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1999-2000
CITY OF AUBURN L. E. O. F. F. BOARD POLICY AND PROCEDURE MANUAL JIM KELLY, POLICE REPRESENTATIVE AND CHAIRPERSON BUD LARSON, MEMBER-AT-LARGE AND CHAIRPERSON PRO TEMPORE RUSS VANDVER, FIRE REPRESENTATIVE JEANNE BARBER, COUNCILMEMBER PETE LEWIS, COUNCILMEMBER 1999- 2000 PREAMBLE The purpose of these policies and procedures is to establish the general operating procedures and to reduce to writing the administrative policies of the Disability Board. The Board recognizes that conditions may exist or come into existence which are not properly encompassed by these policies and procedures. In such cases, the Board reserves the right to take whatever action is necessary to properly deal with the situation, such actions to be consistent with applicable statutes, insofar as found by the Board to be applicable. (See appendix for related State Code). PURPOSE These policies and procedures are adopted pursuant to Section 1, Chapter 294, Laws of 1981 to implement Chapter 41.26 RCW and to provide a basis for uniform administration of disability retirement matters. They shall be followed by each disability board member. (As provided in WAC 415-105-020). EFFECT OF POLICIES AND PROCEDURES All uniformed personnel and retired members covered by the aforementioned chapters shall be subject to the policies and procedures contained herein, to the extent consistent with applicable state statutory provisions, and shall at all times follow the procedures contained herein. In the event any policy or procedure as prescribed to a particular member, shall be held to be contrary to state law, such member shall not be relieved of any other requirement contained herein, and any such findings, shall not relieve the member from the responsibility to comply with all other policies and procedures contained herein. A member's failure to follow these procedures may subject such member to the loss of benefits otherwise due under the acts. LEOFF Board Policies and Procedures SECTION I - THE BOARD ........................................................................................................................................1 1.01 MEMBERSHIP ...............................................................................................................................................1 1.02 TERMS .........................................................................................................................................................1 1.03 VACANCY ....................................................................................................................................................1 1.04 MEETING .....................................................................................................................................................1 1.05 ELECTIONS ...............................................................................................................' ...................................2 1.06 ABSENCE OF MEMBERS ...............................................................................................................................3 1.07 VOTING .......................................................................................................................................................4 1.08 BOARD POWERS ..........................................................................................................................................4 1.09 JURISDICTION OF MEMBERS ........................................................................................................................4 1.10 QUORUM .....................................................................................................................................................4 1.11 DISABILITY BOARD OFFICERS .....................................................................................................................5 1.12 AGENDA AND ORDER OF BUSINESS .............................................................................................................6 1.13 MINUTES .....................................................................................................................................................6 1.14 DELEGATION OF AUTHORITY TO SECRETARY ..............................................................................................7 SECTION II DEFINITIONS .....................................................................................................................................8 2.01 IN LINE OF DUTY .........................................................................................................................................8 2.02 DISABLED OR DISABILITY ...........................................................................................................................8 2.03 DISABILITY LEAVE PERIOD .........................................................................................................................8 2.04 BOARD DOCTOR ..........................................................................................................................................8 2.05 LEGAL COUNSEL .........................................................................................................................................9 2.06 MINIMUM MEDICAL AND HEALTH STANDARDS ..........................................................................................9 2.07 CONDITIONAL RETURN ................................................................................................................................9 SECTION III- DISABILITY LEAVE ....................................................................................................................10 3.01 APPLICATION .............................................................................................................................................10 3.02 BURDEN OF PROOF ....................................................................................................................................10 3.03 DUTY RELATED LEAVE .............................................................................................................................10 3.04 DISABILITY LEAVE ALLOWANCE ..............................................................................................................11 3.05 PLACEMENT ON DISABILITY LEAVE ..........................................................................................................11 3.06 RECUPERATION AND PLACE OF RECUPERATION ........................................................................................| | 3.07 TREATMENTS ............................................................................................................................................11 3.08 MEMBER TO SEEK AUTHORIZATION TO RETURN TO DUTY .......................................................................12 3.09 PHYSICIAN' S REPORT ................................................................................................................................12 3.10 PHYSlCIAN'S LIST ......................................................................................................................................12 3.11 APPEARANCE OF MEMBER ........................................................................................................................12 3.12 MEDICAL REPORTS ....................................................................................................................................12 3.13 EXAMINATION BY THE BOARD PHYSICIAN ................................................................................................13 3.14 RETURN TO DUTY ......................................................................................................................................13 3.15 CONDITIONAL RETURN TO DUTY ..............................................................................................................13 SECTION IV DISABILITY RETIREMENT ..........................................................................................................14 4.01 EXAMINATION FOR DISABILITY RETIREMENT ...........................................................................................14 4.02 GRANTING DISABILITY RETIREMENT ........................................................................................................14 4.03 EXECUTION ...............................................................................................................................................15 4.04 RE-EXAMINATION AND RETURN TO DUTY .................................................................................................15 4.05 DISCONTINUATION OF A RETIREMENT ALLOWANCE, NOTICE OF .............................................................. 16 SECTION V HEARING PROCEDURES ..............................................................................................................18 LEOFF Board POlicies and Procedures 5.0 1 PROCEDURES .............................................................................................................................................18 5.02 SUBPOENAS ...............................................................................................................................................18 5.03 GENERAL PROCEDURE FOR CONDUCT OF HEARINGS .: .............................................................................. 19 SECTION VI APPEAL ............................................................................................................................................22 6.01 DENIAL OR CANCELLATION .......................................................................................................................22 6.02 PROCEDURE FOR RECONSIDERATION OF BOARD DECISION ....................................................................... 22 SECTION VII FALSIFICATION ...........................................................................................................................23 7.01 RECORD OR STATEMENT FALSIFICATION .................................................................................................. 23 SECTION VIII MEDICAL SERVICES ................................................................................................................. 24 8.01 MEDICAL SERVICES PROVIDED .................................................................................................................24 8.02 MEDICAL SERVICES - GENERAL GUIDELINES ............................................................................................ 24 8.03 MEDICAL SERVICES - DEFINED .................................................................................................................26 SECTION IX LEOFF BOARD CLAIM PROCEDURE ....................................................................................... 28 9.01 MEDICAL CLAIM PROCEDURE ...................................................................................................................28 9.02 MEDICAL CLAIMS FOR CORRECTIVE LENSES ............................................................................................ 30 9.03 MEDICAL CLAIMS FOR HEARING AIDS ......................................................................................................30 9.04 SKILLED NURSING FACILITY CARE REIMBURSEMENT ............................................................................... 31 9.05 HOME HEALTH CARE REIMBURSEMENT .................................................................................................... 32 9.06 REJECTED CLAIMS .....................................................................................................................................33 9.07 FILING APPEAL IN CASES INVOLVING CLAIMS FOR MEDICAL SERVICES ................................................... 33 9.08 MEDICAL CLAIMS FOR SERVICES WHERE INSURANCE BENEFITS HAVE BEEN EXPENDED ........................ 34 9.09 MEDICAL CLAIMS FOR SERVICES WHERE TREATMENT IS NOT COVERED BY INSURANCE ........................ 34 9.10 MEDICAL CLAIMS FOR BOARD REQUIRED RE-EXAMINATIONS (WAC 415-105-0901) ............................. 34 SECTION X ADOPTION AND REVIEW ............................................................................................................. 35 10.01 BIENNIAL REVIEW .....................................................................................................................................35 10.02 FORMAL A DOFFION ...................................................................................................................................35 10.03 SEVERABILITY CLAUSE .........................................................................~ ...................................................35 SECTION XI ADDENDUM ....................................................................................................................................36 REVISED 6-10-83 ..........................................................................................................................................................36 REVISED 6-28-84 ..........................................................................................................................................................36 REVISED 1-7-85 ............................................................................................................................................................37 REVISED 1-7-86 ............................................................................................................................................................37 REVISED 11-15-88 ........................................................................................................................................................37 REVISED 5 - 1-90 ............................................................................................................................................................38 REVISED 9/3/91 ............................................................................................................................................................38 REVISED 1 - 1-92 ............................................................................................................................................................38 REVISED 12/7/92: .........................................................................................................................................................39 REVISED 10/4/93 .~ ........................................................................................................................................................39 REVISED JULY 1995: ....................................................................................................................................................39 REVISED 2/5/96 - EFFECTIVE IN 30-DAYS ..................................................................................................................43 9.02 MEDICAL CLAIMS FOR CORRECTIVE LENSES ............................................................................................ 43 REVISED JULY 22, 1996 .............................................................................................................................................43 REVISED AT THE SEPTEMBER 3, 1996 & DESIGNATED PRICE/COSTCO AS HEARING AID PROVIDER ........................... 