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DHHS POLICIES AND PROCEDURES

_______________________________________________________________________________________________________________

Section V:

Human Resources

Title:

Safety and Benefits

Chapter:

Appendix A, Disability Income Plan of North Carolina

Current Effective Date:

4/1/04

Revision History:

7/1/03

Original Effective Date:

10/1/92

_______________________________________________________________________________________________________________

DISABILITY INCOME PLAN OF NORTH CAROLINA

Department of State Treasurer
Retirement Systems Division
325 North Salisbury Street
Raleigh, North Carolina 27611

DESCRIPTION AND USE OF CLAIMS FORMS

Form DIP-1
Employee’s Application for Short-Term Benefits

This application should be completed by or on behalf of the employee and submitted immediately after 90 days of disability, or upon termination of the disability, if the disability ended after the 60th day but before the 90th day. Forms DIP-2, Authorization of Release of Medical and Other Information, and DIP-3, Request for Payment by Employee and Certification of Disability by Physician, should also be completed and submitted along with this application.

Form DIP-2
Employee’s Authorization for Release of Medical and Other Information

Two (2) originals of this form are to be completed by the employee and submitted along with the Form DIP-1. One (1) copy of this form will be retained by the employer and one (1) copy of this form will be forwarded by the employer to the Retirement Systems Division along with the employer’s request for reimbursement.

Form DIP-3
Request for Payment by Employee and Certification of Disability by Physician

This form is to be completed and submitted to the employer only after the disability has lasted more than 60 days. It should be submitted immediately after 90 days of disability or upon termination of disability, if earlier. If the disability lasts more than 90 days, this form should be submitted at 30-day intervals until the disability has lasted more than 12 months, or upon termination of disability, if earlier. This form will not be required to certify any period of continuous disability after it has lasted for more than 12 months.

If the disability is likely to be permanent, the employee or his/her employer may request that the Plan’s Medical Board make a preliminary determination of eligibility for long-term benefits by filing form DIP-5. If this preliminary determination indicates that the employee meets the definition of disability for long-term benefits, this determination may be used at the employer’s discretion in lieu of the physician’s certification required for each 30-day period. Note: A preliminary determination of eligibility for long-term disability benefits does not preclude the requirement that the Medical Board make a determination of eligibility for long-term disability benefits at the conclusion of the short-term disability period.

For those employees whose payrolls are handled by the Payroll Section of the Office of State Controller, a copy of this form must be attached to form DIP-E2 (Employer’s Monthly Calculation and Authorization for Payment of Short-Term Benefits) and both submitted to the Office of state Controller for payment.

Form DIP-4
Application for Long-Term or Extended Short-Term Disability Benefits

This form is used to apply for long-term disability or extended short-term disability benefits and should be completed by the employee and his/her legal representative and should be submitted to the employer for completion of the Employer Certification section. The employer should forward the completed application directly to the Retirement Systems Division and attach the Medical Report, form 7A, or advise the physician to forward the Medical Report directly to the Retirement Systems Division. In order to avoid delay in the payment of long-term benefits, these forms should be completed and forwarded to the Retirement Systems Division within 60 days of the conclusion of the short-term benefit period. Note: Application for long-term disability benefits must be made within 180 days of the conclusion of the short-term disability benefit period or the conclusion of salary payments, whichever is later.

Form DIP-5
Request of the Plan’s Medical Board to Make a Determination of Eligibility for Short-Term Disability Benefits and/or a Preliminary Determination of Eligibility for Long-Term Benefits

This form is used to request that the Medical Board make a determination of eligibility for short-term disability benefits in disputed cases or a preliminary determination of eligibility for long-term benefits. This request may be made by the employee, his legal representative or his employer. Note: A preliminary determination of eligibility for long-term benefits does not preclude the requirement that the Medical Board make a determination of eligibility for long-term benefits at the conclusion of the short-term disability period.

Form DIP E-1
Employer Master Worksheet for Determining Eligibility for Short-Term Benefits

This form is for the employer’s internal use in making payments during the short-term benefit period. This is a prototype form that may redesign to fit its own payroll system, if necessary. The main features of this form included space to enter identifying information regarding the disabled employee, an eligibility check to ensure the employee is eligible for payments, instructions to determine the gross monthly benefit amount, and space to keep a record of payment. Some form of a record of payment must be submitted to the Retirement System along with the employer’s request for reimbursement.

Form DIP-E2
Employer’s Monthly Calculation and Authorization for Payment of Short-Term Benefits

This form is also for the employer’s internal use in making payments during the short-term benefit period, and is prototype form which the employer may redesign to fit its own payroll system, if necessary. This form is intended to serve as a guide in calculating the short-term benefit payable for a specific period including instructions regarding offsets for any worker’s compensation payments or excess earnings the disabled employee may have had during the particular period. This form may be used as a payroll authorization and submitted to your payroll department for payment. Note: For those employers whose payrolls are handled by the Payroll Section of the Office of State Controller, this form must be completed and forwarded to the Office of State Controller for payment.

Form DIP-E3
Employer’s request for Verification of contributing Membership Service

In some instances, you may have a disabled employee who has been employed for less than one year by your employing unit who may have other state employment sufficient to qualify for benefits under the Plan. The use of this form is, therefore, optional and should be used by the employer to verify that the disabled employee meets the requirement of one (1) year of contribution membership service in the Retirement System earned within 36 calendar months preceding the disability. This form should be used only when an employer is unable to certify the service requirement from the employer’s own payroll records. The employer should complete the top portion of this form and forward the form to the Retirement Systems Division.

Form DIP-E4
Employer’s Request to Grant Service Credits and/or for Reimbursement of Payments Made Under the Plan

This form is for the employer’s use in granting Retirement System service credits for period when an employee has received short-term benefits from the plan and/or for the employer’s use in requesting reimbursement for short-term benefit period. The Employer Certification to Grant Service Credits must be completed for each employee to whom you pay short-term benefits, even if the employee receives benefits for less than six (6) months. Employees who receive short-term benefits are eligible for service credits in the Retirement System for each month the employee is eligible for and in receipt of a benefit. Therefore, it is completed for each employee to whom you pay short-term benefits. This form should be submitted immediately after the employee’s short-term benefits cease, if the benefits cease before the employee has reached the seventh month of the short-term benefit period. If the employee has received or will receive short-term benefits for longer than six (6) months, this form may be completed and submitted to the Retirement System when the employer requests reimbursement for payments made during the second six (6) months of the short-term benefit period. Note: Employers may file for reimbursement of payments made during the second six (6) months of a short-term benefit period at the end of each calendar quarter.


For questions or clarification on any of the information contained in this policy, please contact Human Resources. For general questions about department-wide policies and procedures, contact the DHHS Policy Coordinator.


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