Policy and Procedure Name:
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Initial Claim Determination
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Policy #:
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CP-9-01
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Code/Rule Reference:
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R.C. 4123.511,
4123.84;
O.A.C. 4123-3-08,
4123-3-36
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Effective Date:
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09/28/21
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Approved:
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Ann M. Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-9-01, effective 11/07/19
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History:
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Previous versions of this policy are available upon
request.
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Initial Claim Determination Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Auto Claims Processing (ACP)
Fast Response
Lost Time (LT) Claim
LT Indicators
Medical (MO) Claim
Terminating Rules
Triage
IV. POLICY
A.
Investigation and Determination Time Frames for all State Fund Claims –
Claims services staff shall investigate a claim and issue a decision:
B.
Auto Claims Processing (ACP) for Initial Claim Determination
C.
Employer Retains Appeal Rights
D.
Dismissal of a First Report of Injury (FROI)
E.
Claims Not Requested by the IW
F.
Employer Certification
V. PROCEDURE
A.
Claim Note Requirements
B.
ACP
C.
State Fund (SF) and Public Employer (PE) Claims Not Eligible for ACP or
Fast Response
D.
Issuing an Order
E.
Re-filing a Dismissed Claim
F.
Reconsideration
The purpose of this policy is to ensure the Ohio Bureau of
Workers' Compensation (BWC) processes initial claim applications in compliance
with R.C. 4123.511.
This policy applies to BWC Claims Services staff.
Auto Claims
Processing (ACP): the systematic evaluation of low-risk claims with
little or no human intervention. Claims systematically pass through
established business rules that may prevent claims from completing the process
and require claims services staff to conduct further investigation.
Terminating rules will prevent claims from being allowed via ACP.
Fast
Response: a program established to immediately allow specific
medical conditions which have a historical record of being allowed whenever
included in a claim and having low medical costs. Claims in the program
are from state-fund, private employers and public employer taxing district
employers who have access to the Surplus Fund, are filed for medical treatment
only, and are filed with only one (1) diagnosis code/condition.
Lost Time
(LT) Claim: a claim with eight or more days of lost time from work
directly caused by a work-related injury, even if compensation or wages in lieu
of compensation have not been paid to the injured worker (IW) or in any claim
in which BWC awards compensation.
LT Indicators: one type of terminating rule that
presupposes an IW will, or could, miss eight or more days of work.
Medical (MO)
Claim: a claim with seven or fewer days of lost time from work
directly caused by a work-related injury, for which the IW receives no
compensation for lost wages (e.g., temporary total, salary continuation), or is
not awarded any compensation during the life of the claim.
Terminating
Rules: any systematic red flag that presupposes a claim will, or
could, be a LT claim.
Triage:
Systematic Triage: the systematic review of all
claims that evaluates the severity of a claim as identified by International
Classification of Diseases (ICD) codes, indications of lost time, benefit
applications and/or claim accident/illness type and assigns those claims not
allowed by ACP to the appropriate claims office for determination.
Claims Triage: the manual transfer of a claim
to either a claims office or particular discipline within the claims office
(e.g., Intake, Return to Work, Remain at Work) based upon the severity of the
condition or where the claim falls in the life cycle.
A. Investigation
and Determination Time Frames for all State Fund Claims – Claims services staff
shall investigate a claim and issue a decision:
1.
No later than twenty-eight (28) calendar days after sending the notice
of receipt of the claim; or
2.
No more than twenty-eight (28) calendar days after the receipt of the
report for a medical examination in claims in which an examination is required
by statute.
B.
Auto Claims Processing (ACP) for Initial Claim Determination
1.
It is BWC’s policy to consider claims for initial allowance using
ACP. Claims shall be:
a.
Allowed systematically with little to no manual intervention; or
b.
Directed to the appropriate claims office to process.
2.
The claim will remain in ACP until it is determined or one of the
terminating rules removes it from ACP.