44 REVISED AT THE DECEMBER 2, 1996 LEOFF BOARD MEETING ............................................................................... 44 9.01(A)(1) ....................................................................................................................................................................44 9.03 MEDICAL CLAIMS FOR HEARING AIDS ......................................................................................................44 LEOFF Board Policies and Procedures 9.04 REJECTED CLAIMS (RE'NUMBERED) ...........................................................................................................44 9.05 FILING APPEAL IN CASES INVOLVING CLAIMS FOR MEDICAL SERVICES (RENUMBERED) .......................... 44 9.06 MEDICAL CLAIMS FOR SERVICES WHERE INSURANCE BENEFITS HAVE BEEN EXPENDED ........................ 44 9.07 MEDICAL CLAIMS FOR SERVICES WHERE TREATMENT IS NOT COVERED BY INSURANCE (RENUMBERED)44 9.08 MEDICAL CLAIMS FOR BOARD REQUIRED RE-EXAMINATIONS (WAC 415-105-0901) (RENUMBERED)....44 REVISED JANUARY 3, 2000 ..........................................................................................................................................44 9.04 SKILLED NURSING FACILITY CARE REIMBURSEMENT ...............................................................................44 9.05 HOME HEALTH CARE REIMBURSEMENT ....................................................................................................45 9.06 REJECTED CLAIMS (RENUMBERED) ...........................................................................................................46 9.07 FILING APPEAL IN CASES INVOLVING CLAIMS FOR MEDICAL SERVICES (RENUMBERED) .......................... 46 9.08 MEDICAL CLAIMS FOR SERVICES WHERE INSURANCE BENEHTS HAVE BEEN EXPENDED (RENUMBERED)46 9.09 MEDICAL CLAIMS FOR SERVICES WHERE TREATMENT IS NOT COVERED BY INSURANCE (RENUMBERED)46 9.10 MEDICAL CLAIMS FOR BOARD REQUIRED RE-EXAMINATIONS (WAC 415-105-0901) (RENUMBERED)....46 SECTION XII APPENDICES INDEX ................................................................................................................... 47 APPENDIX "A" BOARD MEMBERSHIP ..........................................................................................................................48 APPENDIX "B" FORMS SAMPLES ........................................................................................................................49 City of Auburn LEOFF Board Policies and Procedures SECTION I - THE BOARD 1.01 Membership The Board shall consist of five (5) members, as follows: A. Two (2) members of the City legislative body to be appointed by the Mayor. B. One (1) firefighter to be elected by the active and retired firefighters employed or previously employed by the City. Elections for firefighter representative will be in even numbered years. C. One (1) police officer to be elected by the active and retired police officers employed or previously employed by the City. Elections for police officer representative will be in odd numbered years. D. One (1) member from the public at large who resides within the City to be appointed by the other four (4) appointed members. 1.02 Terms Each member shall serve a two (2) year term. The City legislative members shall serve alternating terms as well as the police and fire representatives. (See Appendix "A" for current terms). 1.03 Vacancy In the event a vacancy occurs in the membership, a successor will be elected or appointed in the same manner as the original election or appointment and shall serve the remaining unexpired term. 1.04 Meeting The Board shall meet regularly on the first (1st) Monday of each month at 10:00 a.m.; provided that when the first (1st) Monday falls on a municipal holiday, the Board shall hold its meeting on the next working day at the regular time. If necessary, special meetings may be called by the Chairperson or a majority vote of the Board. Copies of material relevant to the agenda items shall be prepared and distributed prior to each meeting. Notice of meetings shall be given to the press pursuant to RCW 42.30.060; provided, hearings and decisions on quasi-judicial matter, including consideration of applications for disability retirements, shall be at closed meetings unless the applicant requests an open hearing in writing. City of Auburn LEOFF Board Policies and Procedures 1.05 Elections At the first (1't) meeting of each year, the members shall elect from among the members, a member to serve as Chairperson and a member to serve as Chairperson pro tempore. A. The election of a LEOFF firefighter representative shall be by secret ballot of all active and retired LEOFF firefighter personnel and shall be held during the month of December of every even numbered year. The election of the LEOFF law enforcement officer representative shall be by secret ballot of all active and retired LEOFF law enforcement personnel and shall be held in December of every odd 'numbered year. The name of the elected LEOFF law enforcement officer and firefighter member shall be noted in the minutes of the next regular meeting of the Board subsequent to the election, along with the term for which elected. Each member will hold office for a period of two (2) years, or as soon thereafter as the successor is elected. B. Election procedure for election by secret ballot shall be as follows: 1. In October of each year, the Secretary to the LEOFF Board shall prepare and mail forms for nomination of law enforcement or firefighter representative to each active and retired law enforcement or firefighter personnel at their last address of record. Any active or retired member, either LEOFF I or LEOFF II, wishing to run for representative must nominate themselves on the form provided by the Secretary. Only those nominating themselves will be placed on the election ballot. 2. After the November meeting and upon receipt of nominations, the Secretary shall prepare ballot packages which shall contain: a) ballot, b) self-addressed pre-stamped envelope for returning the ballot, c) a letter sized envelope with no markings on it in which the marked ballot is to be enclosed, and d) an information sheet explaining who is running for the position and the deadline date by which the Secretary shall have to receive all ballots. 3. The time between the mailing out of the ballot packets until the deadline for receipt by the Secretary will in no case be less than seven (7) but no more than ten (10) business days as determined by the Chairperson. Page 2 City of Auburn LEOFF Board Policies and Procedures 4. All returned ballots must be received by the Secretary through the U.S. mail and must be postmarked by midnight of the deadline date and mailed to the Secretary. 5. The Secretary shall be custodian of all returned ballots and shall keep them in a safe place and assure that they remain unopened until authorized, in a locked box. 6. The ballots shall be opened by the Secretary and assistant Secretary and the results will then be announced after the 3-day protest period by the Chairperson and a certification of election results will be sent to the respective department for posting. (Rev 5/94) 7. In the event that there are three (3) or more individuals running for representative and one of the individuals does not receive a simple majority of those voting, a run-off election shall be scheduled between the two individuals receiving the highest vote totals utilizing the same process per this section. 8. All ballots shall be retained by the Secretary for one (1) year. After the one-year period, the Secretary shall prepare the ballots for destruction as authorized by the State of Washington General Records Retention Schedule & Destruction AuthOrization. (Rev 5/94) 9. Any discrepancies regarding the election process shall be submitted in writing to the Secretary of the LEOFF Board within three (3) calendar days following the deadline date. 10. Candidates-elect shall take office at the regularly scheduled meeting in January. 11. In the event that there is only one person nominated for police or fire representative, balloting will not be required and the individual will be considered be elected. (Rev 12/7/92) 1.06 Absence of Members In the case of absence or inability of the Chairperson to act, the Chairperson Pro Tempore shall perform the duties and exercise the powers of the Chairperson. Each Board member is expected to notify the Chairperson or the Secretary prior to a scheduled meeting if that member Page 3 City of Auburn LEOFF Board Policies and Procedures will not be able to attend that meeting. Such notice will serve to establish such absence as excused. All attendance at meetings shall be recorded in the minutes of the meeting. An excused absence shall be construed as either illness, work or vacation. Three (3) unexcused absences in a period of one (1) year shall be cause for review and possible removal from the Board by a majority vote of the Board. 1.07 Voting Each member shall have one (1) vote which must be cast by that member in person. If any person(s) on the Board concludes that he/she has a conflict of interest or an appearance of fairness problem with respect to a matter pending before the Board so that he/she cannot discharge his/her duties, he/she shall disqualify themselves from participating in the deliberations and the decision-making process with respect to the matter. 1.08 Board Powers The Board shall have the powers granted by the state legislature or necessarily implied from such grant of powers in Chapters 41.16, 41.18, 41.20, and 41.26, Revised Code of Washington, as those chapters now exist or may hereafter be amended and per Washington Administrative Code 415-105. 1.09 Jurisdiction of Members Any member who is on disability leave is under the jurisdiction of the Disability Board for all matters pertaining to his/her disability and shall not engage in any activity which is contrary to the directives for the member's or the Disability Board's physician or which might be detrimental to his/her return to active service. The Board has the authority (and it may be at any time in any case) cause an investigation to be made of the activities of any active member or any member retired for disability to determine whether his/her disability continues to exist, and may request the Auburn Police Department or any other agency to make such investigation, subject to any special instructions or conditions related to the member and his/her condition and/or activities. 1.10 Quorum A quorum is a simple majority and shall have the authority to conduct all business of the Board. Page 4 City of Auburn LEOFF Board Policies and Procedures 1.11 Disability Board Officers A. The elective officers of the board shall consist of a Chairperson, and a Chairperson Pro Tempore. The City Clerk shall act as the Secretary to the Board. An Assistant Secretary may be selected by the Secretary with the approval of the Board. B. Nomination and election of officers shall be made at the regular meeting in January of each year. C. The elective officers shall take office at the regular meeting in January and shall serve for a term of one (1) year. D. Boardmembers shall serve a two-year term. In the event of a vacancy, a successor shall be appointed or elected in the same manner as with an original appointment or election to serve the remainder of_the unexpired term or to begin a new term. (Rev 5/94) E. Duties of Officers: 1. Chairperson - The Chairperson shall preside at all meetings and public and/or disability hearings of the Disability Board and call special meetings. The Chairperson shall have the privilege of discussing all matters before the Board except where to do so would constitute a conflict of interest. He/she shall have all the duties normally conferred by parliamentary procedures on such officers and shall perform such other duties as may be requested by the Disability Board During the period of time between regular Board meetings, he/she shall also have the authority to tentatively approve applications for disability leave; provided, that all the required paperwork is in order, such approval being subject to ratification by a majority of the Board members at the next regular Board meeting. 2. Chairperson Pro Tempore - The Chairperson Pro Tempore shall assume the duties and powers of the Chairperson in his/her absence. If the Chairperson and the Chairperson Pro Tempore are both absent, the Disability Board members may elect a temporary Chairperson by a majority vote of those present at a regular, adjourned or special meeting, who shall assume the duties and powers of the Chairperson and Chairperson Pro Tempore during their absence. Page 5 City of Auburn LEOFF Board Policies and Procedures 3. Secretary - The Secretary shall keep the minutes of all regular, adjourned and special meetings of the Disability Board; such minutes shall be approved by the Board and copies shall be distributed to all members of the Board, Police and Fire Chiefs and the Board physician. The Secretary shall give notice of all regular and special meetings to the board members and post all notices of adjournment or continuance of meetings and public and/or disability hearings; shall prepare the agenda of regular and special meetings; shall serve proper and legal notice of all public and/or disability hearings; and shall draft and sign routine correspondence of the Board, and prepare the LEOFF Board approved claims for payment according to the policies and procedures established by the City of Auburn's Finance Department. The Secretary shall maintain a file of all rules, findings, orders, recommendations and all other official records of the Disability Board. (Rev 5/94) 4. Assistant Secretary - The duties of the Assistant Secretary shall be as outlined in the duties of the Secretary to be performed in the absence of the Secretary. 1.12 Agenda and Order of Business An agenda shall be prepared by the Secretary and distributed to the members prior to each regular monthly meeting. "Robert's Rules of Order" shall guide the Board where the proceedings are not otherwise governed by these policies or State law. The Board may, in its discretion, allow the public to attend all regular Board meetings. However, the Board, under RCW 42.30.140(2) may close those portions of meetings relating to consideration of specific applications or claims where consideration of the application or claim may include discussion of sensitive personal information relating to the member. 1.13 Minutes The Secretary shall take and prepare the official minutes of the City of Auburn Disability Board containing the actions of the Board and a summary account of the proceedings. A record of the Board members present and absent shall be entered, and recording of action authorized by the Board. The minutes shall be signed by the Secretary and the Chairperson and placed on record after approval by the Board. Copies Pa~e 6 City of Auburn LEOFF Board Policies and Procedures shall be distributed to all members of the Board and the City of Auburn Executive Office, Police Chief, Fire Chief, Finance Director, and those persons of record who have requested such copies to the Secretary. 