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Business Process Standardization Attachment B Forest Service (FS)
Office of Safety and Occupational Health (OSOH) and Workers’ Compensation (WC) Workstream Integrated Case Management and Incident Reporting and Recording Solution
January 30, 2013 Albuquerque Service Center
SOLICITATION: AG-7604-S-13-0033
Revision History Authors:
OSOH/WC Workstream
| Date |
| Document Version |
| Document Revision Description |
| 1/9/2013 |
| 0.9 |
| Initial version |
| 1/24/2013 |
| 1.0 |
| Incorporated comments from Project Management Office (PMO) review |
Approval History
| Approval Date |
| Approved Version |
| PMO Acceptance Log Number |
| Change Request Number (if applicable) |
Albuquerque Service Center-Human Capital Management
SOLICITATION: AG-7604-S-13-0033
| FS_OSOH_WC_Business_Process_Standardization_v1.0_20130124_PMO.docx | Page 2 of 1 |
| Created on [Insert Creation Date] | Last Updated on [Insert Date] |
| OSOH/WC Business Process Standardization | Page 4 of 80 |
| Created on: 1/9/13 | Last Updated on: 1/30/13 |
Table of Contents
| 1. | Introduction | 5 |
| 1.1 | Purpose | 5 |
| 1.2 | Scope | 5 |
| 1.3 | Approach | 5 |
| 1.4 | Process Mapping Legend | 5 |
| 2. | OWCP Case Management and Case Alignment | 7 |
| 2.1 | Case Management | 7 |
| 2.2 | Initial Case Management Alignment | 9 |
| 2.3 | Intermediate Case Management Alignment | 9 |
| 2.4 | Complex Case Management Alignment | 9 |
| 3. | OWCP Business Process Maps | 10 |
| 3.1 | CA-16 Authorization for Examination and/or Treatment | 10 |
| 3.2 | CA-1 | 12 |
| 3.3 | CA-2 Occupational Disease (On-the-Job) | 14 |
| 3.4 | CA-2a | 16 |
| 3.5 | COP | 18 |
| 3.6 | Return-To-Work Determination (Maximum Medical Improvement (MMI)) | 20 |
| 3.7 | Return to Work | 22 |
| 3.8 | Appeals | 24 |
| 3.9 | Congressional/Freedom of Information Act (FOIA) | 26 |
| 3.10 | LWOP or Extension to LWOP | 28 |
| 3.11 | CA-7 Claim for Compensation | 30 |
| 3.12 | Leave Buy-Back | 32 |
| 3.13 | Medical Bills | 34 |
| 3.14 | Modified or Light-Duty Offer for a WC Claim (Temporary Total Disability (TTD)) | 36 |
| 3.15 | Employee Job Offer Activities | 38 |
| 3.16 | Employee Death | 40 |
| 3.17 | Convert to One Year Appointment | 42 |
| 3.18 | ER/LR, EEO Claim | 44 |
| 3.19 | Investigative Services Anonymous Tip | 46 |
| 3.20 | Investigative Services | 47 |
| 4. | OSOH Business Processes | 49 |
| 4.1 | Employee Injury or Illness Reporting | 49 |
| 4.2 | Employee Injury/Illness Claim for Compensation | 51 |
| 4.3 | Witness Statement | 53 |
| 4.4 | Anonymous Safety Story | 55 |
| 4.5 | Safety Story | 57 |
| 4.6 | Report of Lost, Unserviceable or Damaged Government-Owned Property (i.e., AD-112) | 59 |
| 4.7 | Investigation into Injury/Illness or Safety Story | 61 |
| 4.7.1 | SAI Management | 63 |
| 4.7.2 | Non-Serious Incident Investigation Management | 66 |
| 4.8 | MVA | 69 |
| 4.9 | OSHA 300A Summary and Log Reporting | 72 |
| 4.10 | MVA Frequency Rate | 73 |
| 4.11 | Facility Inspections | 74 |
| 4.12 | Safety Program Evaluation (SPE) | 76 |
| 4.13 | Aviation Mishap Reporting | 78 |
Introduction Purpose This document presents the future-state, standardized functional business processes with supporting process narratives to be used across the FS in regard to the OSOH and WC. The purpose of the overall standardization activity is to streamline the execution of day-to-day functions, improve OSOH incident filing and WC filing, improve tracking processes and achieve the goals outlined in the 2010 Protecting Our Workers and Ensuring Reemployment (POWER) Initiative, Department-wide, to improve overall customer service and increase efficiency. This document serves as a reference guide for the Human Resources (HR) Organization when performing OSOH and WC-related transactions.
Scope This document reflects the future-state, standardized functional business processes for OSOH and WC.
Approach The documented business processes were updated and refined based on:
WC Business Processes originally gathered in Quarter (2) in Fiscal Year (FY) 2012.
Available documentation, including Standard Operating Procedures (SOPs) Feedback provided from the Functional FS Subject Matter Experts (SMEs) in the OSOH Business Process Requirements Session and from the Functional FS and United States Department of Agriculture (USDA) WC Business Process Requirements Session Documented business requirements Desired standardization across all Agencies within the USDA Process Mapping Legend The following table identifies and describes the shapes used in the business process maps.
| Process Shape |
| Description |
· Used to represent the initial step in a process. Often labeled as “Start.”
· Represents an encapsulated process that is detailed elsewhere in the process maps.
· This end-to-end process is established in another process flow representation.
· Represents a specific task in a process.
· Should only include one task per box.
· Represents a decision that is made during a process, the outcome of which results in one of multiple paths.
