Who is responsible for completing the form?
The insurer, self-insured employer or third-party administrator is responsible for completing this form.
Why is this form needed?
The purpose of NOID form is to notify the claimant of a reduction or discontinuance of wage-loss benefits, the amount of benefits paid on the claim and their right to an administrative conference. The department uses the form to review for compliance with the statutes and rules, to verify calculation of benefits and for statistical data.
What, specifically, is this form used for?
To report a reduction or discontinuance of one of following wage-loss benefits:
temporary total disability (TTD)
temporary partial disability (TPD)
permanent total disability (PTD) (only if there is no previously issued judicial or administrative findings of PT status)
To report a reduction or discontinuance of wage-loss benefits for one of the following reasons:
a return to work at full wages
a return to work at reduced wages
a reason other than return to work (always attach appropriate medical reports)
To comply with statutes and rules:
Minnesota Statutes 176.101
Minnesota Statutes 176.238
Minnesota Statutes 176.239
Minnesota Statutes 176.221, subd. 1
Minnesota Rules 5220.2570
Minnesota Rules 5220.2630
Minnesota Rules 5220.2720
When is this form completed?
This form must be filed:
within 14 days of the date you received notice that the claimant has returned to work at full or reduced wages;
at the same time that benefit payments are reduced or discontinued for reasons other than return to work;
when denying primary liability on a previously accepted claim when more than 60 days have elapsed since the employer was notified of the injury.
Where is this form sent?
A copy of this form is sent to:
claimant (Note: Always attach an Employee Request for Administrative Conference form.);
attorney for claimant (if represented);
the Minnesota Department of Labor and Industry, Safety and Workers' Compensation Division;
the employer; and