The Missouri Division of Workers' Compensation administers the programs providing services to all stake holders including workers who have been injured on the job or been exposed to occupational disease arising out of and in the course of employment. The Division makes sure that an injured worker receives benefits that he/she is entitled to under the Missouri Workers' Compensation Law. The Division's Administrative Law Judges have the authority to approve settlements or issue awards after a hearing related to an injured workers entitlement to permanent benefits allowed by Missouri law.
Docketing & Adjudication Unit
The primary responsibility of the local adjudication offices of the Division of Workers' Compensation is to achieve resolution of cases involving work-related injuries due to accidents or occupational diseases. An important component of this responsibility is to provide impartial administrative adjudication services in a timely and cost-effective manner.
Fraud & Noncompliance
The unit is responsible for investigating alleged fraud and noncompliance by employees, employers, lawyers, insurers, or physicians. Noncompliance is the failure by employers to carry workers’ compensation insurance (when they are required by law to do so) or to post notice of workers’ compensation at the workplace. Appropriate cases of fraud and noncompliance are referred to the Missouri Attorney General’s Office for prosecution.
Related: Report Fraud
C.A.R.E. (Case Administration Review and Evaluation) Unit
The C.A.R.E. Unit plays a pivotal role in the Division as it is the recipient of all filings made by the parties with the Division. Examples of documents or reports received by the Division that comprise the workers’ compensation official records in a particular case are Claim for Compensation, Answer to Claim for Compensation, First Reports of Injury, medical records, etc. This unit’s functions include processing of claims and answers, lost time reports, medical reports and other filings made to the Division for collecting medical and return-to-work information from the insurance carriers or third-party administrators, as the case may be. The unit also images records and assists the employers/third-party administrators with the EDI (electronic data interchange) filing of First Reports of Injury.
As an alternative to purchasing an insurance policy, employers and groups of employers may apply to the Division of Workers’ Compensation to self insure their workers’ compensation obligations. Application is made through the Division’s Insurance Unit. The Insurance Unit functions as the chief underwriter, regulator, and auditor for the self-insurance program. The Insurance Unit is responsible for granting self-insurance authority to qualified applicants, monitoring their financial condition and compliance with statutes and regulations. Also, if necessary, the Unit may terminate, suspend or revoke an employer’s or group’s self-insurance authority.
Related: Workers' Compensation Insurance
The Chief Counsel responds to legal questions, provides guidance to all the units within the Division and responds to tasks assigned by the Department Director, Division Director, and Division’s Chief of Operations. The unit also acts as a liaison with the Labor & Industrial Relations Commission. The gamut of services provided by the unit includes responding to calls received by the Customer Service Representatives through the toll free line and verification of proof of workers’ compensation insurance coverage. The importance of providing a centralized point to respond to questions presented by injured workers and other stakeholders, led to the creation of a Customer Service Unit. The oversight of various programs such as medical fee dispute, religious exception, early intervention or mediation services, records release and mailing of awards to the parties to the case that are issued by the Division’s Administrative Law Judges, are fulfilled by the Legal Unit.
The legal unit comprises of the following sections or programs that offer assistance to various stakeholders:
Dispute Management Unit
This unit is responsible for providing information and attempting to resolve disputes between the injured worker and the employer/insurer (parties to the case) prior to a case proceeding to formal litigation. The Dispute Management Program is an alternative dispute resolution process to mediate disputes that arise soon after a workplace injury occurs. The division has one mediator who assists parties in resolving medical treatment and lost wage disputes. This is a voluntary process and both parties must agree to mediate. When one of the parties does not agree to mediate, the party originally requesting mediation services is advised that he or she may take further steps if the problem persists, including requesting a docket setting with an Administrative Law Judge. The unit does not provide voluntary mediation services if a formal Claim for Compensation has been filed with the Division as the filing of a Claim initiates a contested case proceeding where an Administrative Law Judge has the authority to determine the issues in dispute.
The unit reviews the requests for administrative ruling filed with the Division in Medical Fee Dispute - reasonableness cases where the total amount of reimbursement sought is one thousand dollars and less. At the conclusion of an informal summary review, the dispute management unit makes a recommendation to the Division Director who then issues the administrative ruling either awarding the additional reimbursement to a health care provider or denying the additional reimbursement in full. A party aggrieved by the administrative ruling may file a request for an evidentiary hearing before an Administrative Law Judge.
Related: Dispute Management
Customer Service Unit
The Division is required to maintain a public information program that provides assistance to all parties governed by the Missouri Workers’ Compensation Law. The Division recently created the customer service unit to enhance the delivery of services to injured workers, employers, lawyers and all persons interested in contacting the Division with questions related to either a specific case or general questions on the workers’ compensation law and various programs administered by the Division. The unit encompasses the proof of workers’ compensation insurance coverage to ensure that a centralized point of service is established to provide comprehensive service to all stakeholders. Information explaining the requirements of the workers’ compensation law governing proof of insurance coverage issues is indicated below. The Division believes that this unit will fulfill the goal of ensuring that all stakeholders have their issues addressed or transferred to the appropriate person or agency that can offer the required assistance.