· Used to identify two separate tasks that occur simultaneously.
· Unless otherwise noted, both tasks must be completed prior to moving forward in a process.
· Used to connect the tasks, decision points, etc. of a process.
· Used to represent the end of a process. Often labeled as “End.”
· Identifies the individual or group that conducts a specific task within the process.
· Helps to assist in identifying roles and responsibilities in a process.
OWCP Case Management and Case Alignment Case Management
| Trigger/Input |
| An Employee incident results in the need for a WC Case Manager to initiate a case. Examples include, but are not limited to: Compensation Act (CA)-1; CA-16; CA-2 and/or CA-2a; death; medical billing issue; call received from Employee about a medical bill; call received from provider about unpaid medical bill; copy received of medical bill in mail; items are being denied in the Agency Query System (AQS); collection agency sends medical bill or notification. |
| Process Description |
| The initial Case Manager receives documentation. If the documentation is related to a Congressional, Employee Relations (ER)/Labor Relations (LR) case or an Equal Employment Opportunity (EEO) claim, it is escalated to a Complex Case Manager. If it is not, documentation related to the original submission is gathered and processed, as appropriate. If the documentation is related to loss of pay; light-duty work restrictions; Leave Without Pay (LWOP); Leave Buy-Back; more than 30 days of Continuation of Pay (COP) use or death, then it is escalated to an Intermediate Case Manager. If it is not, then case management activities are conducted. Upon completion of these activities, the case is reviewed to ensure all criteria have been met. If they are, the case is closed. If not, it is then elevated to the Intermediate Case Manager. Case information is then organized and assigned within Intermediate Case Management and processed, as appropriate. If documentation is not older than 271 days and all criteria have been met, the case is closed. If these criteria are not met, then the case is escalated. The Complex Case Manager then organizes the documentation, as appropriate, processes appropriate documentation and conducts case management activities until the case is fully resolved. |
| Frequency |
| This process occurs on an ad-hoc basis when a notice or documentation is received. |
| Roles |
| Initial Case Manager, Intermediate Case Manager, Complex Case Manager |
| Results |
| Case is reviewed and escalated as appropriate, with the case being updated and closed |
Initial Case Management Alignment
Intermediate Case Management Alignment
Complex Case Management Alignment
OWCP Business Process Maps CA-16 Authorization for Examination and/or Treatment
| Trigger/Input |
| Contact from Employee/representative requesting CA-16; and/or Employee develops work related condition. |
| Process Description |
| The Employee or Manager/Supervisor contacts the Human Resources Management (HRM) Contact Center; the request is assigned a case number, and it is submitted to the WC queue. The WC Case Manager retrieves the case from the queue and determines if the request meets the Employee checklist criteria. If it does not, the Employee is notified to complete the appropriate claim document (CA-1, CA-2, CA-2a). If it does meet the checklist criteria, the Employee or Manager/Supervisor provides the Medical Provider contact information to the Case Manager. Upon receipt of the contact information, the Case Manager issues a CA-16 to the Medical Provider. The Medical Provider will then provide treatment, as appropriate, and submit applicable medical reports to the Case Manager and Department of Labor (DOL) OWCP. Recommendations for the Employee’s next steps are then provided, and a case is created in the WC case management solution/database. |
| Frequency |
| This process occurs on an ad-hoc basis when a CA-16 is requested or received, or a work related condition has developed. |
| Roles |
| Employee, Manager/Supervisor, WC Case Manager, HRM Contact Center, Medical Provider |
| Results |
| If checklist criteria are not met, a request for the Employee to complete the relevant data is made. If criteria are met, a case is created and managed, as appropriate. |
CA-1
| Trigger/Input |
| An Employee develops an illness or disease and contact from Employee/Representative requesting information or authorization is received. |
| Process Description |
| If a claim is submitted through Customer Relationship Management (CRM), the Employee or Manager/Supervisor contacts the Contact Center describing the work related condition. CRM creates a case number and submits it to the WC Case Manager. If it was not initiated through CRM, the Case Manager receives the inquiry through other measures (e.g., fax, Safety and Health Information Portal System (SHIPS), DOL, etc.). Upon receipt of the inquiry, the Case Manager will advise the Employee on the next steps that should be taken. The Employee then initiates completion of the CA-1 form, and the Manager/Supervisor will complete it prior to submitting to the Case Manager. If the Employee is not requesting the claim be filed to DOL OWCP, a WC database record is created, and the CA-1 form is scanned to the medical folder for documentation. If it is intended to be filed with DOL OWCP, the Case Manager creates and updates the file, subject to Federal Employees Compensation Act (FECA) and Privacy Act regulations, as well as creates a file in the WC database (and CRM if applicable). The form is reviewed for objections, and the Case Manager states the Agency’s position. The CA-1, along with the Agency’s position, is then submitted to DOL, where a case number is issued and additional documentation is requested from applicable parties, if required. The Case Manager receives the DOL case number and issues a letter to the Employee with his/her rights and responsibilities. If the case does not need to be elevated, case management activities are conducted; if it does need to be elevated, then the Case Manager determines if the case warrants an intermediate or complex designation per the SOP criteria. The applicable parties are then advised of the appropriate next steps, and the Employee or Manager/Supervisor will gather documentation, as available, to submit to the Case Manager. This documentation is submitted to DOL, along with the Agency’s response. DOL then adjudicates the claim and notifies the Employee and Agency of the decision. If the claim was accepted, case management activities will be conducted. If it was not accepted, the Employee is advised of his/her appeal rights and will choose to either appeal or end the process. |