1.14 Delegation of Authority to Secretary The City of Auburn Disability Board delegates to the Secretary of the Board the authority to instigate investigative activities, including gathering, collating and presenting facts regarding matters within the scope of the Board's authority. These matters include, but are not limited to, areas of disability leave, pensions, medical expenses and activities collateral to them. Page 7 City of Auburn LEOFF Board Policies and Procedures SECTION II DEFINITIONS 2.01 In Line of Duty "In line of duty" means injury, sickness or illness in consequence or as a result of the performance of the applicant's duties. 2.02 Disabled or Disability "Disabled" or "disability" means the existence of a physical or psychological condition which renders the member unable to discharge with average efficiency the duty of the grade or rank to which the member belongs, or the position in which the member is sewing. Provided, that no member shall be entitled to a disability retirement allowance if there is an available position to which one of such grade or rank is normally assigned and the duties of which the member can perform. 2.03 Disability Leave Period' Disability leave period is a period six months or any portion thereof during which a member is on leave. at an allowance equal to the members' full salary at the time he/she began his/her period of disability leave and prior to the commencement of any disability retirement (as provided in RCW 41.26.030{19} and AGO 1978-8). 2.04 Board Doctor · Unless otherwise directed by the Board in specific instances the LEOFF Board utilizes the services of Objective Medical Assessment Corporation to request the services of a duly licensed and practicing physician or physicians. No disability retirement shall be approved by the Board without prior examination of the claimant by the Board doctor or a separate specialist of his selection, on or near the expiration of the disability leave period. The Board doctor shall render such other medical service as may be requested by the Board. (As provided in WAC 415- 105-030 [1]). In order to carry out the duties of this position, each physician appointed or approved by the Board is required to be knowledgeable concerning the duties, functions and general demands required of the employee being examined. The Disability Board shall furnish to the examining physician the job and/or position description of the applicant (As provided in WAC 415-105-030 [2]). Page 8 City of Auburn LEOFF Board Policies and Procedures Re-examination of any member on disability retirement shall be conducted by a Board appointed or approved physician, (As provided in WAC 415- 105-030 [3]). 2.05 Legal Counsel The City Attorney is to be the legal counsel of the Board, provided, that, if otherwise authorized, the Board may, in lieu thereof, employ as legal counsel an attorney admitted to practice in this state. Each legal counsel shall provide written opinions, when required by the Board, touching the subject the Board may be required to act upon. The legal counsel, upon request of the Board, shall review all applications for disability retirement and prepare a summary and recommendation based upon all the evidence in the applicant's file and submit it to the Board for review prior to the Board entering its order granting or denying a disability retirement allowance. 2.06 Minimum Medical and Health Standards The minimum medical and health standards previously promulgated by the State Retirement Board for entry or re-entry into the LEOFF System membership were provided only to safeguard the fiscal integrity of the pension system and are not the applicable standards for any other purpose. (As provided in WAC 415-105-040 [3]). This includes eligibility for disability leave or retirement benefits. 2.07 Conditional Return "Conditional return" is a return to duty by a member for the purpose of determining whether the member's disability persists. Page 9 City of Auburn LEOFF Board Policies and Procedures SECTION III- DISABILITY LEAVE 3.01 Application No member shall receive disability leave benefits unless he/she has completed and signed an application for disability retirement and it has been filed with his/her representative. In order to be considered at the regular monthly Board meeting, applications must be received by the Disability Board's Secretary by the Wednesday prior to the regularly scheduled Board meeting. Also, applications must be accompanied by a report from two (2) physicians attesting to the existence of a disabling condition. 3.02 Burden of Proof The burden of proving the existence of a disabling condition, and whether or not the condition was incurred in the line of duty, shall be upon the applicant. (As provided in WAC 415-105-040 [2]). The degree of persuasion is by a preponderance of the evidence. To satisfy the preponderance of evidence standard, the Board must be persuaded that the propositions asserted by the applicant are more probably true than not true. 3.03 Duty Related Leave Any member who requests disability leave because of a duty-related disability shall submit an incident report showing the cause of disability. If there is no incident report, the member will be responsible for submitting evidence at the Disability Board meeting immediately following his/her disability request to show that the injury or illness was duty related. If the Board finds the evidence insufficient for making their decision, they may grant disability leave showing cause as "unspecified" and arrive at a decision on duty-relatedness at a later date. In the event the Board finds that insufficient information is available to make a idetermination, the matter may be continued to the next regular Board meeting or be set for consideration at a special meeting. The Board shall also advise the member of the additional information needed, and of the member's obligation to provide additional information and the deadline date by which such information must be provided. (As provided in WAC 415-105-040 [5]). Page 10 City of Auburn LEOFF Board Policies and Procedures 3.04 Disability Leave Allowance Disability leave allowance is not granted for any specific amount of time. Such leave may not encompass a period not to exceed six (6) months. During this time, the member is to receive an allowance equal to his/her full monthly salary commencing on the first day of such leave (per AGO No 78-8), or the applicable portion thereof, from his/her employer. 3.05 Placement on Disability Leave Following receipt of an application for disability benefits, the Board shall review all relevant information pertaining to the question of the applicant's fitness for duty, and if, in the opinion of the majority of the Board, the evidence supports the proposition that the member is unfit for duty. such member shall be granted disability leave, unless such leave is waived pursuant to RCW 41.21.120 (4). In considering such application, the Board shall consider the duties of the position, and any other evidence that is relevant. (As provided in WAC 415-105-040 [1]). All law enforcement officers and firefighters who qualify for disability leave are encouraged to use department sick leave, if available, until the City of Auburn LEOFF Board meets at its regularly scheduled meeting and has reviewed and approved the application for disability leave. 3.06 Recuperation and Place of Recuperation It is the intent of the Board to assure that a member, while on disability leave, shall do all in his/her power to recuperate from such disability and shall do nothing which reasonably appears would prolong the leave or inhibit recovery from such disability. In case the Disability Board should want to contact the member about matters concerning his/her disability leave, the member's place of recuperation will be assumed to be his/her home or a hospital where confined. The Board may, as a condition to authorizing a place of recuperation at a great distance from the City of Auburn, require that the member be responsible for any travel expenses necessary to comply with an order of the Board. 3.07 Treatments During the period of leave, the Board shall have the authority to inquire of any examining physician as to what physical, medical or therapeutic treatments might be employed to rehabilitate the applicant and, based upon such evaluation, to direct the applicant to participate in rehabilitation. If the applicant fails or refuses to submit to such treatments, the Board may terminate the applicant's disability benefits. Page 11 City of Auburn LEOFF Board Policies and Procedures 3.08 Member to Seek Authorization to Return to Duty It shall be the responsibility of each member granted disability leave pursuant to RCW 41.26, to seek authorization to return to service at the earliest possible time the applicant believes he/she is fit for duty (see Section III, 3.14, "Return to Duty"). The Chairperson is authorized to tentatively return an employee on disability leave to work upon receipt of clearances from the treating physicians; provided, that all required paperwork is in order. Should there be any discrepancies or concerns about the required paperwork, the Chairperson may call a special Board meeting to expedite the employee's return to work. In the event the Board finds that a member has not actively sought authorization to return to active service immediately upon cessation of disability, the Board shall have the authority to require the report of the Board-appointed physician to determine his/her ability to return to duty and thereafter to determine whether or not the member's disability leave allowance shall be continued. 3.09 Physician's Report Current medical reports are required each month from all treating and/or attending physicians. They must be received by the Wednesday prior to the next regular Board meeting. Failure to submit reports will be cause for the Board to recommend to the City withholding of payroll checks. (Rev 8/94) 3.10 Physician's List Each application shall be accompanied by a list identifying by name any physician who has been contacted within the last six (6) months for the illness or injury for which disability has been claimed. (As provided in WAC 415-105-040{4}). 3.11 Appearance of Member The Board shall be authorized to demand the appearance of the member and to request the appearance of such other persons as it deems appropriate. (As provided in WAC 415-105-040 {6}). 3.12 Medical Reports It shall be incumbent upon each member obtaining medical evaluations to be used in conjunction with such disability leave and subsequent evaluations, to advise each and every examining physician; that such evaluation is being conducted at the direction of the Board; that any Page 12 City of Auburn LEOFF Board Policies and Procedures reports relating thereto are for the benefit of the Board; that the doctor/patient privilege may not be invoked with respect thereto; and that the physician may be called upon by the Board to testify as to his findings. (As provided in WAC 415-105-040 {6} Part 2 of 2). Medical evaluation reports relating to specific members shall not be distributed to the public or media and in the event specific requests are made for such reports pursuant to Chapter 42.17 RCW (Public Disclosure Law) the designated official shall determine whether or not such document is exempt from disclosure and if not, whether a court injunction should be sought to enjoin such distribution pursuant to Chapter 42.17 RCW. 3.13 Examination by the Board Physician The Board may, in all cases, have the member examined at any time by the Board physician or his/her designate. Refusal to submit to such examination may mean forfeiture of rights to benefits. 3.14 Return to Duty When a member returns from a disability leave,. it shall be the member's responsibility to submit to the Disability Board Secretary a written request to return to work, together with appropriate documentation from the attending physicians treating the disabling condition, authorizing the member's return to work. Upon receipt of the member's request to return to work, the Disability Board's Secretary shall forward a copy of the request and the documentation to the Department Head. The Disability Board shall then take appropriate action on the request. 3.15 Conditional Return to Duty In the event the medical and any other relevant evidence is inconclusive, the Board may specify in written order a reasonable trial service period to determine the member's fitness for duty. The reasonable length of such conditional return to service shall be supported by medical evidence. Such a conditional return to service does not entitle the member to a second six (6) month period of disability leave for the same disability if, based upon this trial period of service, the member is found to be disabled. (As provided in WAC 415-105-050 [2]). Page 13 City of Auburn LEOFF Board Policies and Procedures SECTION IV DiSabilitY RETIREMENT 4.01 Examination for Disability Retirement Applicants for disability retirement shall be examined by the Board doctor during the fifth (5t') or sixth (6th) month of disability leave, or sooner as the Board may require, in order to determine the member's eligibility for disability retirement, with the following exceptions: a) if the Board doctor assures the Board that the applicant's condition has not and will not be corrected before the end of the sixth (6t') month; or b) if the applicant establishes that the disabling condition will be in existence for a period of at least six (6) months and he/she voluntarily waives disability leave. No applicant will be granted a disability retirement allowance unless conditions imposed by this sub-section are met. (As provided in WAC 415-105-050 [1]). ((Rev 5/94)) 4.02 Granting Disability Retirement If the evidence shows to the satisfaction of the Board that the member is physically and/or psychologically disabled from further performance of duty and that the disability has been continuous from the date of commencement of disability leave for a period of six (6) months, the Board shall enter its written decision and order, accompanied by appropriate findings of fact and conclusions of law in compliance with RCW 41.26.120. Such written decision and order with supporting documentation shall thereafter be forwarded to the Director, Department of Retirement Systems, for reviews. In the event a regular meeting of the Board precedes by no more than forty (40) days the date at which the full six (6) months will conclude and the evidence is clear that the disability can be expected to continue through the full six (6) month period, the Board may make a finding of six (6) months continuance disability prior to the actual conclusion of the six month period, so as to eliminate unnecessary delay of receipt of retirement benefits. (As provided in WAC 415-105o 060 [1]). ((Rev 5/94)) In order to receive a disability retirement allowance, the applicant will be required to prove that he/she is physically and/or psychologically disabled to such an extent that he/she is unable to discharge with average efficiency the duty of the position held at the time of discontinuance of service: "Provided, that no member shall be entitled to a disability retirement allowance if the appropriate authority advises that there is an available position for which the member is qualified and to which one of such grade or rank is normally assigned and the Board determines that Page 14 City of Auburn LEOFF Board Policies and Procedures the member is capable of discharging, with average efficiency, the duties of the position." (As provided in WAC 415-105-060 [2]). 