| (a) Applicability
(1) This section applies only to the employer initiation of
benefits as described in subsection (a)(2) of this section. Employer payments
made after the insurance carrier has accepted or been found to be liable for
a claim such as salary continuation, as defined in §129.1 (relating to
Definitions for Temporary Income Benefits), are covered by Chapter 129 of
this title (relating to Temporary Income Benefits).
(2) An employer may initiate benefits including medical
benefits to compensate an employee during a period in which the carrier has:
(A) contested compensability of the injury;
(B) contested liability for the injury; or
(C) has not completed its initial investigation of the injury,
which is limited to seven days after the carrier receives first written notice
of the injury as defined in §124.1 of this title (relating to Notice
of Injury).
(b) Employer Entitlement to Reimbursement
(1) An employer who initiates benefits as provided in subsection
(a)(2) of this section is entitled to reimbursement from the carrier if the
employer timely reported the injury to the carrier in compliance with §120.2
(relating to Employer's First Report of Injury).
(2) An employer who is entitled to reimbursement as provided
in subsection (b)(1) of this section is entitled to the amount of those benefits
which otherwise would have been paid by the carrier had the carrier immediately
accepted compensability for the injury and began payment of income and medical
benefits.
(A) For an employer initiation of indemnity benefits, the amount
of reimbursement that the employer is entitled to is the amount that would
have been paid by the carrier in income benefits. Chapters 128, (relating
to Benefits - Calculation of Average Weekly Wage), 129 (relating to Benefits
- Temporary Income Benefits), 130 (relating to Benefits - Impairment &
Supplemental Income Benefits), and 131 (relating to Calculation of Lifetime
Income Benefits) of this title govern carrier payments of income benefits.
(B) For an employer initiation of medical benefits, the amount
of reimbursement that the employer is entitled to is the amount that would
have been paid by the carrier in medical benefits. An employer is not entitled
to and shall not seek reimbursement from either the carrier or the employee
for amounts paid to a health care provider which are:
(i) in excess of the Commission's fee guidelines;
(ii) for treatment(s) or service(s) which was not reasonable
or medically necessary; or
(iii) for treatment(s) or service(s) which was not related
to the compensable injury.
(3) An employer who is entitled to reimbursement
under subsection (b)(1) of this section but who paid more benefits to the
employee than the carrier was required to pay in income benefits is entitled
to be reimbursed for the difference if the employer initiated the benefits
with the agreement of the employee and the agreement authorized the reimbursement
of this difference. The difference is reimbursable out of impairment income
benefits (IIBs) that the employee becomes entitled to, if any.
(4) An employer is not entitled to and shall not seek
reimbursement from the employee for any benefits initiated by the employer
which are not reimbursed under subsection (c) of this section.
(c) Reporting and Reimbursement Process
(1) An employer who initiates payment of benefits as provided
in subsection (a) of this section shall report the initiation of benefits
to the carrier within seven days of this initiation.
(2) A carrier who is notified by an employer that the
employer has initiated benefits as provided in subsection (c)(1) of this section
shall notify the employer in writing within seven days of the carrier either
accepting or being found to be liable for a claim.
(3) Within seven days of being notified by the carrier
that the carrier has accepted or been found liable for a claim, the employer
shall report to the carrier in the form and manner prescribed by the Commission
the amount of any benefits provided to the employee.
(4) A carrier who receives a report of benefits initiated
by the employer as described in this section shall, not later than the seventh
day after the carrier receives the report, reimburse the employer the compensation
that the carrier would have otherwise paid.
(5) The carrier shall pay the employer a reimbursement
out of IIBs as provided in subsection (b)(3) of this section in lump sum and
shall apportion this amount equally across the employee's remaining weekly
IIBs payments. The carrier shall pay this reimbursement in a lump sum not
later than the seventh day after the later of:
(A) the date the carrier receives a certification of MMI with
an impairment rating of greater than 0%; or
(B) the date an impairment rating dispute is resolved by a
designated doctor's opinion, agreement, or final adjudication.
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