| Frequency |
| This process occurs on an ad-hoc basis when a request or documentation is received. |
| Roles |
| DOL OWCP, WC Case Manager, Employee, Manager/Supervisor, HRM Contact Center |
| Results |
| Case management activities are conducted or the appeals process is initiated. |
CA-2 Occupational Disease (On-the-Job)
| Trigger/Input |
| Employee develops illness or disease and contact from Employee/Representative requesting information or authorization (CA-16) is received. |
| Process Description |
| If a claim is submitted through CRM, the Employee or Manager/Supervisor contacts the HRM Contact Center, describing the work related condition, and CRM creates a case number and submits it to the WC Case Manager. If it was not initiated through CRM, the Case Manager will receive the inquiry through other measures (e.g., fax, SHIPs, DOL, etc.). Upon receipt of the inquiry, the Case Manager will advise the Employee on the next steps that should be taken, including the applicable CA-35. The Employee will then initiate completion of the CA-2 form, and the Manager/Supervisor will complete it prior to submitting to the Case Manager. If the Employee is not requesting for the claim to be filed to DOL OWCP, a WC database record is created and the CA-2 form is scanned into the medical folder for documentation purposes. If it is intended to be filed with DOL OWCP, the Case Manager creates and updates the file subject to FECA and Privacy Act regulations, as well as creates a file in the WC database (and CRM if applicable). The CA-2 form is reviewed for objections and the Case Manager states the Agency’s position. The CA-2, along with the Agency’s position, is then submitted to DOL, where a case number is issued, and additional documentation is requested from applicable parties, if required. The Case Manager receives the DOL case number and issues a letter to the Employee with his/her rights and responsibilities. The applicable parties are then advised of the appropriate next steps on how to respond to the request from DOL and address the CA-35 checklist. The Employee or Manager/Supervisor will gather documentation, as available, for CA-35 A-H, and submit to the Case Manager. This documentation is submitted to DOL, along with the Agency’s response. DOL then adjudicates the claim and notifies the Employee and Agency of the decision. If the claim was accepted, case management activities will be conducted. If it was not accepted, the Employee is advised of his/her appeal rights and will choose to either appeal or end the process. |
| Frequency |
| This process occurs on an ad-hoc basis when a request or documentation is received. |
| Roles |
| DOL OWCP, WC Case Manager, Employee, Manager/Supervisor, HRM Contact Center |
| Results |
| Case management activities are conducted or the appeals process is initiated. |
CA-2a
| Trigger/Input |
| Employee has recurrence of an injury or illness and contact from Employee/Representative requesting information or authorization (CA-16) is received. |
| Process Description |
| If a claim is submitted through CRM, the Employee or Manager/Supervisor contacts the HRM Contact Center, describing the work related condition, and CRM creates a case number and submits it to the WC Case Manager. If it was not initiated through CRM, the Case Manager will receive the inquiry through other measures (e.g., fax, DOL, etc.). Upon receipt of the inquiry, the Case Manager will advise the Employee on the next steps that should be taken. The Employee will then initiate completion of the CA-2a form, and the Manager/Supervisor will complete it prior to submitting to the Case Manager. The Case Manager creates and updates the file subject to FECA and Privacy Act regulations, as well as creates a file in the WC database (and CRM if applicable). The CA-2a form is reviewed for objections, and the Case Manager states the Agency’s position. The CA-2a, along with the Agency’s position, is then submitted to DOL; when this is not a recurrence, and the CA-1 and/or CA-2 process is initiated. If it is a recurrence, it is assigned to the original case number and additional documentation is requested from applicable parties, if required. The Case Manager receives DOL correspondence. The applicable and parties are then advised of the appropriate next steps, and the Manager/Supervisor will provide a response to DOL. DOL then adjudicates the claim and notifies the Employee and Agency of the decision. If the claim was accepted, case management activities will be conducted. If it was not accepted, the Employee is advised of his/her appeal rights and will choose to either appeal or end the process. |
| Frequency |
| This process occurs on an ad-hoc basis when a request or documentation is received for a recurrence. |
| Roles |
| DOL OWCP, WC Case Manager, Employee, Manager/Supervisor, HRM Contact Center |
| Results |
| Case management activities are conducted or the appeals process is initiated. |
COP
| Trigger/Input |
| Employee identifies COP on the CA-1, enters COP on timesheet or the WC Case Manager identifies it on the COP report. |
| Process Description |
| An Employee elects to receive COP; the Manager/Supervisor reviews the request and utilizes the controversion checklist to determine eligibility with assistance from the WC Case Manager. If the Employee meets any of the nine conditions, he/she is informed of the decision to deny, and the process ends. If the Employee does not meet the conditions, the Case Manager reviews to determine if the COP should be controverted for other reasons. If it is, a ruling is requested, and DOL OWCP reviews the information. If they decide to deny the COP, the Employee is informed, and correspondence is given to the Case Manager. The Case Manager then requests an Employee timesheet correction and then monitors the case to ensure completion of the correction. If DOL does not deny the COP request, or it is not controverted by the Case Manager, the Employee uses COP. The Case Manager obtains a copy of the Time and Attendance (T&A) record, with supporting medical documentation, for each pay period. It is then reviewed to determine appropriate use of COP. If it is not appropriate and is unauthorized use, the Employee and Supervisor are notified of determination to terminate COP, a timesheet correction is requested, and the case is monitored, ensuring compliance. If it is not an appropriate use of COP, but is in fact authorized, the Employee and Supervisor are notified for the need to correct the timesheet. If there is appropriate use of COP, time is tracked and monitored. If COP usage will not continue beyond 30 days, the Employee will return to work. If usage will be greater than 30 days, the case is elevated to the intermediate Case Manager, and a determination is made of whether the Employee will be able to return after 45 days, per available medical evidence. If he/she is able to return to work on or before the 46th day, he/she will do so, and the process ends. If he/she is not, then the CA-7 process is initiated. |