4.03 Execution Every order of the Disability Board granting or denying a disability retirement allowance shall contain the following presented in clear and concise terms: A. Findings of fact supported by evidence in the record supporting the granting or denying of the disability retirement allowance. When a disability retirement is granted, findings of fact shall include: 1 ) Whether or not the disability was incurred in the line of duty; 2) Whether or not the disability was incurred in other employment; 3) Dates encompassing disability leave and/or dates relating to authorized trial basis return to duty; and, in the case of return to duty on a trial basis, the factual basis for such decision; 4) Dates encompassing waiver of disability leave, if applicable; and that the applicant established that such disability will be in existence for a period of six (6) months. 5) As required by the Department of Retirement Systems, if the Board relies on the testimony of the treating physician over that of the Board physician, a finding stating that fact. B. Conclusions of law in accordance with law on the basis of facts in the case. C. Decision and order. (Entire Section as provided in WAC 415-105-070, [1], [2] & [3]) 4.04 Re-examination and Return to Duty In the event a member is placed on disability retirement, the Board shall determine whether or not the member is so disabled that no possibility exists for return to duty or that there is no possibility that rehabilitation could restore the member to fitness for duty. Further, the Board may at any point subsequent to retirement make such a determination. A copy of all such determinations shall be sent to the Department of Retirement Systems. Unless the Board has made such a finding, the Board's Page 15 City of Auburn LEOFF Board Policies and Procedures representative shall order a re-examination at six (6) month intervals and advise the Board of the results thereof with a copy to the Department of Retirement Systems: provided, that such re-examination need not be conducted on a member over 49.5 years of age. Each member who is under 49.5 years of age and placed on disability retirement is subject to periodic review, unless the Findings of Fact state there is no chance of rehabilitation. The periodic review includes a medical examination and completion of the Board's re-evaluation questionnaire, every six months, to determine whether disability retirement should be continued. In the event the retired member is residing at a location more than one hundred (100) miles from his/her former place of employment, the member may be authorized to be examined by a physician in his/her immediate area, provided, however, such physician shall first be approved by the Board and prior to such evaluation the examining physician shall be appraised of the basis upon which the examination is to be conducted and the issues to be addressed in the physician's evaluation report (As provided in WAC 415-105-090 [1]). Fees charged for medical evaluation report letters for required re- examination of disability retirees under the age of 49.5 years may be covered by health insurance providers. The Board will consider authorizing payment for fees charged for medical reports toward fulfillment of the periodic medical examination review which have been shown to have first been submitted to the member's health insurance provider. The Board will cover the amount of the billing not reimbursed by or rejected by the health insurance provider_. 4.05 Discontinuation of a Retirement Allowance, Notice of In the event such evaluation discloses fitness to perform duties of the rank or position held by the member at the time of disability retirement, the member shall be entitled to a hearing before the Board, and further consideration of the matter. Such notice of hearing shall comply with the Administrative Procedures Act, Chapter 3404 RCW. (As provided in WAC 415-105-090 [2]). The member shall be notified of the Board's action to discontinue or cancel his/her retirement allowance Ey mail, and the notification shall contain notice of the time, place and that the hearing will be to determine whether the member continues to be disabled. The hearing provided by RCW 41.26.140 (2) is to be held, unless the retiree waives such hearing, prior to actual cancellation of a disability retirement allowance. (As provided in WAC 415-105-090 [3]). Page 16 City of Auburn LEOFF Board Policies and Procedures The retirement allowance of any member who fails to submit to medical examination as provided herein shall be discontinued and in the event such refusal continues for one (1) year, his/her retirement allowance shall be canceled. Failure of the member to affirmatively respond to the request for re-examination shall be deemed a continuing refusal. (As provided in WAC 415-105-090 [4]). Page 17 City of Auburn LEOFF Board Policies and Procedures SECTION V HEARING PROCEDURES 5.01 Procedures Whenever the Board holds a hearing pursuant to these rules or RCW 41.26, the following rules shall govern the general conduct of such hearing and shall not be inconsistent with RCW 34.04. 5.02 Subpoenas The Board may compel the attendance of a witness at any hearing as follows: A. The Board may issue a subpoena on its own motion or upon the request of any party. The issuance and service of a subpoena may be obtained upon the filing of an affidavit therefore, which: 1 ) States the name and address of the proposed witness; and, 2) Specifies the nature of the evidence sought and the materiality thereof to the issues involved; and, 3) States that the witness has the desired evidence in his/her possession or under his/her control. The Board may refuse to issue a subpoena when the affidavit is defective or incomplete in any particular. The Board's Secretary is authorized to sign the subpoena for the Chairperson. B. If an individual fails to obey a subpoena without lawful excuse or refuses to testify when requested concerning any matter under examination or investigation at the hearing or fails without lawful excuse to produce material evidence in his/her possession or under his/her control as required by any subpoena issued by the Board and served upon such person, the Board may petition the superior court of the county where the hearing is being conducted for enforcement of the subpoena. The petition shall be accompanied by a copy of the subpoena and proof of service, and shall set forth in what specific manner the subpoena has not been complied with, and shall ask an order of the court to compel the witness to appear and testify before the Board or to produce material evidence. Page 18 City of Auburn LEOFF Board Policies and Procedures C. Any subpoena issued by the Board shall be served in the manner provided for any civil suit according to the Washington Court Rules. D. Witnesses subpoenaed to attend such a hearing shall be paid the same fees and allowances, and in the same manner and under the same conditions, as provided for witnesses in the courts of this State by RCW 2.40 and by RCW 5.56.010, as now or hereafter amended: Provided, that the Board shall have the power to fix the allowance for meals and lodging in like manner as is provided in RCW 5.56.010, as now or hereafter amended, as to courts. Such fees and allowances, and the cost of producing records required to be produced by its subpoena, shall be paid by the Board, or by the party requesting the issuance of the subpoena. 5.03 General Procedure for Conduct of Hearings A. Submission of Briefs - The member applying for retirement may submit a brief of evidence in support of his/her application. The brief must be submitted to the Board's Secretary three (3) working days prior to the hearing. B. Record - A record of the entire proceeding shall be made by tape record. Such tape recording shall be preserved for a period of two (2) years by the Board's Secretary. The cost of any reproduction of the tape shall be paid by the requesting party unless requested by the Board. C. Continuance - The Board may grant a continuance for good cause. Good cause is to be determined by the Board. D. Oaths/Certification - In any proceeding under the Board's rules, any member of the Board may administer oaths and affirmations and may certify official acts. E. Reasonable Dispatch - The Board and its members shall proceed with reasonable dispatch to conduct any matter before it. F. Rules of Evidence - Hearings need not be conducted according to the technical rules relating to evidence and witness. Page 19 City of Auburn LEOFF Board Policies and Procedures G. Oral Evidence - Oral evidence shall be taken only on oath or affirmation. H. Hearsay Evidence - Hearsay evidence may be used for the purpose of supplementing or explaining any direct evidence, but shall not be sufficient in itself to support a finding unless it would be admissible over objection in civil actions in courts of competent jurisdiction in this state. I. Admissibility of Evidence - Any relevant evidence shall be admitted if it is the type of evidence on which responsible persons are accustomed to rely in the conduct of serious affairs, regardless of the existence of any common law or statutory rules which might make improper the admission of such evidence over the objection in civil court action in a court of competent jurisdiction in this state. J. Exclusive Evidence - Irrelevant and unduly repetitious evidence may be excluded by the Board. K. Rights of the Applicant Member - The member applying for retirement shall have these rights, among others: 1) Call and examine witnesses on any matters relevant to the issues presented in the hearing, 2) Introduce documentary and physical evidence, 3) Cross examine witnesses on any matter relevant to the issues of the hearing, 4) Impeach any witness regardless of who called him/her to testify, 5) Rebut the evidence against him/her, 6) To represent him/herself or to be represented by legal counsel. Page 20 City of Auburn LEOFF Board Policies and Procedures L. Presentation of Testimony 1) Order of Presentation of Testimony - The applicant member, who bears the burden of proof shall present his/her evidence first. Then other witnesses may testify as directed by the Board.'. After any witness concludes his/her testimony, the Board may direct questions to the witness. 2) Closing Statement - After presentation of all testimony and evidence, the applicant member or his/her representative shall be allowed to make a summarizing statement. The Board may impose a reasonable time limit on such statement, but a minimum of fifteen (15) minutes shall be allowed. M. Official Notice 1) What May Be Noticed - In reaching a decision, official notice may be taken either before or after submission of the case for decision, of any fact which may be judicially noticed by the courts of this state or of official records of the Board or departments and ordinances of the City or rules and regulations of the Board. 2) Applicant Member to Be Notified - The applicant member, if present at the hearing, shall be informed of the matters to be noticed by the Board, and these matters shall be noted in the record, referred to therein, or appended thereto. 3) Opportunity to Refute - Any applicant member or his/her representative, if present at the hearing, shall be given reasonable opportunity, upon request, to refute the officially noticed matters by evidence or by written or oral presentation of authority, the manner of such reputation to be determined by the Board. Page 2 1 City of Auburn LEOFF Board Policies and Procedures SECTION VI APPEAL 6.01 Denial or Cancellation If the Board denies a disability leave or disability retirement or cancels a previously granted disability leave or retirement, the applicant shall be immediately notified and advised of the right of appeal such decision or order to the Director of the Department of Retirement Systems, pursuant to RCW 41.26.200. Such notification shall be made in writing and served by personal service or mail. Provided, that written notice need not be given if applicant or his/her duly authorized representative is in attendance at the meeting or hearing and is advised of the decision and of the right of appeal (As provided in WAC 415-105-080). 6.02 Procedure for Reconsideration of Board Decision Any party aggrieved by a decision of the Board may request the Board to reconsider its action by filing a written request with the Board's Secretary for reconsideration within fifteen (15) days of the decision of the Board. The request for reconsideration shall set forth a concise statement of the fads or errors upon which the request for reconsideration is based. The Board may direct that a copy of the request for reconsideration be mailed to other interested padies at least three (3) days prior to any Board meeting to consider the request. The Board may grant or deny such request for reconsideration at its discretion. Page 22 City of Auburn LEOFF Board Policies and Procedures SECTION VII FALSIFICATION 7.01 Record or Statement Falsification All applications and other documents filed in conjunction with disability leave or disability retirement must be accurate and truthful. RCW 41.26.300 provides as follows: "Any employer, member or beneficiary who shall knowingly make false statements or falsify or permit to be falsified any record or records of the retirement system, shall be guilty of a felony". Page 23 City of Auburn LEOFF Board Policies and Procedures SECTION VIIi MEDICAL SERVICES 8.01 Medical Services Provided Whenever any active member, member on disability leave, member retired for service or disability which requires medical services, such services shall be paid for by the employer, subject to approval by the Disability Board. Only those medical services which are deemed necessary shall be approved, unless the Board finds the condition which has caused the need for such medical service was caused or brought on by dissipation or abuse. Determinations of dissipation or abuse and the necessity of such medical services shall be determined by the Board after considering the medical evaluation of the Board's medical advisor together with any other relevant evidence. Applications to the Board for medical services shall be approved by the Board prior to receipt of services except in extraordinary circumstances. Medical services payable shall be reduced by any amount received or eligible to be received under Workers' Compensation, Medicare, insurance provided by another employer, other pension plan, or other similar sources. In the event any such alternative source of payment is available, it shall be incumbent upon the requesting member to apprise the Board of such source, if known to the member, and failure to do so may result in the loss of medical benefits. It shall be the policy of the Board to seek repayment from other sources. NOTE: Medical services payable by insurance provided by an employer pursuant to RCW 41.26.150 shall not be subject to approval by the Board. 