Resources needed for filing annual claims for reimbursement
1. Date of injury
2. Date of birth
3. Average annual wage (AWW)
4. Last claim submitted, including any adjustment letter: permanent total disability (PTD) rate, Social Security weekly offset amount and dates claimed
Information, resources
From DLI
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Minnesota Statutes § 176.645 adjustment charts that provide percentage increases
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How to calculate benefits, proper form completion and general workers' compensation benefits are available in the Basic adjuster's training guide (see bottom of page)
From other sources
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Social Security cost-of-living adjustment rates effective Dec. 1 each year
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Social Security statement of benefits (or yearly benefit statement)
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Use gross benefit amount; the monthly rate multiplied by 12 and divided by 52 equals the weekly rate
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Workers' Compensation Reinsurance Association's (WCRA's) CompCalc calculator
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Calculates benefits with dates of injury Oct. 1, 1979 and later
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Calculates the proper number of weeks for each time period claimed
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Second-injury fund claims only
1. Indemnity claimed – If the second-injury claim is not accompanied by a supplementary benefit claim, a completed Interim Status Report form is needed, showing from and through dates, rates, Social Security offset amounts and any other type of government benefit received by the employee.
2. Medical claimed – A payment ledger is needed listing each amount claimed and including the date of service, name of payee and amount paid.
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For office visits, a medical report is needed and an explanation of benefit (EOB) form is helpful.
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For prescription drugs, the drug name is needed, as well as the dosage, amount dispensed and amount paid.