C.
Employer Retains Appeal Rights
1.
The employer retains the right to contest the allowance of a claim
determined by ACP, including Fast Response claims.
2.
Employer certification of a claim does not eliminate the employer’s
right to appeal a BWC Order.
D.
Dismissal of a First Report of Injury (FROI)
1.
It is BWC policy to dismiss a claim prior to issuance of a BWC Order or
during the BWC Order appeal period when:
a.
The IW voluntarily withdraws his/her claim application without
prejudice; or
b.
An IW/IW representative requests dismissal of a claim either verbally or
in writing.
2.
BWC shall not dismiss an initial claim application if the appeal period
has expired.
3.
BWC may dismiss a claim at any time during the twenty-eight (28) day
determination period when:
a.
The IW has filed a claim for a psychological condition which did not
arise out of forced sexual contact and there is no physical condition alleged
following the Psychiatric Conditions policy and procedure;
b.
The IW has signed a sports waiver, which BWC has on file;
c.
The IW is covered by federal workers’ compensation;
d.
The employer and employee are exempt from coverage because they, on
religious grounds, conscientiously object to the acceptance of workers’
compensation benefits; or
e.
Claims services staff has received approval from a supervisor for
dismissing the claim prior to the end of the twenty-eight (28) day determination
period for other good cause.
4.
Once a claim is dismissed, BWC can take no further action in the claim,
except updating claim notes, unless a party re-files the claim application.
5.
The dismissal and subsequent re-filing of a claim application for the
same injury and same injury date will not change the statute of limitations in
which the IW must file.
a.
For injury claims with a date of injury (DOI):
i.
Prior to 09/29/17, the statute of limitations is two (2) years; or
ii.
On or after 09/29/17, the statute of limitations is one (1) year.
b.
For occupational disease claims, the statute of limitations is:
i.
Two (2) years for claims with a DOI before 09/28/21; or
ii.
One (1) year for claims with a DOI on or after 09/28/21.
E.
Claims Not Requested by the IW
1.
BWC employees are prohibited from filing any claim on behalf of the IW
or IW’s family if there are any indications that the IW or the IW’s family does
not want a claim filed.
2.
BWC employees may file on behalf of the IW or IW’s family when the IW or
IW’s family expressly requests BWC file on their behalf.
F.
Employer Certification
1.
Certification may be written or verbal.
2.
When the claim is certified, the employer has accepted the validity of
the IW’s claim. Specifically, certification only means the employer
acknowledges that a work-related injury occurred.
3.
State fund and public employers cannot certify a claim in part (i.e.,
certification cannot be specific to allowing medical costs, but denying
lost-time benefits).
A.
Claim Note Requirements
1.
BWC staff shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note requirements; and
2.
Shall follow any other specific instructions for claim notes included in
this procedure.
1.
If the claim does not meet the ACP eligibility rules, the claims
management system will generate a “new claim-ineligible for ACP” work item and
claims services staff shall process the claim per sections C and D below.
2.
If the claim meets the ACP eligibility rules, the claims management
system systematically places the claim in “accepted” status and assigns the
claim to the ACP group.
3.
If additional information is needed to determine if the claim meets the
ACP eligibility rules, claims services staff shall receive a “new claim pending
ACP” work item after three (3) days from the date the claim is filed.
a.
Claims services staff shall ensure the claim is assigned an appropriate
ICD code(s), in accordance with the narrative description of the injury or
disease.
b.
Within two (2) business days of receipt of the work item, claims
services staff shall review all available information and attempt to obtain the
missing data elements.
i.
If the missing information is available, claims services staff shall
enter it in the claims management system and allow the claim to go through ACP.
ii.