8.02 Medical Services - General Guidelines A. Where deemed necessary, the local Disability Board may approve payment for any medical services which constitute preventative as opposed to curative services. Preventative services are those which are meant to prevent future occurrence of an illness, injury or Page 24 City of Auburn LEOFF Board Policies and Procedures disabling condition, as opposed to curative services meant to restore health or cure or correct an existing condition. B. The Board will not ~:onsider any service of a cosmetic nature or which is beyond that reasonably necessary to correct the condition complained of to be a necessary medical service. C. In the event the member has obtained medical services without obtaining prior approval of the board, the Board may authorize payment upon filing of such claim by the applicant. D. Dental expenses will not be considered necessary medical services except in those circumstances where they are incurred by a member who sustains an accidental injury to his/her teeth and commenced treatment within ninety (90) days after the accident, unless said treatment can be justified by the way of curing or correcting an existing health problem (See also section 8.03{B}). E. The Board will authorize the payment of the expense of an eye exam by an optometrist. F. The Board may presume that each individual who has attained the age sixty-five (65) is eligible for Medicare and will not authorize payment for necessary medical services where such expenses are met by Medicare, pursuant to RCW 41.26.150. Where the expense of necessary medical services exceeds that which is paid by Medicare, the Board may authorize the payment of the excess. G. Members possessing insurance benefits covering the expense of necessary medical services which would otherwise be the obligation of the employer shall first present the claim to the appropriate insurance carrier and only thereafter make claim to the Board for those costs which are not paid by the insurer. The Board will designate those services where this procedure will not be followed. H. Upon making payment for authorized medical services, the employer shall be subrogated to all rights of the member against any third party who may be held liable for the member's injuries or for the payment of the costs of medical services in connection with a member's sickness or disability. Such subrogation shall be to the extent necessary to recover payments made by the employer. Page 25 City of Auburn LEOFF Board Policies and Procedures 8.03 Medical Services - Defined Medical services for persons who establish membership in the retirement system on or before September 30, 1977, shall include the following as minimum services to be provided. Reasonable charges for these services shall be paid in accordance with RCW 41.26.150 A. Hospital expenses are the charges made by a hospital, in its own behalf, for: Board and room not to exceed semi-private room rate unless private room is required by the attending physician due to the condition of the patient. Necessary hospital services, other than board and room, furnished by the hospital. B. Other medical expenses; Provided, that they have not been considered hospital expenses. The fees of the following: A physician or surgeon licensed under the provisions of Chapter 18.71 RCW. An osteopath licensed under the provisions of Chapter 18.51 RCW. A chiropractor licensed under the provisions of Chapter 18.25 RCW. The charges of a registered graduate nurse other than a nurse who ordinarily resides in the member's home, or is a member of the family of either the member or the member's spouse. The charges for the following medical services and supplies as provided in RCW 41.26.030 [22]: Drugs and medicines upon a physician's prescription; Diagnostic x-ray and laboratory examinations; X-ray, radium, and radioactive isotopes therapy; Anesthesia and oxygen; Page 26 City of Auburn LEOFF Board Policies and Procedures Rental of iron lung and other durable medical and surgical equipment; Artificial limbs and eyes, and casts, splints, and trusses; Professional ambulance service when used to transport the member to or from a hospital when he/she is injured by an accident or stricken by a disease; Dental charges incurred by a member who sustains an accidental injury to his/her teeth and who commences treatment by a legally licensed dentist within ninety (90) days after the accident; Nursing home confinement or hospital care extended facility; Physical therapy by a registered physical therapist; Blood transfusions, including the cost of blood and blood plasma not replaced by voluntary donors; An optometrist licensed under the provisions of Chapter 18.53 RCW. (This entire section as provided in RCW 41.26.030 [22]). Page 27 City of Auburn LEOFF Board Policies and Procedures SECTION IX LEOFF BOARD Claim PROCEDURE 9.01 Medical Claim Procedure a. Obtain prior LEOFF Board approval for any necessary medical expense not covgred by insurance, Medicare or other similar sources. All medical expenses incurred and claimed for reimbursement by the member will be submitted through the member's health insurance provider(s) BEFORE the claim is sent to the Board for approval. The medical expenses claim submitted for reimbursement is to be that portion NOT covered by the existing health insurance provider(s). 1. The Board may presume that each individual who has attained the age of sixty-five (65) is eligible for Medicare and will not authorize payment for necessary medical services where such expenses are met by Medicare, pursuant to RCW 41.26.150. It is each members' responsibility to obtain Medicare insurance whether or not the employer pays the premiums. Pursuant to RCW 41.26.150(5) Medicare premiums supplementing other medical insurance coverage are authorized for reimbursement upon receipt of Form SSA-1099, Social Security Benefit Statement, showing annual Medicare premiums paid for individual members. 2. Members are advised to consult their employer or personnel office regarding eligibility for Medicare health insurance coverage, Parts A and B. Where the expense of necessary medical services exceeds that which is paid by Medicare, the Board will authorize the payment of any balance which may exist after coordination of benefits with the provided medical insurance carrier. B. Process all medical expenses through the appropriate insurance carriers. Members are advised to consult first with their health insurance providers or their employedpersonnel officer to learn what Page 28 City of Auburn LEOFF Board Policies and Procedures is or is not covered in existing health insurance BEFORE incurring treatment services. Elective medical procedures, surgery and/or appliances/supplies may not be covered by the health insurance provided by the employer or authorized by the Board. C. If the medical expense is not covered by insurance, a claim can be submitted to the LEOFF Board for payment. The burden is upon the claimant to establish necessity of a provided medical service and that the reasonableness of the service charge in order for the Board to consider the claim for payment._ D. Complete a Claim for Payment form and attach all explanation of benefits insurance documentation forms showing the amount they paid and/or rejected and any physician documentation necessary to support a claim. E. Submit the claim with the above information to your LEOFF Representative by the last Tuesday of the month. LEOFF Board agendas are prepared the last Wednesday of the month and mailed to each Board member at their last address of record. Any claims submitted after that date will be held until the next regularly scheduled LEOFF Board meeting, the first Monday of each month. F. If the LEOFF Board approves the claim for payment, the claim will be processed according to established Finance Department policies and procedures. G. Claims which do not have complete documentation shall be tabled until the next LEOFF Board meeting or until the required documentation is provided so it is crucial to have the required paperwork. Only those medical services which are deemed necessary shall be approved, unless the Board finds the condition which has caused the need for such medical service was caused or brought on by dissipation or abuse. Determinations of dissipation or abuse and the necessity of such medical services shall be determined by the Board after considering the medical evaluation of the Board's medical advisor together with any other relevant evidence. H. All claims for hearing aids must have prior authorization by the LEOFF Board. Failure to obtain advance authorization may result in only partial reimbursement or rejection of the claim at the Boards discretion. Page 29 City of Auburn LEOFF Board Policies and Procedures I. All claims shall be submitted to the Board within ninety (90) days of date processed/paid by the insurance documentation. Failure to comply may result in rejection of the claim. J. All medical expenses are the member's responsibility to pay. Claims for necessary medical services submitted to the Board shall be reimbursed to the member in the amount approved by the Board. K. Upon making payment for authorized medical services, the employer shall be surrogated to all rights of the member against any third party who may be held liable for the member's injuries or for the payment of the costs of medical services in connection with a member's sickness or disability. Such subrogation shall be to the extent necessary to recover payments made by the employer. L. The Board may approve a maximum one-time only $500 weight loss program fee if the member submits a description of a physician monitored and prescribed weight loss program documenting a medical necessity of losing at least 60 pounds. The Board will not consider payment or costs of food supplements/replacements. 9.02 Medical Claims for Corrective Lenses The City of Auburn LEOFF Board will authorize a flat payment of prescription corrective lenses including frames up to $175.00 every two (2) years. Lenses for glasses which involve special prescription due to injury, disease or other unusual circumstances will be considered on a case-by-case basis for exception to the $175.00 maximum limit. Any insurance benefits provided by the City or other sources will be applied toward the $175.00. Any amount over the $175.00 will be the responsibility of the applicant except as indicated above. 1 .)$100.00 for frames every two years (24 months). 2.)$ 75.00 prescription lenses every 1 year (12 months). 3.)$175 for prescription contact lenses every 2 years (24 months). 9.03 Medical Claims for Hearing Aids The City of Auburn LEOFF Board will authorize a payment for hearing aid(s) up to an amount determined by the LEOFF Board designated hearing aid provider (Price/Costco as of 1/1/97). The LEOFF Board will Page 30 City of Auburn LEOFF Board Policies and Procedures consider payments for a hearing aid device every five (5) years. Any claim submitted by a member who chooses not to use the LEOFF Board designated hearing aid provider or lives outside the service area is subject to review by the LEOFF Board's designated hearing provider and will be limited to reimbursement up to what the designated hearing aid provider would charge. Hearing aids prescribed due to injury, disease or other unusual circumstances will be considered on a case by case basis for exception to this policy. The Board will also authorize the cost of necessary repairs, however, routine maintenance and batteries shall be the members responsibility. 9.04 Skilled Nursing Facility Care Reimbursement A. The City of Auburn LEOFF Board will provide reimbursement for the reasonable expenses incurred by a LEOFF I member needing the services of a skilled nursing facility. Expenses which shall be reimbursed may include: 1. An amount not to exceed the daily benefit for nursing care under the City's existing long term care insurance. 2. The semi-private room and board rate plus the "level of care" charge where charged separately by a skilled nursing facility so long as the total does not exceed the Board allowed rate. 3. Charges for medically necessary physician prescribed medications, medical services (e.g. x-rays) and other medically necessary physician prescribed supplies. B. Non-medical charges, including but not limited to hair care, personal toiletries and sundries, bed holds, and recreational events organized by the skilled nursing facility shall not be reimbursed. C. Before any skilled nursing facility charges may be reimbursed, the Board must be provided with a letter from the member's attending physician stating medical necessity for and estimated duration of skilled nursing facility care. Private room charges may be reimbursed provided the Board is supplied with written documentation of medical necessity for the same from the member's attending physician. The question of medical necessity for skilled nursing facility care may be subject to annual or more frequent review by the Board, at the Board's discretion. Page 3 1 City of Auburn LEOFF Board Policies and Procedures D. All charges must be submitted to the appropriate insurance carriers, Medicare, Medicaid or other available long-term care . insurance before submission to the Board. The Board may reduce the amount of reimbursement for skilled nursing facility care by the amount a LEOFF I member receives from these other sources. E. The Board reserves the right, at its sole discretion based on the record before it, to approve or disapprove reimbursement for skilled nursing facility care incurred by a LEOFF I member. F. The Board shall only reimburse for services rendered; advance payment of any charges will not be made by the Board. 9.05 Home Health Care Reimbursement A. The City of Auburn LEOFF Board may provide reimbursement for the reasonable expenses incurred by a LEOFF I member needing the services of home health care. It is the intent of this policy to reduce the amount paid for skilled nursing facility care. 1. Before any home health care charges may be reimbursed, the Board must be provided with a "Medical Request for Home Health Care" form completed by the member's attending physician. The physician shall state the medical necessity and the estimated length of time during which home health care will be required and the type of care required (medical, daily living, and/or other). This form may be obtained from the LEOFF Board Secretary. The attending physician must provide to the Board a description of work to be performed by the home health care provider. This description is to be as detailed as possible. The question of medical necessity for home health care may be subject to annual or more frequent review by the Board, at the Board's discretion. 2. The total amount allowed shall not exceed the current Board allowed rate for skilled nursing home care as provided for in the Skilled Nursing Facility Care Reimbursement Policy. 