| Frequency |
| On an ad-hoc basis when COP is being requested or has been identified. |
| Roles |
| Employee, Manager/Supervisor, WC Case Manager, DOL OWCP |
| Results |
| COP is used and the Employee returns to work, or COP is used and after 45 days, the CA-7 process is initiated. |
Return-To-Work Determination (Maximum Medical Improvement (MMI))
| Trigger/Input |
| An Employee has not been able to perform his/her job-related duties and has received work related restrictions. |
| Process Description |
| The WC Case Manager receives work related restrictions in regard to an Employee. It is then reviewed to determine if accommodation is possible. If accommodation is possible, it is determined if restrictions are permanent. If they are, the return to work process is initiated; if they are not permanent, the modified or light duty job offer process is initiated. If accommodation is not possible, and the Employee is not permanent, he/she is terminated and advised on his/her compensation. Case management activities are conducted, and the process ends. If he/she is a permanent Employee, he/she is advised of compensation options, and a course of action is determined, based upon Case Manager advisement. Case management activities then occur, and the process ends. |
| Frequency |
| An Employee has received his/her work related restrictions and has been cleared to return to work in some capacity |
| Results |
| An Employee is advised of his/her options and the appropriate course of action is taken, based on appointment status and ability to accommodate. Case Management activities are also conducted. |
Return to Work
| Trigger/Input |
| It is determined that an Employee can be accommodated, and he/she is able to return to work in some capacity (but not perform his/her prior job duties). |
| Process Description |
| If a classified position is available within the Employee’s documented limitations, the Case Manager will consult with the applicable or relevant branches within the Agency, obtaining required documentation. Determinations are then made to offer the Employee either a modified, equivalent or lower paying position. If one of these options is offered and the Employee is permanent, the job offer process is initiated. If he/she is temporary, he/she is converted or placed into a new Not to Exceed (NTE) one year appointment, and a Wage Earning Capacity (WEC) is requested between 90 to 120 days of the new appointment. Case management activities occur, and the process ends. If one of the offers is not made, a Rehabilitation Counselor is requested and assigned by DOL OWCP; the Employee is interviewed and his/her skills are assessed. The Case Manager can then either reconsider making a job offer or have the process to pursue another Agency, private sector or training opportunities begin for the Employee, and the process ends. If a classified position is not available, the Case Manager will pursue opportunities within another Agency. After exhausting all intra-Agency options and determining the Employee can be placed within another Agency, reassignment activities will be conducted, and a request for a WEC determination will be made to DOL OWCP. If he/she cannot be placed within another Agency, a Rehabilitation Counselor is requested and provided by DOL OWCP, where the Employee interviews and assessments will occur. The Case Manager can then either reconsider making a job offer or have the process to pursue another Agency, private sector or training opportunities begin for the Employee, and the process ends. |
| Frequency |
| Occurs when a determination has been made that an Employee can be accommodated, and his/her restrictions are permanent. |
| Roles |
| WC Case Manager, DOL OWCP |
| Results |
| An Employee returns to work or is assisted in pursuing training or additional job opportunities. |
Appeals
| Trigger/Input |
| An Employee is denied a specific OWCP benefit request and appeals the decision. |
| Process Description |
| DOL notifies an Employee and the WC Case Manager of the formal decision to deny a specific OWCP benefit. The Employee can then request a hearing within 30 days; if he/she decides to do so, the Case Manager will have the opportunity to participate in the oral hearing or request a transcript with written responses. DOL conducts the oral hearing and issues a written transcript to the Employee and Case Manager. The Case Manager then has the opportunity to provide a response, and DOL will make a decision to deny or overturn their original decision. If it is not upheld, all applicable parties are notified of the decision to all the OWCP benefit. If the decision is upheld or the Employee has elected to not request a hearing, he/she may request reconsideration. If reconsideration is requested, DOL will submit the request along with any new documentation to the District Director for reconsideration. If the original decision is not sustained, all applicable parties are informed of the decision to allow the OWCP benefit. If it is sustained, the Employee is formally notified. After notification, or if the Employee does not request reconsideration, the Employee has 180 days to appeal to the Employees' Compensation Appeals Board (ECAB). If he/she elects not to appeal to ECAB, case management activities are conducted until expiration of the appeal timeline. If appealing to ECAB, the Employee will submit the appeal, and ECAB will make the decision to deny or overturn the decision. If the decision is upheld, the process ends; if it is not, all applicable parties are notified of the decision to allow the OWCP benefit. |
| Frequency |
| Occurs on an ad-hoc basis when an Employee appeals a decision denying an OWCP benefit |
| Roles |
| Employee, WC Case Manager, DOL OWCL, ECAB |
| Results |
| The appeal is denied after exhausting all venues or the specific OWCP benefit is allowed. |
Congressional/Freedom of Information Act (FOIA)
| Trigger/Input |
| An Employee initiates a claim that has resulted in a Congressional inquiry. |
| Process Description |