If the missing information is not available, claims services staff shall
contact the managed care organization (MCO) to obtain the information.
iii. If,
after three (3) calendar days, the missing information is still not available,
claims services staff shall make one more attempt to obtain it.
iv. After
fourteen (14) days, the system will generate a “no claim decision” work item if
the claim is still undetermined. Claims services staff shall continue to
manage the claim and the claims management system will continue to evaluate the
claim using the ACP eligibility rules.
4.
Fast Response Claims
a.
The claims management system will set the acceptable fast response ICD
codes to “accepted” upon the acceptance of the claim in ACP.
b.
See Appendix A to OAC 4123-3-36 for a list of acceptable ICD
codes.
c.
When the diagnosis code(s) is one which can be allowed through fast response,
but the claim does not meet the ACP eligibility criteria, claims services staff
shall:
i.
Verify all other compensability tests under section V.C.2. below
ii.
Update all available claim information in the claims management system;
iii. Enter
a claim note to indicate a fast response claim;
iv. Immediately
update the claim status to “allow” in the claims management system; and
v.
Place the claim in “hearing” status if an appeal is filed to the BWC
Order.
C.
State Fund (SF) and Public Employer (PE) Claims Not Eligible for ACP or
Fast Response
1.
General Requirements:
a.
Claims services staff shall review all MCO notes in the claims
management system to determine what information has already been gathered and
what additional information is necessary.
b.
Claims services staff shall ensure the claim is assigned appropriate ICD
codes, in accordance with the narrative description of the injury or disease.
c.
Claims services staff shall make a determination in the claim if all
necessary documentation is present.
d.
If additional information is required, claims services staff shall allow
the MCO up to three (3) days to gather the required information.
e.
Claims services staff shall contact the MCO after three (3) days if
additional information is needed to make the claim determination, but shall not
contact the MCO solely to validate the information in claim notes.
f.
Claims services staff shall e-mail the BWC MCO Business Unit Referral
e-mailbox for assistance when:
i.
After supervisory staffing with the MCO, the MCO fails to provide the
required data elements and/or necessary medical documentation to make a
determination on the claim and fails to establish good cause for that failure;
or
ii.
An MCO has shown a pattern of not providing the required data elements
or obtaining the required documentation.
g.
Claims services staff shall request certification information, verify
the manual number, also referred to as the National Council on Compensation
Insurance (NCCI) manual classification number, and, if appropriate, request
necessary wage information in addition to any other missing information,
including interstate jurisdiction information from the employer of record (EOR)
after the MCO has completed their initial contacts. If certification has
not already been established and contact with the EOR is unsuccessful, claims
services staff shall send the “Employer Certification Request” letter.
h.
If wages are still needed, claims services staff shall follow the Wages
policy and procedure.
i.
Claims services staff shall document verbal certification information in
claim notes. The notes must reflect the name and title of the person
providing certification. Claims services staff shall also note employer
certification information in the claims management decision note when issuing
an initial BWC Order.
j.
If no employer information is available, claims services staff shall
follow V.C.2.i.(i-ix.) below.
k.
Claims services staff shall ensure that an initial contact has been made
on or before seven (7) days from the date of filing. If contact has not
been made, staff shall immediately call the necessary party(ies) to the claim
to complete the initial contacts.
l.
When claim applications are received more than seven (7) days after the
filing date, claims services staff shall immediately contact the MCO if
additional information is required to make a determination. If the MCO
does not provide the necessary information within three (3) days, claims
services staff shall contact the appropriate party for missing
information. If claims services staff is unsuccessful in the attempted
phone contact, claims services staff shall send an Additional Information
Request (C-63) to the party.
2. Claim
Investigation
a.
Claims services staff shall investigate the claim to ensure the claim is
assigned to the appropriate claims office. Claims may need to be
reassigned to a claims office based on benefit type (medical only or lost
time), accident type (injury, occupational disease, death), and/or requested
condition (psychiatric or forced sexual conduct).
i.
Example: Medical claims shall reassign forced sexual
conduct claims to the appropriate claims office.
ii.