3. All charges must be submitted to the appropriate insurance carriers, Medicare and other available long-term care insurance before submission to the Board. Page 32 City of Auburn LEOFF Board Policies and Procedures 4. The Board shall only reimburse for services rendered; advance payment of any charges will not be made by the Board. 5. The Board reserves the right to have an independent assessment agency evaluate the member's home health care needs. The Board also reserves the right to approve or deny home health care reimbursement based upon the findings of the independent assessment agency. 6. The Board will not reimburse for home health care provided by an individual who ordinarily resides in the member's home, or is a member of the family of either the member or the member's spouse. 7. Requests for reimbursement shall be made on a Claim for Payment form. All explanations of benefits insurance documentation forms showing the amount paid and/or rejected and any physician documentation necessary to support the claim must be attached. 8. The Board reserves the right, at its sole discretion based on the record before it, to approve or disapprove reimbursement for home health care expenses incurred by a LEOFFImember. 9.06 Rejected Claims The Board shall act upon all claims promptly, advising the claimant in writing of any claim that is rejected, together with the reason for rejection. 9.07 Filing Appeal in Cases Involving Claims for Medical Services Any person feeling aggrieved by any denial of payment of a claim for medical services by the Board shall have the right to request the Board to reconsider its decision and the Board may grant or deny such request at . its discretion. A request for reconsideration must be filed with the Board Secretary within thirty (30) days following the denial of the claim by the Board. The Board will set a date and time for reconsideration at which time the member may present such evidence deemed relevant. If the denial of the claim is sustained by the Board, the member has the right of judicial review. Page 33 City of Auburn LEOFF Board Policies and Procedures 9.08 Medical Claims for Services Where Insurance Benefits Have Been Expended In instances where insurance benefits have been exhausted or where treatment is not covered by insurance, the Board may require a written report from the claimant's physician or, at the Board's discretion, be referred to the Board doctor requesting information on the diagnosis, prognosis, and recommended treatment for the medical problem. 9.09 Medical Claims for Services Where Treatment is Not Covered by Insurance In instances where insurance does not cover treatment, the member must seek prior authorization by the Board prior to commencing treatment. Failure to do so may cause denial or only partial approval of the medical claim. 9.10 Medical Claims for Board Required Re-examinations (WAC 415-105-0901) Upon receipt of proper documentation for medical claims for Board required re-examinations, the Board shall authorize the Secretary to institute the process to pay the bill to the provider according to established Finance Department policies and procedures. Page 34 City of Auburn LEOFF Board Policies and Procedures SECTION X ADOPTION AND REVIEW 10.01 Biennial Review These policies and procedures shall be reviewed in even years in January to assure that: A. Provisions herein remain in conformance with Washington Statutory and Administrative Codes. B. Dollar amounts specified in schedules of benefits reflect current average charges in the local area. C. Provisions herein reflect current philosophy and intent of the Board. 10.02 Formal Adoption Adopted at the Board meeting on February 8, 1982. 10.03 Severability Clause The LEOFF Board Policies and Procedures are declared to be separate and severable. The invalidity of any clause, sentence, paragraph, subdivision, section or portion of these policies, or the invalidity of the application thereof to any person a circumstance shall not affect the validity of the remainder of these policies, or the validity of its application to other persons or circumstances. Page 35 City of Auburn LEOFF Board Policies and Procedures SECTION XI ADDENDUM Revised 6-10-83 1.05 Elections - Wording has been added to designate years the elections will be held and procedure for election by secret ballot. 1.11 Disability Board Officers - Adds an Assistant Secretary. 3,0'1 Application - Requires reports from two (2) physicians when applying for disability leave/retirement. 3.09 PhVsician's Reports - Changes date monthly disability leave reports are due from Monday to Wednesday preceding the LEOFF Board meeting. 3.14 Return to Duty - Clarifies the procedure to return to duty from disability leave. 5.01 Procedures {Hearinqs) - Adds State hearings procedures statute reference, 6.01 Denial or Cancellation - Corrects RCW reference typographical error. 8.02 DIE Medical Services - General Guidelines - Corrects references to other sections. 9.0'1 Procedure to File Medical Claims - Title change to Medical Claim Procedure and further clarifies procedure. Also requires prior Board approval for hearing aids. 9.02 General Information on Medical Claims - Title change to Medical Claims for Corrective Lenses. Changes LEOFF guidelines for payment limitations for corrective lenses to a fiat fee of $120.00 every two (2) years, or sooner if correction is required, minus any insurance benefits available. Revised 6-28-84 1.01 B Designates even numbered years for fire fighter representative elections. 1.01 C Designates odd numbered years for law enforcement officer representative elections. 1.05 B6 Permits Secretary and Assistant Secretary to schedule date to open ballots. 2.03 Corrects typographical error. 3.05 Clarifies disability leave will be retroactive and sick leave restored when applicant is placed on disability leave. 3.08 Authorizes Chairperson to return employee to work from disability leave if clearances are in order, or call for a special meeting. 3.09 Changes due date of physician's reports for employees on disability leave to the Wednesday before Board meetings. 6.01 Corrects 41.16.200 to 41.26.200. 9.01 H Sets time limitation on submission of medical claims. 9.02 Changes allowance for corrective lenses to include exam fee of up to $50.00 for a total of up to $170.00. Page 36 City of Auburn LEOFF Board Policies and Procedures Page 30 Updates Board membership list. Revised 1-7-85 1.05 B Provides new procedure to nominate Fire/Police representatives. Revised 1-7-86 1.05 B3 Changes time between the mailing out of ballot packets and the receipt by the Secretary to no less than seven (7) but no more than ten (10) business days. Revised 11-15-88 Entire All references in the masculine gender only were revised to include the feminine and/or neuter gender where appropriate. Entire All cursive numerical references were revised to include the analog number and vice-versa. Index The index was revised to reflect current page numbers. Index Section X - Annual Review was revised to Biennial Review. 1.01 B/C Revised to include retired police and fire. 1.04 Changed meeting date to third (3rd) Tuesday of each month. 1.05 A Active and retired employees may vote for LEOFF representative. 1.05 B1 Add retired and LEOFF II members may serve on Board. 1.05 B2 Include a security envelope in ballot packages. 1.05 B7 Makes provision for run-off election in the event one candidate does not receive a simple majority of those voting. 1.08 Includes WAC 415-105 in the Board's powers and authority. 1.11 E1 Gives Chairperson authority to tentatively approve disability leave applications between regular Board meetings. 2.04 Removes reference to City Health Officer. 3.01 Specifies the date that agenda items must be received by the secretary. 3.05 Encou?ages use of employee sick leave until the Board meets and approves disability leave and removes restoration of sick leave so used. 3.08 Clarifies that the Chairperson's actions returning a member from disability leave between meetings as tentative. 9.01 A Specifies advance approval for medical services. Page 37 City of Auburn LEOFF Board Policies and Procedures 9.01 G Claims submitted without complete documentation will be tabled. 9.01 H Failure to obtain advance authorization penalties. 9.01 J Medical bills are the member's responsibility to pay, 10.01 Changes annual review of policies and procedures to biennial review. Revised 5-1-90 1.04 Meetinq - Changes regularly scheduled monthly meeting from the third (3rd) Tuesday of each month to the first (1't) Monday of each month. 8.02(E) Medical Services - General Guidelines - Authorizes the Board to pay for the eye exam by an optometrist. 9.01 (E) Medical Claim Procedure - Changes the LEOFF Board meeting from the third (3'd) Tuesday of each month to the first (1't) Monday of each month. 9.02 Medical Claims for Corrective Lenses - Changes the flat maximum fee of $170.00 to $175.00 and deletes "(includes $50.00 for exam) reference App A Deletes Jim Waiters from membership. Adds Pat Burns to membership. Changes Stacey Brothers contact information. App B Deletes 'Active" reference on claim forms. Revised 913191 9.01(H) Designates Northwest Hospital as the LEOFF Board approved hearing aid clinic. Revised 1-1-92 1.05(B.7) Deletes "The election shall be conducted at the respective department during a two (2) hour period following appropriate notification." Revises to read '...a run-off election shall be scheduled between the two individuals receiving the highest vote totals utilizing the same process per this section." App A City Legislative Appointments of Trish Borden and Jeanne Barber with term expiration dates of 12-31-93 and 92. Police Representative Bob Phillips with term expiration date of 12-31-93. 2.02 Corrects last sentence from ..."member is can perform." to "member can perform." 3.08 Corrects ..."receipt of clearances from the Secretary;"... to "receipt of clearances from the treating physicians;"... 4.02 Changes ..."physically or mentally disabled"... to 'physically and/or mentally disabled" Page 38 City of Auburn LEOFF Board Policies and Procedures 9.01 (D) Changes "-Documentation from the insurance carrier(s) showing the amount they paid and/or rejected" to "King County Medical Explanation of Benefits documentation form (and other insurance carrier(s) showing the amount they paid and/or rejected." 9.06 Adds section for medical c/aims for services where treatment is not covered by insurance. 10.01 Changes Biennial Review every two years to even years. Revised 12/7/92: 1.05(B.11) Adds "If only one person nominated, balloting will not be required and the individual will be considered elected. 9.02 Changes corrective fee to $175.00 every two (2) years. 10.01A Adds "and Administrative Codes". App A Mick Crawford Term expires 12-31-94; Bud Larson Member-at-Large, adds address and phone number, selected 1-4-93, term expires 12/31/94; Trish Borden term expires 12-31-95; Jeanne Barber term expires 12-31-94, Jim Kelly adds home phone number, elected 6-1-93, term expires 12-31-95 (Bob Phillips resigned, Jim Kelly fulfills end of term); Mick Crawford appointed Chairman at 1-94 meeting, Bud Larson appointed Pro-tem at 1-94 meeting. Claim Form Adds to Instruction #3: "NOTE: A copy of the bill and insurance explanation of benefits must accompany your claim." Revised 1014193 Claim Form Deletes the sentence "1 hereby assign all benefits to the physician or purveyor." Revised July 1995: 1.05 (B) Election procedure for election by secret ballot change are as follows: 6. The ballots shall be opened by the Secretary and assistant Secretary and the results will then be announced after the 3-day protest period by the Chairperson and a certification of election results will be sent to the respective department for posting. 8. All ballots shall be retained by the Secretary for one (1) year. After the one-year period, the Secretary shall prepare the ballots for destruction as authorized by the State of Washinqton General Records Retention Schedule & Destruction Authorization. 1.11 Disability Board Officers D. V3c3ncioc in olootive officors chall bo fillod immodiatoly by rogular oloction procoduro for the uncxpirod portion of tho torm. Boardmember shall serve a two-year term. In the event of a vacancy, a successor shall be appointed or elected in the same manner as with an ori.qinal appointment or election to serve the remainder of the unexpired term or to be.Qin a new term. (Rev 5/94) 3. Secretary - The Secretary shall keep the minutes of all regular, adjourned and special meetings of the Disability Board; such minutes shall be approved by the Board and copies Page 39 City of Auburn LEOFF Board Policies and Procedures shall be distributed to all members of the Board, Police and Fire Chiefs and the Board physician. The Secretary shall give notice of all regular and special meetings to the board members and post all notices of adjournment or continuance of meetings and public and/or disability hearings; shall prepare the agenda of regular and special meetings; shall serve proper and legal notice of all public and/or disability hearings; and shall draft and sign routine correspondence of the Board, and prepare the LEOFF Board approved claims for payment accordin.cl to the policies and procedures established by the City of Auburn's Finance Department. The Secretary shall maintain a file of all rules, findings, orders, recommendations and all other official records of the Disability Board. 1.13 Minutes The Secretary shall take and prepare the official minutes of the City of Auburn Disability Board containing the actions of the Board and a substantial summary account of the proceedings. A record of the Board members present and absent shall be entered, along with tho ayos, nays and abstontions of oach mombor whon voting. and recordin.el of action authorized by the Board. The minutes shall be signed by the Secretary and the Chairperson and placed on record after approval by the Board. Copies shall be distributed to all members of the Board and the City of Auburn Executive Office, Police Chief, Fire Chief, Finance Director, and Board Physicjan those persons of record who have reauested such copies to the Secretary. 2.03 Adds 2.03, Disability Leave Period Disability leave period is a period six months or any portion thereof durin.cl which a member is on leave at an allowance e~lual to the members' full salary at the time he/she beclan his/her period of disability leave and prior to the commencement of any disability retirement ('as provided in RCW 41.26.030{19} and AGO 1978-8). 2.04 Adds, Unless otherwise directed by the Board in specific instances, the LEOFF Board utilizes the services of Objective Medical Assessment Corporation to recluest the services of licensed and practicin.cl a" duly physician or physicians shall bo 3ppointod by tho Board. 2.07 Adds new section, Conditional Return "Conditional return" is a return to duty by a member for the purpose of determinina whether the member's disability persists. 3.02 Adds to existing section the following: The degree of persuasion is by a preponderance of the evidence. To satisfy the preponderance of evidence standard, the Board must be persuaded that the propositions asserted by the applicant are more probably true than not true. 3.14 VVhen a member returns from a disability leave, he/she must submit a signed slip from all attending physicians treating the disabling condition to the Disability Board Secretary authorizing his/her return. Al~o, a roquoct in writing, along with ho physician's roportc, ¢hall bo dirooted to tho mombors Dopartmont Hoad, Porr.,onnel Dirc-,ctor, and Dieability 5oard's 8oerotary asking to o roturnod to work. Insert, The Disability Board Secretary shall then notify the appropriate Department Head, Personnel Director and other staff. Upon receipt of the request to return to work, the Department Head shall submit his/her written recommendation to the Disability Board. The Disability Board shall then take appropriate action on the rec~uest. 4.01 Adds to the first sentence, ...disability leave, or sooner as the Board may require, in order to determine the~: the members eligibility for disability...(As provided in WAC 415-105-05011 ]. Page 40 City of Auburn LEOFF Board Policies and Procedures 4.02 Replaces the word .... If the evidence shows to the satisfaction of the Board that the member is physically and/or mont311y ((psychologically)) disabled from further performance of duty and that the disability has... Replaces the word in the second paragraph .... In order to receive a disability retirement allowance; the applicant will be required to prove that he/she is physically and/or mont311y ps¥cholo.qicallv disabled to such an extent... 4.03 Adds: Unless the Board, at its discretionaN approval, chooses to rely upon the opinion of the treatinq physician, every decision and order revoking a disability retirement shall be in writincl or stated in the record and shall be accompanied by findinqs of fact and conclusions of law. The member shall be notified of the decision and order bv certified mail return receipt. 4.04 Added a second paragraph to read: Each member who is under 49.5 years of age and placed on disability retirement is subject to periodic review, unless the Findings of Fact state there is no chance of rehabilitation. The periodic review includes a medical examination and completion of the Board's re-evaluation questionnaire, every six months, to determine whether disability retirement should be continued. Adds paragraph four to read: Fees charged for medical evaluation report letters for required re- examination of disability retirees under the age of 49.5 years may be covered by health insurance providers. The Board will consider authorizing payment for fees charged for medical reports toward fulfillment of the periodic medical examination review which have been shown to have first been submitted to the member's health insurance previder. The Board will cover the amount of the billing not reimbursed by or rejected by the health insurance provider. 4.05 Adds Section 4.05, Discontinuation of a Retirement Allowance, Notice of, to Policies and Procedures and moves paragraphs two, three and four of Section 4.04 to Section 4.05. Paragraph two in Section 4.05 is moved to Paragraph one. Paragraph three in Section 4.04 is moved to Section 4.05. Paragraph two. Paragraph four of Section 4.04 is moved to Section 4.05, paragraph three. In Paragraph 1, adds, The member shall .be notified of the Board's action to discontinue or cancel his/her retirement allowance by mail, and the notification shall contain notice of the time, place and that the hearing will be to determine whether the member continues to be disabled. 5.02 This section was revised to the following: Subpoenas ' The Board may compel the attendance of a witness at any hearing as follows: A. The Board may issue a subpoena on its own motion or on the request of any party; B. If an individual fails to obey subpoena, or obeys a subpoena but refuses to testify when requested concerning any matter under examination or investigation at the hearing, the Board may petition the superior court of the County where the hearing is being conducted for enforcement of the subpoena. The petition shall be accompanied by a copy of the subpoena and proof of service, and shall set forth in what specific manner the subpoena has been complied with, and shall ask an order of the court to compel the witness to appear and testify before the Board. C. Witnesses subpoenaed to attend such a hearing shall be paid the same fees and allowances, and in the same manner and under the same conditions, as provided for witnesses in the Page 4 1 City of Auburn LEOFF Board Policies and Procedures courts of this State by RCW 2.40 and by RCW 5.56.010, as now or hereafter amended: Provided, that the .Board shall have the power to fix the allowance for meals and lodging in like manner as is provided in RCW 5.56.010, as now or hereafter amended, as to courts. Such fees and allowances, and the cost of producing records required to be produced by its subpoena, shall be paid by the Board, or by the party requesting the issuance of the subpoena. 8.02(F) Corrects the first sentence to read, The Board may presume that each individual who has attained the age sixty-five (-6-) (65) is eligible for Medicare... Corrects the last sentence to read ....which is paid by Medicare, the Board wig may authorize the payment of the excess. 8.03(B) Adds ....The Charges for the following medical services and supplies as provided in RCW 41.26.030 [22}: 9.01(A) Adds to the first paragraph, All medical expenses incurred and claimed for reimbursement b the member will be submitted throu.qh the member's health insurance provider(s) BEFORe' the claim is sent to the Board for approval. The medical expenses claim submitted for reimbursement is to be that podion NOT covered by the existincl health insurance provider(s))).((Rev 8/94)) 9,01 (A)(1) Adds Subsection 1, The Board may presume that each individual who has attained the age of sixty-five (65) is eli.qible for Medicare and will not authorize payment for necessary medical services where such expenses are met by Medicare, pursuant to RCW 41.26.150. It is each members' responsibility to obtain Medicare insurance whether or not the employer pays the premiums. 9.01(A)(2) Adds Subsection 2, Members are advised to consult their employer or personnel office reqardina elic~ibilitv for Medicare health insurance coverac~e, Pads A and B. Where the expense of necessary medical services exceeds that which is paid by Medicare, the Board will authorize the payment of any balance which may exist after coordination of benefits with the provided medical insurance carrier. 9.01(B) Adds the following at the end of the first sentence, Members are advised to consult first with their health insurance providers or their employer/personnel officer to learn what is or is not covered in existing health insurance BEFORE incurrinc~ treatment services. Elective medical procedures, surqery and/or appliances/supplies may not be covered by the health insurance provided by the employer or authorized by the Board. 9.01© Adds, The burden is upon the claimant to establish necessity of a provided medical service and that the reasonableness of the service charge in order for the Board to consider the claim for payment. 9.01(D) Adds .... all explanation of benefits insurance documentation forms showing the amount they paid and/or rejected and any physician documentation necessary to suppod a claim. Deletes the following: · A copy of the doctor(s) bill(s) · King County Medical Explanation of Benefits documentation form (or other insurance carrier(s) showing the amount they paid and/or rejected,_ 9.01(E) Adds and deletes the following: Submit the claim with the above information to our LEOFF Representative by the last Tuesday of the month. Wodnoc.,day prior to tho rogular~ P..,c, hodulod LEOFF Board mooting (first (1'~) Monday of oac, h month). LEOFF Board aclendas are prepared the last Wednesday of the month and mailed to each Board member at their last Page 42 City of Auburn LEOFF Board Policies and Procedures address of record. Any claims submitted after that date will be held until the next regularly scheduled LEOFF Board meeting, the first Monday of.each month. 9.01(F) Adds and deletes the following: If thcro am no irrogularitios and the LEOFF Board approves the claim for payment, the claim will be processed ((accordinc~ to established Finance Department policies and procedures.)) (Rev 5/94) 9.01 (K) This section is added. 9.01(L) This section is added. 10.03 This section is added: Severability Clause The LEOFF Board Policies and Procedures are declared to be separate and severable. The or the invalidity of the application thereof toany person a circumstance shall validity of the remainder of these policies, or the validity of its application to other persons or circumstances. Claim Form: Added a statement to the Claim For Payment Form to read, "The medical provider first submits to the members insurance provider any costs for medical evaluations and/or medical reports. After the member's insurance provider has made a determination on the claim, the LEOFF member then submits to the LEOFF Board Secretary a claim for any unpaid costs. REVISED 2/5196 - Effective in 30-days 8.02 (E), Medical Services - General Guidelines The Board will authorize the payment of the expense of an eye exam by an optometrist. 9.02 Medical Claims for Corrective Lenses The City of Auburn LEOFF Board will authorize a flat payment of prescription corrective lenses including frames up to $175.00 every two (2) years. Lenses for glasses which involve special prescription due to injury, disease or other unusual circumstances will be considered on a case-by-case basis for exception to the $175.00 maximum limit. Any insurance benefits provided by the City or other sources will be applied toward the $175.00. Any amount over the $175.00 will be the responsibility of the applicant. 1 .) $100.00 for frames every two years (24 months). 2.) $ 75.00 prescription lenses every 1 year (12 months). 3.) $175 for prescription contact lenses every 2 years (24 months). REVISED July 22, '1996 9.02, Medical Claims for Corrective Lenses Any amount over the $175.00 will be the responsibility of the applicant except as indicated above. Page 43 City of Auburn LEOFF Board Policies and Procedures REVISED at the September 3, 1996 & designated Price/Costco as hearing aid provider REVISED at the December 2, 1996 LEOFF Board Meeting 9.01(A)(1) Pursuant to RCW 41.26.150(5) medicare premiums supplementing other medical insurance coverage are authorized for reimbursement upon receipt of Form SSA-1099, Social Security Benefit Statement, showing annual medicare premiums paid for individual members. 9.03 Medical Claims for Hearing Aids The City of Auburn LEOFF Board will authorize a payment for hearing aid(s) up to an amount determined by the LEOFF Board designated hearing aid provider (Price/Costco as of 1/1/97). The LEOFF Board will consider payments for a hearing aid device every five (5) years. Any claim submitted by a member who choses not to use the LEOFF Board designated hearing aid provider or lives outside the service area is subject to review by the LEOFF Board's designated hearing provider and will be limited to reimbursement up to what the designated hearing aid provider would charge. Hearing aids prescribed due to injury, disease or other unusual circumstancess will be considered on a case by case basis for exception to this policy. The Board will also authorize the cost of necessary repairs, however, routine maintenance and batteries shall be the members responsibility. 9.04 Rejected Claims (renumbered) 9.05 Filing Appeal in Cases Involving Claims for Medical Services (renumbered) 9.06 Medical Claims for Services Where Insurance Benefits Have Been Expended (renumbered) 9.07 Medical Claims for Services Where Treatment is Not Covered by Insurance (renumbered) 9.08 Medical Claims for Board Required Re-examinations (WAC 415-105-0901 ) (renumbered) Revised January 3, 2000 9.04 Skilled Nursing Facility Care Reimbursement A. The City of Auburn LEOFF Board will provide reimbursement for the reasonable expenses incurred by a LEOFF I member needing the services of a skilled nursing facility. Expenses which shall be reimbursed may include: 1. An amount not to exceed the daily benefit for nursing care under the City's existing long term care insurance. Page 44 City of Auburn LEOFF Board Policies and Procedures 2. The semi-private room and board rate plus the "level of care" charge where charged separately by a skilled nursing facility so long as the total does not exceed the Board allowed rate. 3. Charges for medically necessary physician prescribed medications, medical services (e.g. x-rays) and other medically necessary physician prescribed supplies. B. Non-medical charges, including but not limited to hair cam, personal toiletries and sundries, bed holds, and recreational events organized by the skilled nursing facility shall not be reimbursed. C. Before any skilled nursing facility charges may be reimbursed, the Board must be provided with a letter from the member's attending physician stating medical necessity for and estimated duration of skilled nursing facility care. Private room charges may be reimbursed provided the Board is supplied with written documentation of medical necessity for the same from the members attending physician, The question of medical necessity for skilled nursing facility care may be subject to annual or more frequent review by the Board, at the Board's discretion. D. All charges must be submitted to the appropriate insurance carriers, Medicare, Medicaid or other available long-term care insurance before submission to the Board. The Board may reduce the amount of reimbursement for skilled nursing facility care by the amount a LEOFF I member receives from these other sources. E. The Board reserves the right, at its sole discretion based on the record before it, to approve or disapprove reimbursement for skilled nursing facility care incurred by a LEOFF I member. F. The Board shall only reimburse for services rendered; advance payment of any charges will not be made by the Board. 9.05 Home Health Care Reimbursement A. The City of Auburn LEOFF Board may provide reimbursement for the reasonable expenses incurred by a LEOFF I member needing the services of home health care. It is the intent of this policy to reduce the amount paid for skilled nursing facility care. 1, Before any home health care charges may be reimbursed, the Board must be provided with a "Medical Request for Home Health Care" form completed by the members attending physician. The physician shall state the medical necessity and the estimated length of time during which home health care will be required and the type of care required (medical, daily living, and/or other). This form may be obtained from the LEOFF Board Secretary. The attending physician must provide to the Board a description of work to be performed by the home health care provider. This description is to be as detailed as possible. The question of medical necessity for home health care may be subject to annual or more frequent review by the Board, at the Board's discretion. Page 45 City of Auburn LEOFF Board Policies and Procedures 2. The total amount allowed shall not exceed the current Board allowed rate for skilled nursing home care as provided for in the Skilled Nursing Facility Care Reimbursement Policy, 3. All charges must be submitted to the appropriate insurance carriers, Medicare and other available long-term care insurance before submission to the Board. 