| The Public Affairs Office (PAO) receives a request and forwards it to the applicable parties. The Congressional/FOIA Point of Contact (POC) researches to identify the WC Case Manager responsible for the constituent’s region. The Case Manager reviews the inquiry and investigates the areas of concern, while reviewing applicable regional laws, regulations and policies. A narrative response to the inquiry is then completed. The Congressional/FOIA POC reviews the narrative response and determines if the inquiry requires changes. If it does, the POC and Branch Leadership will coordinate with the Case Manager to make changes. After changes are made, or if the inquiry did not require changes, it is forwarded for final review to the Branch Leadership, where additional changes would be made if needed, and then it would be submitted to the PAO. A draft letter of response is then prepared by the Director and is sent to the Case Manager for final review. The draft letter is then submitted to Branch Leadership, where changes are made, if needed, and the letter is submitted to the PAO. The final copy is then submitted with the appropriate signatures to the Case Manager, and the process ends. |
| Frequency |
| Occurs on an ad-hoc basis where PAO receives a request warranting action. |
| Roles |
| WC Case Manager, Branch Leadership, Congressional/FOIA POC, PAO |
| Results |
| A signed letter is submitted to the Case Manager for documentation purposes. |
LWOP or Extension to LWOP
| Trigger/Input |
| Employee is unable to return to work; COP ends; Employee is not eligible for COP. |
| Process Description |
| The WC Case Manager receives a notification that an Employee requires LWOP or an extension of LWOP and submits the notification to the Manager/Supervisor to initiate an SF-52. The Supervisor initiates the SF-52 action to affect the LWOP and provides notification. The WC Case Manager will attach the SF-52 to an SF-2810, if applicable, and assign the case to the |
WC Supervisor. The WC Supervisor signs the SF-52 and submits it to Personnel Action Processing (PAR). PAR processes the action and notifies Benefits to process the SF-2810 to transfer Federal Employee Health Benefits (FEHB) to the DOL. The WC Case Manager will monitor the SF-52 and SF-2810 to ensure they have processed, and determine if the Employee will return prior to the NTE date. If the Employee returns prior to the NTE date, the WC Case Manager will initiate the Return to Work Process. If the Employee does not return to work prior to the NTE date, the WC Case Manager will determine if LWOP will be extended. If LWOP will be extended, the LWOP extension is initiated, and the process begins with receiving notification to initiate the SF-52. If LWOP will not be extended, the WC Case Manager will consult with necessary groups (i.e., Employee Relations Specialists (ERS)) to determine Employee removal. The LWOP extension will be reconsidered if the Employee will not be removed. If removal from the role is determined, ERS will conduct non-disciplinary removal actions; the WC Case Manager conducts case management activities, and the process ends.
| Frequency |
| This process occurs on an ad-hoc basis when an Employee is placed on LWOP or requires an extension to LWOP. |
| Roles |
| WC Supervisor, Benefits Specialist, Manager/Supervisor, WC Case Manager, PAR, ERS |
| Results |
| Employee is placed on LWOP; LWOP is extended; Non-disciplinary removal action is completed |
CA-7 Claim for Compensation
| Trigger/Input |
| COP ends; Employee is unable to work when COP has ended; Schedule Award; Other Wage Loss. |
| Process Description |
| The Employee notifies the WC Case Manager of an inability to work, receives advice on the next steps and completes a CA-7 Page 1. The WC Case Manager receives the completed CA-7 Page 1 from the Employee and calculates and certifies the Employee’s pay. The claim is submitted to DOL OWCP with supporting medical documentation. DOL OWCP will review the claim and determine if additional information is required. If required, additional information is requested from all applicable parties. If additional information is not required, DOL OWCP will render a formal decision on the compensation request. If the compensation request is granted, the WC Case Manager will conduct case management activities, and the process ends. If the compensation request is not granted, the Employee is advised on his/her appeal rights and determines if he/she wants to appeal. If the Employee appeals, the appeals process is initiated; otherwise, the process ends. |
| Frequency |
| This process occurs on an ad-hoc basis when an Employee is unable to continue work. |
| Roles |
| Employee, WC Case Manager, DOL OWCP |
| Results |
| CA-7 form is completed and submitted to DOL OWCP; Compensation Request Approved |
Leave Buy-Back
| Trigger/Input |
| Employee ineligible for compensation/COP; claim under review at DOL OWCP and then accepted; Employee elected to use annual/sick leave and wants to buy back leave used. |
| Process Description |
| The Employee works with the WC Case Manager to request leave buy-back. The WC Case Manager counsels the Employee on the leave buy-back process and determines eligibility. If the Employee is not eligible, the process ends. If the Employee is eligible, the WC Case Manager provides counsel, and the Employee makes a determination if he/she still wants to pursue leave buy-back. If the Employee determines to proceed with the leave buy-back, the CA-7/CA-7a forms are completed and submitted. The Employee’s salary is calculated, timesheets are verified and the WC Case Manager completes the Agency portion of the CA-7/CA-7b. The forms are submitted to the National Finance Center (NFC) to provide an estimate and complete the remaining CA-7b. Based on NFC’s estimate, the Employee determines whether to continue the leave buy-back process. If the Employee does not want to continue the leave-buy back, the process ends. If the Employee determines he/she wants to continue the leave buy-back, he/she completes the CA-7b and submits. The WC Case Manager will determine if the forms are complete. If the forms are not complete, they are returned to the Employee for completion. If the forms are complete, Pay will be notified, and all applicable documentation will be submitted. DOL OWCP will determine if additional information is required to render a formal decision. If additional information is required, it is requested from the applicable parties; otherwise, DOL OWCP will review and determine if the case is accepted. If the case is accepted, a check will be distributed to NFC. NFC will generate a bill for the Employee portion of the leave buy-back. The Employee will pay the bill, and upon receipt of final payment, NFC notifies the Agency. Pay/Leave will adjust the leave in the system, notify the applicable parties, and the process ends. If the case is not accepted, the WC Case Manager will be notified, provide advice to the Employee on his/her appeal rights, and the Employee will determine whether to appeal the decision. If the Employee determines he/she does not want to appeal, the process ends. If the Employee appeals the decision, the appeal process is initiated. |
