NOTE: Using dictated language always generates an “R” or Review notice alert. Any notice with dictated language is reviewed in the processing center (PC) prior to release. See NL 00719.025 – Dictated Text (NOT) Screens for processing dictated text.
The Claims Representative (CR)/Claims Authorizer (CA)/Claims Technical Examiner (CTE) is required to create the notice data for any WC/PDB ICF adjudicate input, regardless of whether it is a post-entitlement (PE) input, A101, or EF101. In non-MCS cases, all requested paragraphs and fill-ins are listed on an SSA-573 or coded via the ICF WC notice screens.
All MADCAP paragraphs for WC/PDB begin with the letters “WCP.” Some WCP paragraphs are automatically generated (i.e., no input necessary) and some must be manually input. See NL 00720.395 “WCP Workers’ Compensation” for all WC/PDB MADCAP paragraphs and the corresponding “Systems Generated” or “Requested” designation of each paragraph.
Review all paragraphs to be sure all pertinent information is provided.
Include numbered or completely dictated paragraphs, as needed.
For A101 or EF101 cases, include in the ICF ENB required non-WC/PDB claims paragraph and all required “WCP” paragraphs (in this situation, code the paragraphs in ICF ENB, not the A101 or EF101 ENB).
NOTE: Use the SSA-573 or the ENB but not both. See DI 52165.030 for information on ICF WC/PDB notices.
The following tools are available to help find, select and code MADCAP paragraphs for the ICF ENB: