33. Common denials that can be resolved by redetermination
Late application denial or partial approval of dates
In general, applicants have 90 days from the start of PFML leave to apply for benefits. If the application is submitted late, then DFML will approve only the portion of leave that falls within 90 days of the application date. If the application was filed more than 90 days after the end of PFML leave, the entire application will be denied.
Always appeal a late application denial. GBLS has won appeals for applications that were filed up to 2.5 years late. The appeal should explain why the application was late. It must be for “circumstances beyond the party’s control.” 458 C.M.R. 2.02 (“Good Cause”). Past examples of good cause for late application include: employer did not tell worker about PFML, employer said they would not be eligible, worker did not know about PFML, worker did not know PFML could be received at the same time as workers comp, worker applied for unemployment because they did not know about PFML (and got denied unemployment due to incapacity), worker did not have a doctor at the time of the accident or start of leave, it took a long time to get a doctor’s appointment to certify the condition, worker did not have a printer to print the certification form, worker submitted random medical records because they did not know there was a special PFML certification form (see below about documentation), worker was unemployed and did not know an unemployed worker retains eligibility for PFML for six months after losing their job.
Documentation denials
Notify the appeals department of when you believe you will get the updated document (medical certification or ID), and they can postpone the hearing and allow you time to upload the updated document. Once uploaded, they will try to redetermine the case before re-scheduling the hearing. Hearings can be postponed for months to allow time for documents to be fixed or obtained.
One of the most common denials is lack of Certification of Serious Health Condition (CSHC) or missing information in the CSHC. It can be time-consuming to get a health care provider to correct the certification. Tip: the doctor can write a letter with clinic or hospital letterhead that states the missing information. Many times, it is faster to get a letter than to have the doctor update the 4-page CSHC form.
Common mistakes include:
- Questions 14-16: Must put an end date for incapacity. When health care providers are not sure how long the incapacity will last, they sometimes write “TBD” or leave the end date blank. Advocate with your provider that they must put an end date. The end date can be updated in the future.
- Question 10: Must state job functions the worker cannot perform. This question requires the patient to describe their job to the health care provider and list the job functions the illness is preventing them from doing.
- Questions 17-24: Must contain all healthcare provider information. For doctors in other countries, DFML also requires a letter on hospital letterhead, a copy of the provider’s license, a letter stamped with the provider’s official stamp, or some other document showing the provider is licensed.
Some claims are also denied if the photo ID is blurry, black-and-white, expired, or does not meet some other criteria. For example, passports must show the signature, which is sometimes on the page above the photo page. Photo ID must be in color. Acceptable IDs include: driver's license, state ID, federal ID such as Permanent Resident or Work Authorization card, passport (US or foreign), tribal ID card, or liquor license. For alternative documents, see DFML’s ID verification page.
Benefit reduction due to other income
If there is an error in the application or the employer response about whether any other income is being paid during the leave, then the PFML benefits may be reduced. Appeal and explain what other income is being received for what dates. For example, if the worker uses 4 weeks of PTO at the start of a 12 week leave, DFML may accidentally reduce benefits to $0 for all 12 weeks. Usually, after the worker provides information in the appeal, DFML can confirm with the employer and fix the issue.
Benefit allotment was exhausted
PFML medical leave can last up to 20 weeks and PFML family leave can last up to 12 weeks each benefit year. The maximum combined leave is 26 weeks each benefit year. The “benefit year” starts on the Sunday prior to the first day of any leave for a qualifying reason and lasts for 52 weeks. G.L. c. 175M, § 1. If the worker or the employer report prior use of leave for a qualifying reason in the past 12 months, then the worker’s PFML allotment will be reduced.
Sometimes there is a misunderstanding. For example, a worker who takes a vacation for 2 weeks to visit her parents is not taking PFML leave. But if the employer knows the parents are sick, they may report it as a prior use of family leave. Or a worker may accidentally report past illness as “medical leave.” However, without hospitalization or in-patient treatment, it is very unlikely that the illness was a “serious medical condition,” so it was probably not a “qualifying reason” for PFML. Usually, these misunderstandings can be cleared up by the worker appealing, asking why the benefit allotment was reduced, and then giving more information.
In other cases, the leave allotment reduction is correct. For example, any past use of workers comp will count against the PFML leave allotment. Or, if the worker cares for a sick family member and then has a baby in the same benefit year, they will receive less “bonding leave.” The reason is “family leave” used to care for the sick family member comes out of the same 12-week allotment as “bonding leave” for a new child.
Employer-provided information
The most frustrating denial notice says “You are not eligible for Paid Family and Medical Leave (PFML) benefits because your employer provided information indicating that your application for family or medical leave benefits should be denied.” Always appeal immediately! You can leave the appeal reason blank or say “the denial notice does not explain why I was denied, so I cannot tell you why it is wrong. I just disagree.”
To find out what the employer wrote, request the “appeal case folder” from DFML’s public records request form. Then, workers can contact the call center and provide their version of events, and ask them to share with appeals or ask appeals to call the worker.
Usually, the information the employer provides is false or irrelevant. For example, the employer might say the worker didn’t tell them about needing PFML leave until 1 day before the PFML leave started. DFML will deny benefits. However, the benefits should be approved if:
- The worker actually provided 30 days of notice G.L. c. 175M, § 4(b).
- The worker had a good reason for providing 1-day notice (like a car accident or other sudden medical need). G.L. c. 175M, §4(b) (“or shall provide notice as soon as practicable if the delay is for reasons beyond the employee's control.”)
- The worker did not receive written instructions about PFML from the employer at the time of hire. G.L. c. 175M, § 4(b) (“If an employer fails to provide notice of this chapter as required under subsection (a), the employee's notice requirement shall be waived.”)
Private plan denial or incorrect approval
A worker who disagrees with a decision by a private plan must appeal to the private plan and send a copy of the appeal to the employer that maintains the private plan. 458 C.M.R. 2.07(2)(c); 458 C.M.R. 2.14(3). In practice, private plans are very informal and may fix a claim with a phone call. In other cases, the private plan may simply not process the appeal or refuse to process the claim all together.
An appeal to a private plan should be in writing, with a date. After making a good-faith effort to appeal the private plan decision, the applicant can appeal to DFML. There is no formal channel to appeal to DFML, so the worker can try the following:
- Call the DFML call center and request an appeal of the private plan decision. Explain that the worker already tried to appeal the decision to the private plan.
- Fax or mail an appeal to the DFML appeals department and explain that the worker already tried to appeal the decision to the private plan, and why the worker believes the decision was wrong. Include a copy of the written appeal to the private plan, showing the date it was sent.
Department of Family and Medical Leave
P.O. Box 838
Lawrence, MA 01842
Fax: 617-855-6180 - Email AnnMarie.Coughlin@mass.gov (DFML private plan point person) and explain that the worker already tried to appeal the decision to the private plan, and why the worker believes the decision was wrong. Include a copy of the written appeal to the private plan, showing the date it was sent.