| Frequency |
| This process occurs on an ad-hoc basis when the Employee wants to reinstate annual/sick leave used. |
| Roles |
| Employee, WC Case Manager, NFC, DOL OWCP, Pay/Leave Specialist |
| Results |
| Annual/Sick Leave reinstated |
Medical Bills
| Trigger/Input |
| An Employee and/or Medical Provider contacts WC regarding an unpaid bill; an unpaid bill is received in the mail; medical payments are denied in Affiliated Computer Services (ACS) Web bill processing portal; a collection agency sends a bill or delinquent notification. |
| Process Description |
| The WC Case Manager receives notice of an unpaid medical bill and researches for an existing WC claim in applicable databases. The WC Case Manager will determine if the bill is a denial. If the bill is not a denial, the WC Case Manager will determine if the medical bill is for an Agency Employee. If the medical bill is not for an Agency Employee, it is returned with an explanation, and the process ends. If the medical bill is for an Agency Employee, but the Employee does not have a WC claim, the medical bill is returned with an explanation, and the process ends. If the medical bill is for an Agency Employee with a valid WC claim and the paperwork has not been submitted, the WC Case Manager will refer to the CA-1 process. If the medical bill is for an Agency Employee with a valid WC claim and the paperwork has been submitted, the WC Case Manager contacts the medical provider to request resubmission of the medical bill or authorization request. If the bill has been denied, ACS is verified for prior authorization, denial code or payment status. The WC Case Manager advises the Employee on the next steps and contacts the medical provider to request resubmission of medical bill or authorization request. The WC Case Manager monitors ACS to receive status of billing; at the same time, the Manager/Supervisor will make determination on the bill. Once the billing status has updated, the WC Case Manager will notify the Employee/medical provider, as appropriate, and the process ends. |
| Frequency |
| This process occurs on ad-hoc basis when a medical bill has not been paid. |
| Roles |
| Medical Provider, WC Case Manager, Manager/Supervisor |
| Results |
| Medical Bill is Paid, Medical Bill is denied with explanation |
Modified or Light-Duty Offer for a WC Claim (Temporary Total Disability (TTD))
| Trigger/Input |
| WC receives work restrictions for an Employee; an Employee has been injured and can no longer perform prior job duties, but is capable of light/modified job duties. |
| Process Description |
| WC Case Manger receives Employee work-related restrictions and reviews to determine if accommodation is possible. If accommodation is not possible, the Employee is advised of compensation options (e.g., CA-7, COP, etc.). The Employee will determine action based on WC Case Manager advisement, and the process ends. If accommodation is possible, light-duty tasks are requested. The Supervisor will provide a list of light-duty assignments available; the WC Case Manager will prepare a light or modified duty letter, submit to the Employee, and initiate the job offer process. |
| Frequency |
| This process occurs on an ad-hoc basis when work restrictions are received and the Employee is offered modified or light-duty. |
| Roles |
| Employee, WC Case Manager, Supervisor/Manager, DOL OWCP |
| Results |
| Light/Modified Duty Letter Issued; Employee accepts Light/Modified Job Offer made |
Employee Job Offer Activities
| Trigger/Input |
| Employee receiving WC is offered Date of Injury (DOI) position or position of similar pay/duties to return to work. |
| Process Description |
| The Employee will receive a job offer and determine if he/she accepts the offer. If the job offer is accepted, the Employee will return to work. If the job offer is not accepted, the Employee provides a response for declining. The WC Case Manager submits to DOL OWCP for a suitability determination. DOL OWCP responds to suitability request. If the job offer is not suitable, WC Case Manger will conduct Case Management activities. If the job offer is suitable, the Employee will have the option to reconsider. If the Employee accepts the suitability determination, he/she will return to work and the WC Case Manager will monitor until the Employee is able to return to full duties. When the Employee is able to return to full duty, the WC Case Manager will notify the applicable parties, and the process ends. If the Employee declines the suitability determination, a declination is submitted. DOL OWCP reviews and determines to accept/decline the Employee response. If the Employee declination is accepted, the WC Case Manager will conduct case management activities. If the Employee response is not accepted, the Employee is notified of compensation loss. The WC Case Manager will inform the Employee of appeal rights. If the Employee appeals, the appeals process is initiated; otherwise, the process ends. |
| Frequency |
| This process occurs on an ad-hoc basis when an Employee on WC is offered a job. |
| Roles |
| Employee, WC Case Manager, DOL OWCP |
| Results |
| Job Offer Accepted; DOL OWCP Suitability determination made |
Employee Death
| Trigger/Inputs |
| Employee passes due to work related incident. |
| Process Description |