4. The Board shall only reimburse for services rendered; advance payment of any charges will not be made by the Board. 5. The Board reserves the right to have an independent assessment agency evaluate the members home health care needs. The Board also reserves the right to approve or deny home health care reimbursement based upon the findings of the independent assessment agency. 6. The Board will not reimburse for home health care provided by an individual who ordinarily resides in the members home, or is a member of the family of either the member or the members spouse. 7. Requests for reimbursement shall be made on a Claim for Payment form. All explanations of benefits insurance documentation forms showing the amount paid and/or rejected and any physician documentation necessary to support the claim must be attached. 8. The Board reserves the right, at its sole discretion based on the record before it, to approve or disapprove reimbursement for home health care expenses incurred by a LEOFF I member. 9.06 Rejected Claims (renumbered) 9.07 Filing Appeal in Cases Involving Claims for Medical Services (renumbered) 9.08 Medical Claims for Services Where Insurance Benefits Have Been Expended (renumbered) 9.09 Medical Claims for Services Where Treatment is Not Covered by Insurance (renumbered) 9.10 Medical Claims for Board Required Re-examinations (WAC 415-105-0901 ) (renumbered) Page 46 City of Auburn LEOFF Board Policies and Procedures SECTION XII APPENDICES INDEX 12.01 Appendix "A" Board Membership Appendix "B" - Forms Samples R.C.W. 41.26 and W.A.C. 415-105 are available to view at Auburn Public Library. RCW 41.26 is also available to view at the City Clerk's office. WAC 415-105 is also available to view at the City Attorney's office. Page 47 CITY OF AUBURN LEOFF BOARD POLICIES & PROCEDURES Appendix "A" Board Membership Jim Kelly* Police November 22, 1993 December 31, 2001 Police Dept Representative January 1, 1996 253.931.3081 January 1, 1998 January 1, 2000 Clarence "Bud" Member-at-Large January 4, 1993 December 31, 2000 Larson** January 4, 1999 121 K Street NE Auburn, WA 98002 Home: 833-5485 Cellular: 970-3246 Jeanne Barber City Legislative December 20, 1999 December 31, 2000 3028 Scenic Dr Auburn WA 98092 Home: 253.939.1524 Pete Lewis City Legislative January 5, 1998 December 31, 2001 PO Box 2154 December 20, 1999 Auburn WA 98001 Home: 833-2409 Russ Vandver Fire Representative January 1, 1999 December 31,2000 Fire Department Work: 931-3060 *Chairperson Elected February 7, 2000 **Chairperson Elected February 7, 2000 ProTempore APPENDIX "B" FORMS SAMPLES Application for Disability Leave or Retirement Name SSAN Address Zip Sex Date of Birth Phone ( ) - Name of Employer Date Hired Rank and Position I hereby apply for disability benefits effective (date) according to the provisions of R.C.W. 41.26.120 (duty incurred) or R.C.W. 41.26.125 (non-duty incurred). My last day of service was or will be (date) The nature of my disability is (describe briefly): This disability [ ] was, [ ] was not (MUST check one) incurred in the line of duty. This disability [ ] was, [ ] was not (MUST check one) incurred while in other employment. This is a [ ] physical, [ ] mental, [ ] physical and mental (MUST check one) disability. I hereby submit statement(s) by my physician(s) regarding my disability and authorize my physician(s) to supply you with any information which you may request. I also consent to examination by your board appointed physician or board approved specialist. I understand that my consent is given only for the purpose of establishing my right to disability benefits. The information contained herein is true and complete to the best of my knowledge and belief. Applicant Signature Date LEOFF Representative Signature Date Revised 10/92 (F:\clerk\leoff\ppforms) Physician List Per WAC 415-105-040(4) and the City of Auburn LEOFF Board Policies and Procedures 3.10, each application shall be accompanied by a list identifying by name any physician who has been contacted within the last six months for which disability is claimed. This form is to be comleted by the applicant and submitted with his/her application for disability leave or retirement. Failure to complete this form and submit it with the application will result in delay or' refusal of the application. The following list is of any physician who has been contacted within the last six months. for the illness or injury for which disability is claimed. Name and Address Name and Address Name and Address Name and Address Name and Address Name and Address Name and Address Family Information Wife's Given Name, Initial, Birth Date Date of Marriage, Place of Marriage Child (Stepchild), Birth Date, Place of Birth Child (Stepchild), Birth Date, Place of Birth Child (Stepchild), Birth Date, Place of Birth Child (Stepchild), Birth Date, Place of Birth Child (Stepchild), Birth Date, Place of Birth I hereby certify, under oath, that the above information is true and correct. Applicant Signature ATTENDING PHYSICIAN'S STATENENT OF ACCIDENT OR SICKNESS 1. Patient's Name I Age: 2. Nature of sickness or injury (Describe complications if any) 3. When did symptoms first appear or accident happen? I 4. When did patient first consult you for this condition? (Oate) (Oate) 5. !s condition due to injury or sickness 6. Has patient ever had same or similar condition? arising out of pat ient's employment? [.'] Yes [ ] No [ ] Yes [ ) No If yes, explain on separate sheet of paper. Zf yes, explain on separate sheet of paper. 7. Describe any other disease or infirmity affecting present condition. 8. Nature of surgical or obstetrical procedure, if any. Describe fully. 9. Give Dates of Treatment. 10. If patient is hospitatized, give name and address. Off ice Hospi ta L Address Home Ci ty/State/Zip Hospital Date Admitted Date Discharged 11,How Long was or wilt patient be lZ. How Long was or will patient be partially disabled? continuously total ty disabled (unabte to work)? From 19-- through 19. From 19__ through 19__ 13. If due to pregnancy. Complications if any. 14 Is tile patient competent to endorse checks and direct the proceeds with a clear understanding of the nature of his/her acts? Yes [ ] No [ ] Comments LHP Date EOC Date Remarks: Attending Physician,s Name (PLease Print) ' I Degree Street Address City State Zip Telephone ( ) Signature Date Revised 10/92 (F:\cterk\teoff\ppforms) Law Enforcement Officers' and Fire Fighters' Disability Board,' Physician's or Provlder Statement Instructions Purpose The purpose of the physician's statement is to provide the City of Auburn Law Enforcement Officers' and Fire Fighters' Disability Board with information related to your patient's application for disability retirement and/or claim for medical expenses. Billinq The City of Auburn covers your patient by Washington Physicians' Medical, Group Number 55890. Please submit charges to the patient's insurance carrier. Any fee not covered by the insurance carrier will be paid by the LEOFF Board upon receipt of documentation of charges and insurance carrier explanation of benefits. Statement The nine items on the statement are self-explanatory. Should you prefer to put your report on your stationary, the Board will still need explanation on the nine items in addition to the ICDA and/or CPT codes. Reports The LEOFF Board may require a follow-up report or monthly reports depending on the disability of your patient. Ouestions Should you have any questions' related to this statement, please feel free to call the LEOFF Board Secretary, Robin Wohlhueter, at 931-3039. Claim for Payment LEOFF I Members ' 1. Name Social Security Number Date of Birth Address ":"" ZiP. Phone Number Department Rank & Position Sex. . : 2. A. .The injury or cp. ndition. causing .the expenses is as fOilO~NS: . . : .: . B. If job related, check here [ ] and attach incident report. 3. A. Has any portion of ~e amount claimed been paid or been processed through all possible insurance sources i.e., City of Aubum insurance, spouse insurance, Medicare, Workers' Compensation, etc.? [ ] Yes [ ] No , B. If YES, please .attach the explanation of benefits from the insurance company in addition t~ the bill. C. If NO, please explain why not · ') D. Has physician'S form been provided to your physician(s)? ' [ ] Yes'[] No If NO, please explain why not 4. These expenses are solely for necessary medical services as directed by my physician listed below. i understand it is my responsibility to advise the medical prorider that the medical prorider must first submits: to the members insurance prorider any costs for medical evaluations and/or medical reports. After the members insurance prorider has made a determination on the claim, the LEOFF member then submits to the LEOFF Board Secretary a claim for any unpaid costs. Doctor Phone Address 5. Total bill Amc~unt ~ubmitted to LEOFF I hereby authorize any insurance company, pre-payment organization, 'employer, .hospital or physician to release all information with respect to myself which may have a beadng on the benefits payable under any plan providing benefits or services to me. I also ceriify that the information and charges here shown are true and correct, and that these services and/or medications were received by me, and that I am liable for these charges. Applicant Signature ~. Date I .hereby certify that I have reviewed the above request and that all the necessary paperwork is in order. LEOFF Representative Signature Date Form Revised' 6/95, f:~clerk\Xeot'f IPPforrns.doc Claim for Payment Instructions LEOFF I Members 1. Please complete as indicated. .. 2, PleaRe compl.ete as indicated, 3. A., B. and C. - R.C.W. 41.26,150 (2) reads, 'The medical services payal:;ieunder this section will be reduced by any amount received or eligible to be received by the member Under Workers' Compensation, sodal security- including the changes incori:~orated under Public Law 98-97 as now or hereafter amended,. Insurance provided by another employer, other pension plan, or any other similar source." A City Attorney opinion interprets this to mean all LEOFF medical services payable to*a LEOFF I employee is secondary to all benefits which are' available as noted above, The LEOFF Board will require proof that all avenues of payment have been exhausted before submittal to the Board for payment, NOTE: A COPY OF THE BILL AND ALL MEDICAL INSURANCE EXPLANATION OF BENEFITS FORMS MUST ACCOMPANY YOUR CLAIM, .. 4, Please complete as indicated, 5. Total bill means the total'cost of services provided. Amount submitted to LEOFF is the total bill minus any .insurance or other payments.eligible to be received. Please sign and date and submit to your LEOFF Board Representative along with the required documentation for review and processing, " General Information Corrective Lenses - See Policy 9,02 Claim Processing Procedure - Submit your claim to your LEOFF Reeresentative by the .WEDNESDAY bel~ore the' regularly scheduled LEOFF Board meetina (first Monday of each month1, Any claim submitted after that day will be held until the next regularly scheduled meeting, Claims which do not have complete documentation will be tabled until the .. next LEOFF Board meeting so it is crucial to have the required paperwork, Payment Procedure - I1' there are no irregularities and the Board approves your request, your claim will be processed in the next regular vouchedng-period after the Board meeting, The vouchers are issued to the LEOFF Board member, All medical expenses are the members responsibility to pay, Claims for necessary medical services submitted to the Board shall be reimbursed to the member in the amount approved by the Board, f:~lerkUeoff~opforrns EYE EXAM AND CORRECTIVE LENSES WORKSBEET TO: Eye Care Provider FROM: City of Auburn Law Enforcement Officers~ and Fire Fighters~ Disability Board Your patient is covered under the provisions of the City of Auburn Law Enforcement Officers~ and Fire Fighterst (L.E.O.F.F.) Disability Board (R.C.W. 41-26) which means that he/she may be entitled to reimbursement by the LEOFF Board for excess costs not covered by other insurance. In order to properly determine the correct amount, we request that you provide the following information: Billed Amount Ins. Paid Amt. Balance Due Eye Examination Frames ......... Lenses * ....... $ $ $ · Lense costs may include tinting, anti-scratch, .multi-focal, coating, oversize, charges etc. Please return this form to your patient as soon as it is completed so that he/she may submit it to the LEOFF Board for consideration. Thank You. patient's'Signature: Eye Care Provider~s Name: LEOFF Representativeis Signature: C. ITY OF AUBURN LAW ENFORCEMENT OFFICERS AND FIREFIGHTERS' DISABILITY BOARD HEARING AID(s) VOUCHER CREDIT CARD AUTHORIZATION This voucher is for eligible LEOFF I Member use only in obtaining a hearing aid (s). Prior authorization is required per LEOFF Board Policy 9.03, Medical Claims for Hearing Aids. This voucher should be presented to Costco, Hearing Aid Provider who will bill the City of Auburn. Date: Headn.a Aid(s) Reauested for: LEOFF I Member Name: LEOFF I Member Address: Phone Number: Social Security No. Date of Birth: Date of Hire/Retirement Active/Retired: LEOFF Board Approval on day of ,199__. by: LEOFF Board Secretary COSTCO USE ONLY: (Return original to Auburn Finance Department) Model Devices Price Each Date Signature This voucher authorizes the use of the City of Auburn, Cardholder Account, by the above referenced individual for the purchase of hearing aid(s) from Price/Costco, Hearing Aid Provider who will advance funds for such purchase and bill the City of Auburn. Return original receipts to the City of Auburn, LEOFF Board Secretary, 25 West Main Street, Auburn, WA 98001-4998. 9/97 f:\CLER~\LEOFRVOUCHER LAW EN FORCEMEN T OFFICERS' AND FIREFIGHTERS ' ANNUAL MEDICAL/INSURANCE UPDATE Name: Social Security No. __/__/__ Mailing Address: Phone No: ( ) City: State Zip Code {Winter or seasonal address): City State: Zip Code Date of Birth Current Status: Active or Retired: Department: Fire __ or Police If retired, date of retirement: Spouse Name Spouse Date of Birth ctm yr ' ' ,.'[ Employer Phone No. ( ) Employer address: City State Zip Insurance: Pension Plan Are you eligible for Medicare Benefits: Yes __ No __ (If yes, provide Social Security Statement} Are you currently receiving Medicare benefits: Yes No Are you eligible to receive Workmen's Compensation through State Industrial Insurance: Yes (If not, provide statement from employer stating why yon are not eligible to receive benefits.) Are you currently eligible or receive insurance coverage provided by your current employer: Yes No __ Are you currently eligible or receive insurance coverage through spousal insurance coverage, or any other source: Yes __ No __ Ims n,txv- You wnsa AGE ;'OF 49.1:/,2.. 1) If, within the last 6 months, you visited a physician involving the condition for which you were disabled, submit a physician report. 2) Physician Name/Address/Telephone CERTIFICATION.' I, , certify the foregoing information is true and correct and to the best of my knowledge. SIGNATURE DATE F:clerkXLeoffi99update