Context: At a high-level, there are two aspects of approving a leave:
(1) An eligibility check – i.e. a determination as to whether an employee meets the eligibility criteria for being considered for leave. For example, under federal FMLA, there are three eligibility criteria (i.e., being employed by the employer for at least 12 months; being employed by the employer for at least 1,250 hours in the 12-month period immediately preceding the first day of level; and being employed at a worksite where 50 or more employees are employed by the employer without 75 miles of that worksite). Federal FMLA and some state leave laws require employers to send written notices of eligibility to ensure employees know how the employer resolved these eligibility checks. Once employees submit their leaves, Cocoon’s software immediately conducts eligibility checks and sends legally required notices of eligibility and rights and responsibilities.
(2) A qualification check - i.e., a determination as to whether the circumstances for which an employee seeks leave qualifies them for leave under applicable federal or state leave law or company policies. This would include, for example, whether the medical certifications employees provide establish that they or a family member have a qualifying serious health condition and the leave is needed due to the employee’s inability to work due to their own or a family member’s serious health condition. Once this review (what Cocoon calls the leave adjudication process) is completed, federal FMLA and some state leave laws require employers to send written designation notices telling employees whether they qualify (i.e., are approved) for the leave sought.
Note: Cocoon’s software always sends employees designation notices, however, Cocoon does not always handle leave adjudication. Cocoon believes this flexible approach to leave adjudication is necessary to empower employers to approach qualification checks in the manner they believe is best for their business.
Employers often prefer different approaches to qualification checks, especially with regard to medical and caregiver leaves and the review of supporting medical certifications. Some employers prefer to minimize employee friction and HR involvement while others prefer to optimize for absence management and ensuring that employees do not take leave without sufficient documentation supporting their need for leave.
With these dynamics in mind, Cocoon now includes features that enable employers to adopt different approaches to leave adjudication for continuous leaves. (Cocoon’s product features supporting leave adjudication for intermittent leaves are discussed here.)
Approach/Option 1: Choose to minimize friction and HR decision-making by approving all medical and caregiver leaves where employees simply submit the requested supporting documentation. In this approach, the documentation submitted is not reviewed to confirm that it is sufficient to qualify the employee for the leave sought. Cocoon refers to this as a completeness review. Cocoon conducts the completeness review when employers adopt this approach. Employers preferring this option should not enable leave adjudication in Cocoon.
Approach/Option 2: Exercise your legal right to more closely examine and confirm the medical sufficiency of an employee’s medical or caregiver leave request. Cocoon refers to this as a sufficiency review. Guided by Cocoon’s software, employers who enable leave adjudication will review SHC forms and conduct both a completeness and sufficiency review of the uploaded SHC forms. Employers preferring this option should enable leave adjudication in Cocoon.
If an employer chooses not to enable leave adjudication for continuous medical and caregiver leaves, Cocoon’s software will adopt Approach/Option 1 automatically. If an employer enables leave adjudication for continuous medical and caregiver leaves, Cocoon’s software will adopt Approach/Option 2 automatically. By default, Cocoon’s software will adopt the same leave adjudication approach for continuous medical and caregiver leaves; however, employers can choose to adopt different approaches for continuous medical and caregiver leaves but the software will ask you to confirm that you intend to do so.
Note: In all cases: Cocoon’s software instructs employees to upload medical certifications (SHC forms) into Cocoon.
Regardless of whether you choose to enable leave adjudication for continuous medical or caregiver leaves, Cocoon’s software will drive the communications to employees explaining their need to upload the certifications, the consequences of not doing so, and reminding them to fulfill this important obligation. If employees do not upload the required documents by the 15-day deadline,Cocoon will automatically take the next steps to keep the leave process moving. This may include following up with the employee, reducing HR burden by providing an initial one-time five day extension of the time to upload the certification or, if necessary because employees fail to return any certifications, denying the leave request. Once employees upload the certifications, the leave adjudication process for you or Cocoon, depending on whether you enable leave adjudication in Cocoon, begins.