Example: Death claims shall be reassigned to the Survivor
Benefits Team, except for statutory occupational disease death claims for
specific conditions when there is no existing claim.
b.
Social Security Number (SSN)
i.
When a new application has been entered, the claims management system
will identify if there are any possible duplicate claims. The indexer
shall review any identified claims to determine if the new claim could be a
duplicate of an existing claim.
a) If
the application is an exact duplicate, the indexer shall not create a new claim
and image the application to the existing claim.
b) If
it is unclear or not a duplicate, the indexer shall move forward with creating
a claim number.
ii.
Upon release of the claim, the claims management system creates a work
item if the IW has any previous claims. Claims services staff shall
review for any potential duplicates or claims in which the same/similar body
part(s) is allowed.
a) If
a duplicate claim is identified, claims services staff shall refer to the Duplicate
Claims and Customers policy and procedure for processing
instructions.
b) If
a duplicate claim is not identified, claims services staff shall continue
processing the claim.
c)
If there are same or similar body parts allowed in other claims, claims
services staff shall investigate to determine if the recently filed claim is a
new claim or an aggravation of a condition allowed in an existing claim.
iii. Claims
services staff shall look up the IW by name only if the SSN is not known or the
IW does not have one.
iv. Claims
services staff shall document any changes to SSN, name, and/or date of birth in
claim notes and customer level notes.
v.
Claims services staff shall not update a SSN until the update has been
verified.
vi. If
an IW does not have a SSN or a visa number, claims services staff shall check
the “Tax ID unavailable” box in the claims management system so that
compensation may be released to the IW when appropriate.
c.
Claims services staff shall review the FROI and claim documentation and
make appropriate referrals for any potential:
i.
Employer management issue;
ii.
Subrogation;
iii. Fraud;
or
iv. Safety
trending.
d.
Claims services staff shall refer to the Psychiatric
Conditions policy and procedure when a psychiatric condition is
requested on the FROI.
e.
Claims services staff shall review all MCO claim notes as part of
his/her investigation.
f.
Claims services staff shall review the claim documents to determine if
there is missing documentation, including supporting medical
documentation.
i.
Claims services staff shall refer to the Medical Evidence for Diagnosis
Determination (MEDD) Coding Reference Guide ICD-10 for additional information
about what supporting medical documentation may be required.
ii.
Claims services staff shall request the missing information from the MCO
by phone and/or e-mail during initial contact or as it is identified.
iii. Claims
services staff shall document in claim notes what information was requested.
iv. If
required documentation is not received from the MCO within three (3) days of
making the request or the MCO requests assistance from BWC to obtain the
required documentation, claims services staff shall call the appropriate party
to the claim (IW, IW representative, employer, or employer representative) to
obtain missing documentation.
v.
If claims services staff is unable to reach the appropriate party to the
claim by phone, he/she shall send a C-63 and continue attempts at phone
contact.
vi. If
documentation is not received within seven (7) calendar days from the phone
call to the party to the claim, claims services staff shall make a second call
to the IW only if he/she is unrepresented.
vii. Claims
services staff may contact the provider of record for supporting documentation
if the MCO is unable to obtain it.
viii.
Claims services staff shall deny a claim for lack of supporting
documentation only when he/she:
a) Reviews
MCO notes and/or requests the required documentation from the MCO;
b) Attempts
at least one (1) phone call to obtain the required documentation and the IW/IW
representative does not respond;
c)
Sends the C-63 if unable to reach the IW/IW representative by phone and
the IW does not respond to the C-63; and
d) Attempts
one (1) final phone call to the IW if the IW is not represented and the IW
fails to respond to the C-63 within 10 days.
g.
If a claim will be denied due to lack of supporting documentation,
claims services staff should call the IW to explain:
i.
IW’s right to withdraw the claim; and
ii.
How to re-file with the necessary supporting documentation within the
applicable statute of limitations.
h.