The Division maintains a toll free number 800-775-2667 for injured workers, employers, insurers, lawyers, and any person to call in with questions relating to the Workers' Compensation Law. The Division has three Customer Service Representatives that respond to calls received on the toll free numbers. If the Customer Service Representatives need assistance to respond to the calls, either the mediator or the legal staff provides the necessary assistance.
According to Missouri Law, workers’ compensation coverage is compulsory for all employers that have five or more employees. Partners and sole proprietors may elect to obtain workers’ compensation coverage on themselves. Construction industry employers who erect, demolish, alter or repair improvements must carry workers’ compensation insurance if they have one or more employees. Any employer who is exempt from carrying workers’ compensation coverage may elect coverage by purchasing and accepting a valid workers’ compensation insurance policy or endorsement.
Section 287.090.1(5) RSMo permits a corporation that has no more than two owners of the corporation who are the only employees of the corporation to withdraw from carrying workers’ compensation insurance liability by filing a notice of election to be withdrawn with the Division. All requests relating to this exemption must be submitted to the Division at P.O. Box 58, Jefferson City, MO 65102, ATTN: Legal Unit.
The unit also conducts a search for prior workers’ compensation records after an employer submits an Authorization to Release Information and Instructions, that has been completed by the employer and employee. The information requested from the Division is on applicants where a conditional job offer has been made and the information is not used to discriminate in any manner against the individual who is the subject of the request on the basis of disability, in violation of the American With Disabilities Act, 42 U.S.C. Section 12101 et seq.
Religious Exception Program
The Religious Exception Program receives, reviews and responds to all questions related to granting a waiver or exception to an employer and employees of an employer who are members of a recognized religious sect or division, defined in 26 U.S.C. 1402(g) by reason of which they are conscientiously opposed to acceptance of benefits of any public or private insurance which makes payments in the event of death, disability, old age, or retirement or makes payments toward the cost of, or provides services for, medical bills, including the benefits of any insurance system established under the Federal Social Security Act, 42 U.S.C. 301 to 42 U.S.C. 1397jj. The Division has developed forms to be used by an applicant applying for the religious exception. An exception granted to an employee shall continue to be valid until such employee rescinds the prior rejection of coverage or the employee or sect ceases to meet the requirements of Section 287.804.1 RSMo.
Related: Religious Exception Information
Medical Fee Dispute Program
There are two types of medical fee disputes, direct pay and additional reimbursement for payment or reasonableness disputes. The functions undertaken by the Medical Fee Dispute Program include processing the applications for direct payment and applications for payment of additional reimbursement of medical fees filed by a health care provider; processing answers filed by the employer or insurer; setting the reasonableness disputes for an evidentiary hearing; and responding to all queries and telephone calls for assistance. If the total amount of reimbursement sought is less than one thousand dollars and a request for administrative ruling is filed by a party, the matter is referred to the dispute management unit. If the total amount of reimbursement sought is more than one thousand dollars a health care provider may file an application for evidentiary hearing with the Division and the case will be heard by an Administrative Law Judge. All requests for awards on undisputed facts in direct pay cases are reviewed and decided by an administrative law judge.
Related: Medical Fee Disputes
Request for Records
The procedure governing requests for records from the Division is contained in the code of state regulations at 8 CSR 50-2.020(4).
Please submit all requests for records in writing to the Division atDivision of Workers' Compensation
P.O. Box 58
Jefferson City, MO 65102
The Legal Unit responds to constituent inquiries that are received either directly by the Division or transferred by the Department.
Please note that the Division’s staff is unable to offer any legal advice to any caller or to the parties regarding the workers’ compensation proceeding or medical fee dispute proceeding. Division staff will make every effort to respond to the call received or refer the caller to the appropriate agency or person who can assist them.
The Enterprise Functions Unit supports functions Division wide by providing data analytics, statistical reporting, training and reviewing processes for improvement and standardization. As the Division moves forward with modernizing, the unit will also provide technical assistance and communications for both internal and external stakeholders.
Second Injury Fund Unit
The Second Injury Fund Unit is responsible for the billing and collection of the Second Injury Fund Surcharge from insurance carriers writing workers’ compensation premiums in Missouri and from self-insurers or group trusts authorized to self insure in Missouri.
In addition to billing and collecting, upon the requisition of the Division warrants on the state treasurer for the payment of compensation benefits from the Second Injury Fund are issued to the claimants. These payments are consistent with the awards or settlements approved by administrative law judges.
The Second Injury Fund Unit also is responsible for certifying physical rehabilitation facilities that are interested in rehabilitating injured workers. A seriously injured worker may be eligible for this benefit if attending a facility that has been certified by the Division of Workers’ Compensation prior to the physical rehabilitation treatment dates.
Related: Second Injury Fund