| The WC Case Manager will receive fatality notification and inform applicable groups. If the death is not work related, the WC Case Manager will search for existing WC claims and provide appropriate documentation to Benefits/DOL OWCP, and the process ends. If the death is work related, the applicable parties (e.g., Benefits) will be notified and the POC is informed of next steps. The POC will complete and submit a CA-6. The CA-6 is reviewed and submitted to DOL OWCP with the Agency's stated position. DOL OWCP issues a claim number to the WC Case Manager and coordination with the POC will occur to obtain all necessary documentation. A letter is submitted to the Survivor/Estate Representative. The POC assists with completion and submission of the CA-5/CA-5b and supporting documentation. The documentation is reviewed by the WC Case Manager and submitted. DOL OWCP will determine to accept or deny the claim. If the claim is accepted, the WC Case Manager and Survivor/Estate Representative are notified of the benefits payment. The WC Case Manager will provide notification to Budget and Finance (B&F) of eligibility for death gratuity, monitors the claim to ensure payment, and the process ends. If the claim is not accepted, it is determined if the denial was due to insufficient documentation. If the denial is due to insufficient documentation, DOL OWCP will request additional information from the Survivor/Estate Representative, until the required documentation is submitted, and the claim is accepted. If the denial is not due to insufficient documentation, the decision may be appealed. If the Survivor/Estate Representative appeals, the appeals process is initiated; otherwise, the process ends. |
| Frequency |
| This process occurs on an ad-hoc basis when an Employee passes as a result of a work related incident. |
| Roles |
| WC Case Manager, Supervisor/Manager (POC), DOL OWCP, Survivor/Estate Representative |
| Results |
| Death Gratuity payments are made |
Convert to One Year Appointment
| Trigger/Input |
| 1,039 hours are received and a determination is made that the Employee will not return to work or full-duty prior to expiration of the NTE date. |
| Process Description |
| The WC Case Manager will obtain and submit all applicable documentation (e.g., resume, Position Description (PD), etc.). Staffing/PAR will determine if the Employee qualifies for a new position. If the Employee does not qualify for a new position, notification is submitted to the WC Case Manager, and a new PD is requested from the Supervisor. If the Employee qualifies for the position, the WC Case Manager will create a job offer letter and complete the job offer process. |
| Frequency |
| This process occurs on an ad-hoc basis when an NTE appointment will expire prior to the Employee being able to return to full duty. |
| Roles |
| WC Case Manager, WC Supervisor, Staffing/PAR, Supervisor/Manager |
| Results |
| Employee qualifies for new position and the Job Offer process is initiated. |
ER/LR, EEO Claim
| Trigger/Input |
| Designated POC will respond to an ER/LR/EEO/Union inquiry. |
| Process Description |
| The designated POC will receive, review and determine the WC Case Manager. The WC Case Manager will coordinate with applicable parties to provide considerations and assist the POC to draft an inquiry response. The POC and WC Case Manager will determine if Leadership approval is required. If Leadership approval is required, Leadership will review and approve the inquiry. Upon Leadership approval, or if Leadership approval is not required, the POC and WC Case Manager finalize and submit the inquiry. |
| Frequency |
| This process occurs on an ad-hoc basis when an ER/LR/EEO/Union inquiry is made. |
| Roles |
| WC Case Manager, Designated POC, Union/Civil Rights/ER/LR/EEO |
| Results |
| ER/LR/EEO/Union inquiry is finalized and submitted |
Investigative Services Anonymous Tip
| Trigger/Input |
| WC receives a tip regarding potential WC fraud. |
| Process Description |
| An individual contacts WC via the hotline/Web site to report potential WC fraud. WC documents information in the claim case file and determines if the individual will sign a witness statement. If the individual will sign a witness statement, WC requests the information, documents the additional information in the claim case file and initiates the investigative services process. If the individual will not sign a witness statement, WC will initiate the investigative services process. |
| Frequency |
| This process occurs on an ad-hoc basis when tips regarding potential WC fraud are received. |
| Results |
| Information is obtained regarding the potential fraud and investigative services are initiated. |
Investigative Services
| Trigger/Input |
| WC Case Manager will receive evidence/information and identify claim to perform claim ranking score. |
| Process Description |
| The WC Case Manager will identify claim, perform evidence checklist and obtain claim ranking score. If the fraud risk score does not indicate the need for an investigation and evidence received does not indicate discontinued compensation, the WC Case Manager will continue to monitor the claim and update the fraud risk score as information/evidence is made available, and the process ends. If the fraud risk score indicates further investigation is warranted, the WC Case Manager will provide justification for investigative services to WC Leadership. WC Leadership will confirm funding is available and release authorization to perform investigative services. Upon authorization, the Third Party Investigator will conduct investigation, document and report findings to the WC Case Manager. The WC Case Manager will attach the investigation findings to the claim and review to determine if the claim will be challenged. If the claim will not be challenged, the WC Case Manager will document justification for not challenging the claim, continue to monitor/update the claim with new evidence, and the process ends. If the claim is challenged, the WC Case Manager will document justification and submit to DOL with request to suspend compensation. DOL will review the justification and evidence to determine if compensation will be suspended. If compensation is suspended, DOL will provide notice to the WC Case Manager. The WC Case Manager will document notice of suspended compensation, provide to the claimant, and the process ends. If DOL does not approve suspension of compensation, they will submit reason for denial to the WC Case Manager. The WC Case Manager will determine if additional information is available and submit to DOL; otherwise, the process ends. |
| Frequency |
| This process occurs on an ad-hoc basis when evidence/information is received regarding a WC claim that requires investigation. |
| Roles |
| WC Case Manager, WC Leadership, Third Party Investigator, DOL |
| Results |
| Investigation is completed; Determination is made to challenge WC claim and discontinue compensation. |
OSOH Business Processes Employee Injury or Illness Reporting
| Trigger/Input |
| An Employee becomes ill or injured while employed at the Agency. |
| Process Description |