If a claim is withdrawn at the IW’s request, claims services staff shall
dismiss the claim (See section V.D.2. below.
i.
Claims services staff shall review the claim to ensure the elements of
the Jurisdiction,
Coverage
and Employer/Employee Status, and Compensable
Injuries policies and procedures have been met (employer/employee
relationship, timeliness, etc.).
i.
Correcting the Employer and/or Policy Number – Upon receipt of an
initial application that lists incomplete or incorrect employer information or
is missing employer information, or upon notice from the MCO or a party to the
claim alleging an incorrect employer, claims services staff shall determine the
correct employer information, policy number and the NCCI manual classification
number prior to making the claim determination.
ii.
Claims services staff shall use one or more of the following methods to
investigate and obtain correct employer information, including the correct
policy number:
a) Call
the IW or assigned employer to request evidence (e.g., W-2, paystub for the
date of injury that includes the employer’s federal identification number as
part of the printed form i.e., the ID number is computer-generated and not hand
written) to help identify the correct employer.
b) Contact
the provider’s office initially filing the claim for the name of the employer;
c)
Perform a person customer search by name and SSN for the IW on the claims
management system to determine if there is a duplicate claim or previous claim
that may list the employer information;
d) Investigate
the employer in BWC systems, which will include a business customer search or
consult with Employer Management (EM) staff for assistance with investigating
the correct employer (Claims services staff may refer to the EM Policy
#EP-05-04, entitled Employer
of Record Change.);
e) Investigate
using the Internet;
f)
Investigate the claims documents, including hospital information, to
determine if employer information has been included in any of them;
g) Staff
the issue with the local Account Examiner 2 (AE2) or supervisor; and/or
h) Run
a system report or query to assist in locating the correct policy number.
iii. If
claims services staff obtains the correct employer information and policy
number, a claim number must be assigned, and the pertinent information must be
scanned and indexed into the claim.
iv. Claims
services staff shall notify the original employer that the employer named in
the claim is being corrected, and the claim in question will not be assigned to
the original employer’s policy number.
v.
Claims services staff shall notify the correct employer of the claim
assignment.
vi. If
claims services staff cannot obtain employer information, including the policy
number, the issue shall be staffed with the local AE2, Employer Services
Specialist (ESS) or supervisor.
vii. If
all attempts to obtain employer information and policy number are unsuccessful,
claims services staff shall:
a) Add
“No Insured Found” as the insured customer;
b) Assign
a claim number to the initial application;
c)
Scan and index claim documents into the file; and
d) Document
all attempts to locate employer information and policy number in the claims
management system.
viii. The claim
will default to the assigned claims services staff’s worklist, so the contact
person shall complete a brief review of the information, and reassign the claim
to the claims specialist based on case leveling or employer policy assignment.
ix. If
claims services staff is able to determine the correct employer, but the
employer has no policy number or coverage, claims services staff shall refer to
the Coverage
and Employer/Employee Status policy and procedure.
3.
Claim Determination
a.
If the EOR certified the claim, compensation and medical benefits are
payable once the BWC Order is issued for the initial determination.
Claims services staff shall not hold payment for a waiver or the 14-day appeal
period. However, the EOR still has the right to appeal the BWC Order.
b.
If the EOR and IW submit a waiver in writing or electronically during
the appeal period, compensation and medical benefits can be paid without
waiting for the appeal period to expire.
c.
If an order is issued and the EOR is out of business or in a final
cancelled status, no waiver from the EOR is required.
d.
Claims services staff shall assign an E-code based on the accident
description. If claims services staff is unable to determine the correct
E-code, he/she shall discuss the issue with the supervisor or Medical Services
Specialist (MSS), or send an e-mail to BWC Claims Policy Field Techs.
e.
Claims services staff shall follow the Temporary
Total Compensation policy and procedure when a request for an initial
award of temporary total compensation is being decided at the same time as the
initial claim allowance.
f.
