The Flow Of A Pennsylvania Workers' Compensation Claim printable pdf download

The Flow of a Pennsylvania Workers’ Compensation Claim

Employers are required to post form LIBC-500, Remember: It is Important to Tell Your Employer

About Your Injury, to inform employees of the name, address and phone number of their

Notice of Injury

workers’ compensation insurance company, their third-party administrator or internal workers’

compensation contact person.

An employee injury is to be reported to the employer within 21 days; if not reported within 120

Injury

days from the date of injury or having knowledge of a work-related disease, no compensation is

allowed (except for cases involving progressive diseases).

Employers are required to immediately report all employee injuries to their insurer or, if self-

insured, to report them to the person responsible for management of the employer’s workers’

compensation program. Employers are also required to file a First Report of Injury via EDI

First Report of Injury

transaction in the IAIABC Claims Release 3 format with the Bureau of Workers’ Compensation

within 48 hours for every injury resulting in death, and within seven days for all other injuries that

result in disability lasting more than a day, shift or turn of work.

Within 21 days from the date the employee provides notification of an injury, the employer/carrier

denies liability and issues a Notice of Workers’ Compensation Denial (LIBC-496) to the employee;

the Denial and appropriate EDI transaction must also be filed with the Bureau of Workers’

Notice of WC Denial

Compensation. The claim is now closed, though the injured worker can seek legal advice to

pursue a claim through the litigation system. See the Flow of a Litigated Workers’ Compensation

Claim on page 4 for more information.

Within 21 days from the date the employee provides notification of an injury, the employer/

Notice of Temporary

carrier issues a Notice of Temporary Compensation Payable (LIBC-501) to extend the investigation

Compensation Payable

period to 90 days before accepting or denying full liability for the injury. This paper form and EDI

transaction must be filed with the bureau along with the Statement of Wages (below).

When the employer elects to stop paying the injured worker temporary compensation, a Notice

Stopping Temporary Compensation (LIBC-502) is completed. The employer must then issue either

Notice Stopping

a Notice of Workers’ Compensation Denial, Notice of Compensation Payable or Agreement for

Temporary Compensation

Compensation to the injured worker as well as the appropriate EDI transaction with the bureau

within the 90-day temporary window.

Within 21 days from the date the employee provides notification of an injury, the employer/

Notice of

carrier accepts liability for the injury and issues a Notice of Compensation Payable (LIBC-495)

Compensation Payable

to the injured worker. The Notice of Compensation Payable, the appropriate EDI transaction and

Statement of Wages must be filed with the bureau.

Within 21 days from the date the employee provides notification of an injury, the employer/carrier

accepts liability for the injury and issues an Agreement for Compensation (LIBC-336) to the

Agreement for Compensation

injured worker. The appropriate EDI transaction, the Agreement for Compensation in paper form

and the Statement of Wages must be filed with the bureau.

Employers must use the Statement of Wages (LIBC-494C) to calculate the employee’s wages and

Statement of Wages

should send a copy to the injured employee. This form must be submitted to the bureau.

When an injured worker returns to their previous employment, the insurer may file a Notice of

Notice of Suspension

Suspension or Modification (LIBC-751) within seven days of the injured party’s return to work

or Modification

along with the appropriate EDI transaction. Additional LIBC-751s for further modifications may be

filed as necessary within seven days of the modification date.

The insurer must provide the injured worker with the LIBC-392A, Final Statement of Account

Final Statement of Account

of Compensation Paid and submit the appropriate EDI transaction to the bureau after the final

of Compensation Paid

payment of compensation.

Supplemental Agreement

The insurer must provide the injured worker with a Supplemental Agreement (LIBC-337) to alter

for Compensation

the worker’s benefits and submit the appropriate EDI transaction and paper form to the bureau.

The insurer must provide the injured worker with the LIBC-392A, Final Statement of Account

Final Statement of Account

of Compensation Paid and submit the appropriate EDI transaction to the bureau after the final

of Compensation Paid

payment of compensation.

The Final Receipt (LIBC-340) is filed when an injured worker’s benefits terminate. The insurer

Agreement to Stop Weekly

must provide the injured worker with the Final Receipt and submit the appropriate EDI

WC Payments

transaction to the bureau. The worker has three years from the date of the last received workers’

(Final Receipt)

compensation check to file a claim petition contesting the termination of payments.

The Flow Of A Pennsylvania Workers' Compensation Claim

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