| The Employee identifies if the injury/illness occurred while in active status. If the injury did not occur while in active status, the Employee will document the injury/illness sustained during off-duty hours, and the process ends. If the injury/illness occurred while in active status, the Employee will report the details of the injury/illness. If the injury/illness is an emergency, the Employee or Supervisor will contact the Albuquerque Service Center (ASC) for medical authorization. If the injury/illness is not a medical emergency or medical authorization was received, the Supervisor and Safety Manager will be notified of the incident. At the same time, the Employee will determine if there was a witness to the incident. If there was a witness, the Employee will initiate the Witness Statement process. Upon completion of initiating the Witness Statement process or if there was no witness, the Employee will initiate the injury/illness claim for compensation process. Upon notification of the incident, the Supervisor will attach notes to the incident, and the process ends. At the same time, the Safety Manager will determine if the incident is recordable per Occupational Safety and Health Administration (OSHA) guidelines and document recordability. The Safety Manager will then determine if a serious investigation is needed. If a serious investigation is required, the Safety Manager will initiate a Serious Accident Investigation (SAI) Management process, and the process ends. If a serious investigation is not warranted, the Safety Manager will initiate a non-serious incident investigation, and the process ends. |
| Frequency |
| This process occurs on an ad-hoc basis when an Employee becomes ill or injured while employed at the Agency. |
| Roles |
| Employee, Supervisor, Safety Manager |
| Results |
| The Injury/Illness incident is documented, the investigation is completed, corrective actions are implemented and lessons learned are shared. If applicable, an injury/illness claim for compensation is submitted. |
Employee Injury/Illness Claim for Compensation
| Trigger/Input |
| An Employee becomes ill or injured while working for the Agency and submits a claim for compensation. |
| Process Description |
| The Employee will document the incident date and determine if he/she are feeling effects from the incident. If the Employee is feeling effects from the incident, the Employee will describe effects and nature of the incident and determine if they want to elect COP. If the Employee decides not to use COP, the Employee will elect sick or annual leave, and the Supervisor is notified. If the Employee is not feeling effects from the incident or determines to elect COP, the Supervisor will receive notice of the incident. The Supervisor will validate the incident, complete the Supervisor’s Report and determine if lost time occurred. If lost time did not occur, the Supervisor will determine if medical expenses are expected. If medical expenses are not expected, the Supervisor will file a precautionary notice of incident, and the process ends. If lost time occurred or medical expenses are expected, the Safety Manager will determine OSHA recordability at the same time the WC Team processes the incident claim, and the process ends. |
| Frequency |
| This process occurs on an ad-hoc basis when an Employee becomes injured/ill and decides to file a claim for compensation. |
| Roles |
| Employee, Supervisor, Safety Manager, WC |
| Results |
| The Employee’s claim for compensation is processed, the Supervisor’s Report is completed and, if applicable, the Supervisor files a precautionary notice of incident. |
Witness Statement
| Trigger/Input |
| An Employee/non-Employee is identified as a Witness to an incident resulting in an injury, illness or Safety Story. |
| Process Description |
| The Employee will identify the Witness to the incident. The Witness will receive notification of being identified as a Witness to an injury, illness or Safety Story. The Witness will determine if he/she will enter a witness statement. If the Witness will not complete a witness statement, the process ends. If the Witness will complete a witness statement, he/she will determine if the incident witnessed was a Motor Vehicle Accident (MVA). If the incident was a MVA, the Witness will complete a Standard Form (SF)-94 and identify if he/she witnessed injuries. If injuries were witnessed, the Witness will complete the appropriate number of witness statements for each injury witnessed and submit to the Program Manager. If the incident witnessed was not a MVA and he/she did not witness injuries, the Witness will document details of incident witnessed and submit to the Program Manager. The Program Manager will receive the witness statement(s) attach to the appropriate incident file, and the process ends. |
| Frequency |
| This process occurs on an ad-hoc basis when an Employee/non-Employee is identified as a Witness to an incident resulting in an injury, illness, MVA, aviation mishap or Safety Story. |
| Roles |
| Witness, Employee, Program Manager |
| Results |
| The Witness Statement is completed and attached to the appropriate incident file. |
Anonymous Safety Story
| Trigger/Input |
| An anonymous tip is reported to the OSOH regarding a Safety Story. |
| Process Description |
| An anonymous tip regarding a Safety Story is reported to OSOH via the Web site or hotline. OSOH receives the tip, documents and determines if the individual who reported the anonymous tip will provide a witness statement. If the individual will provide a witness statement, OSOH will request additional details from the individual. The individual will supply a written detailed account of the incident and submit to OSOH. OSOH will attach the written detailed account to the appropriate incident file. Upon receipt of additional details or if the individual will not provide written detailed account of the incident, OSOH will perform necessary incident investigation, seek resolution/mitigation and share lessons learned from the investigation/resolution. OSOH will notify applicable parties, post the incident follow-up response for Agency Employees to review, and the process ends. |
| Frequency |
| This process occurs on an ad-hoc basis when an anonymous tip regarding a Safety Story is received. |
| Roles |
| Anonymous Tip, OSOH |
| Results |
| The anonymous tip is documented, an investigation is performed, mitigation/resolution is identified and applicable parties are notified of resolution. |
Safety Story
| Trigger/Input |
| An Employee experiences a near-miss, incident or event and desires to share information as a Safety Story. |
This is the start of the file's text. The full file is on GovTribe.