Below is some additional information on an employer’s responsibilities when leave adjudication is enabled to help you decide whether it makes sense for your organization to enable leave adjudication for your employees’ continuous medical and caregiver leaves.
Adjudication Enabled: What You Must Do as the Employer
When adjudication is enabled for continuous medical and caregiver leaves, and employees upload medical documentation supporting their leaves, Cocoon’s software will direct you to: (1) review the documents uploaded to Cocoon to determine if they are complete; (2) determine whether the leave is sufficient; and (3) approving or denying the leave based on the review.
To perform #1, Cocoon’s system will ask you to enter all the key information required to make a certification complete. The certification will be incomplete if it is missing information needed to complete all of the entries Cocoon’s software requires.
To perform #2, you will assess whether the information included in the certification is complete but is vague, ambiguous or non-responsive.
If the certification is incomplete or insufficient, using Cocoon’s software, you will send a deficiency notice to the employee requesting they correct or provide additional information.
The software will automatically provide employees with seven calendar days to cure any identified deficiencies.
If employees fail to provide required updated certifications, Cocoon’s software will automatically deny the leave.
If employees submit complete and sufficient certifications, you will then perform #3 approving or denying the leave as you find appropriate.
It may be helpful to think of your role in leave adjudication in two steps:
Step One: Review Documents Submitted in SHC Folders In Support of Leave:
Your job at this point in the flow is to review the documents uploaded to the SHC folder and decide whether they are complete and sufficient. You can determine if all the key required information by completing leave details in the flow. If the documentation is missing information required by the leave details flow, it is likely incomplete and this will be addressed in Step Two below. If all key information is provided, then you must determine whether the information is sufficient to establish a right to FMLA, state or applicable company leave.
Step Two: Determine Whether The Leave Is Deficient or Should be Approved or Denied
Deficiency Flow: If the documents in support of leave are incomplete or insufficient, before denying all or a portion of the leave, your team must initiate a deficiency flow. This flow helps you meet your compliance obligation to provide employees written notice of the specific deficiencies (i.e., missing or inadequate information) in the documentation employees submitted. The flow will advise employees that they have the legally required 7 calendar days to cure the identified deficiencies. Providing deficiency notices in the flow is legally required and, without this action, you may not deny (either in whole or part) the employee’s leave request.
Approval or Denial: After reviewing the documents in support of leave and addressing any deficiencies, your team will make the final decision to approve or deny the leave request based on your internal policies.
If adjudication is enabled, failure to properly manage the review process may result in denied leaves or delays.
Adjudication Not Enabled: Cocoon Handles the Process
When adjudication is not enabled, Cocoon takes over the responsibility for reviewing and approving leave requests based on completeness checks or automatic leave approvals.
What Happens When Cocoon Handles Adjudication?
Cocoon’s process differs slightly from the employer-driven review when leave adjudication is enabled for continuous medical and caregiver leaves:
Completeness Review: Cocoon will perform a completeness review of the documents in support of leave documentation submitted by the employee. This means Cocoon will check if all necessary fields are filled out, but not whether the provided documentation is sufficient or correct to establish an employee’s qualification for leave. If something is missing, Cocoon will flag it and request the necessary information from the employee.
Sufficiency Not Reviewed: Unlike when the employer is handling adjudication, Cocoon will not assess whether the documents in support of leave meet the regulatory standards for employees to qualify for leave (i.e., sufficiency). We focus solely on ensuring all required information is present. The determination of sufficiency falls under your purview if adjudication is enabled.
Employee Communication: If anything is missing or unclear in the documents in support of leave, Cocoon will automatically request the missing information from the employee to complete their leave request.
If you have any question regarding leave adjudication for continuous medical and caregiver leaves, please feel free to reach out to [email protected]
Questions? Reach out to the Cocoon Support team at [email protected]