FMLA
The four eligibility rules checked when evaluating a claimant for FMLA
1. Does the Employee have FMLA time remaining
2. Does the Employee work at an eligible job site
3. Has the employee worked for the employer for greater than 12 months.
4. Has the employee worked more than 1250 hours in the 12 months prior to the absence date
The only section of the 'Person Details' screen that may be updated by a claim manager
What is the contact details section of the person details screen?
The task that 'pulls' the claim manager back to the claim to make a decision if no documentation has been received.
What is the claim determination?
The timeframe in which an initial call MUST be completed
What is two business days?
The standard eligibility waiting period for (almost) all TMO benefits
180 days
The number of hours alotted for an employee that works 40 hours per week (on average)
What is 480 hours?
The section of the AC claim that may contain information obtained at the time of claim creation
What is Claim Intake notes?
Tasks like 'Run Eligibility Rules' and 'Send Employer Notification Email' are reminding you to do this.
Confirm the system has performed the appropriate new claim processes and correct where needed.
The first step in almost every process when a claimant has a request.
Call the employee and confirmt the details of the request
The TMO New Claim task in a C-claim is directing you to do this.
The relationships covered by Care of a Family Member under FMLA
Parents, children, spouses, and 'in loco parentis'
The method by which a claim manager may approve, deny or even add pending time to a claim.
What is the physician statement button?
The two tasks that indicate the end of a certified claim, typically created upon claim approval.
What are 'Confirm RTW' or 'Claim Closure Review'?
A claimant may be given this long when submitting incomplete documentation
The percentage at which COFM and STD benefits are paid.
What is 85%?
This is the way that an employer MAY calculate the '12 month' period (and the way TMO currently uses)
What is a fixed year calculation?
The location of a claimant's previous claims for review
The absence claims section of the person details screeen
The task by which a claim manager is expected to obtain a 'manager sign-off' prior to a denial
What is a denial review?
When a claimant has failed to turn in paperwork by the original due date and is denied on an continuous claim they are expected to do this.
Return to work immediately.
The field to be updated to indicate the approved through date for the benefit in the C-claim
What is the Adjusted Benefit Through Date?
The number of days in which an employer must provide an eligibility notice to an employee
What is 5 business days?
The defining difference that sets the "Leave Letters for Managers" button apart from it's companion; "Leave letters for Employees"
The return address on the letter sent will allow a response to the associated liaison inbox
A task that indicates immediate intervention is required and should be treated as a same-day PG.
What is 'Claim Note - Action Required?'
The due date for documentation when a claimant is recertifying a claim
The next step when a provider recommends a leave greater than ODG Max+30 in a non-behavioral health claim.
Approve through ODG Max+30, Request additional supporting medical, CA Review
The process by which an employee may become eligible for FMLA despite failing to meet the hours worked
What is the inherited FMLA eligibility policy?
The System will not allow an AC claim to be closed due to the presence of...
A pending absence
The task indicating a voicemail has been received, to be left open until the callback is completed.
What is 'Voice Message Received'?
When recertifying an approved leave the claimant's new date falls on this date.
The fifteenth day following the first absence date of the new time period
The primary reason the employee receives an amount less than what is communicated to them at the time of approval
Taxes/Deductions applied via client payroll
What is 7 years?
The method by which automated return to work communications may be stalled to prevent confusion
The tasks to be opened indicating a new due date after either a paperwork extension has been provided or paperwork has been deemed incomplete.
The process by which we verify a document was either completed by or certified the provider
What is the authentication process?
TMO STD Denial - Meds Do Not Support
The three primary questions to ask yourself when evaluating previous claims for FMLA inherited eligibility
1. Is the previous claim in the same 12-month period (calendar year for TMO?)
2. Does the previous claim share the same or similar diagnosis as the new claim?
3. Does the previous claim contain approved FMLA absence time in the same 12-month period
The method by which the 'Last Day Worked' field may be updated.
Hover over the claim intake link and click the edit button to access the LDW field for update.
The task to be assigned to the claim manager of an existing intermittent claim to indicate that the claimant is now on an ongoing continuous claim.
What is 'Transition to Continuous'?
If a claimant seeks a COFM leave and is not eligible for FMLA they may only take the leave if....
They are eligible for a company leave/benefit or a state benefit in lieu of FMLA
The next step when the Date of Disability is updated in the BC
Calculate the BC and payment specification