Claims services staff shall review the FROI, MCO notes, the MEDD policy
and procedure and all available documentation to make a determination on the
requested condition(s).
i.
Claims services staff shall:
a) Follow the ICD
Modification policy and procedure if any condition(s) cannot be accurately
coded or if clarification is necessary;
b) Use
the encoder and copy and paste the International Classification of Diseases
(ICD) code to the diagnosis window in the claims management system when claims
services staff is otherwise unable to obtain the correct ICD code.
ii.
Claims services staff shall send the claim to the MSS for medical review
if the claim falls outside the MEDD guidelines for CSS determination or he/she
is unable to interpret the medical documentation or determine the accuracy of
the requested condition(s).
iii. The
CSS must attempt to obtain all medical documentation including exam results or
testing reports from the MCO prior to sending the issue for medical review.
iv. The
MSS must obtain a physician file review or schedule an independent medical exam
if necessary, but an exam does not extend the 28-day time frame to issue a
decision as required by law, except for occupational disease claims that
require an exam prior to determination. Claims services staff must refer
to the Occupational
Disease Claims (OD) policy procedures for additional information.
v.
The MSS shall enter notes in the claims management system detailing the
opinion of the physician reviewer and listing the documentation used to form
that opinion.
vi. Claims
services staff must address all conditions listed on the FROI. If
conditions cannot be allowed or denied, claims services staff must explain in
the “add text” section of the order if additional documentation is needed to
make a determination or if the requested condition(s) cannot be allowed under BWC
guidelines. Claims services staff shall indicate in the order that the
condition(s) is neither allowed nor denied but can be addressed upon submission
of additional evidence or that BWC will not consider the condition(s) based on
BWC guidelines.
vii. Claims
services staff shall deny the claim when only one condition that cannot be
allowed is listed on the FROI and there is not another condition(s) within the
supporting medical that can be allowed.
viii. For the
initial determination only, claims services staff may allow a condition(s) that
is identified in medical documentation but not specifically requested by the
IW. Staff shall not deny a condition(s) not specifically requested.
ix. If
an additional allowance(s) has been requested on a C-86 or recommended on a C-9
and BWC has not published an initial claim decision yet, claims services staff
shall include the newly requested or recommended allowance(s) in the initial
decision, even though it is not listed on the First Report of Injury (FROI). For
more information regarding additional allowances, refer to the Additional
Allowance policy and procedure.
x.
If a subsequent request is filed during the appeal period of the initial
decision, claims services staff shall refer to the Additional
Allowance or Motions
policy and procedure.
g.
Claims services staff must complete all necessary clarifications,
modifications, or reviews prior to issuing a BWC Order.
h.
Claims services staff shall issue a BWC Order to accept or deny the
claim based on the claim investigation and the evidence in the file.
Claims services staff shall note in the add text section of the BWC Order the
documentation and rationale used to make the claim determination.
i.
If a FROI is not signed by the IW, the claim may be allowed, but staff
cannot deny a claim solely because the FROI is not signed. If the claim
would be denied and a signed FROI is not on file at the end of the 28-day
determination period and cannot be obtained, claims services staff shall
dismiss the claim by Miscellaneous Order.
ii.
Claims services staff may allow a claim for a minor injury without
supporting medical documentation if the injury is “self-evident” or a “common
knowledge” injury.
a) The claim is compensable
even if the injured worker did not seek treatment for the injury.
b) Self-evident or common
knowledge injury examples include, but are not limited to:
i)
First degree burns over less than 10% of the body;
ii)
Superficial laceration (cut, open wound);
iii) Superficial
contusion (bruise, hematoma);
iv) Insect
stings; or
v)
Blisters.
iii. When
allowing a claim, claims services staff shall update the claim to an allowed
status when the fourteen (14) day appeal period has expired and no appeal has
been filed. Benefits are then payable, and the claims management system
will update the claim status.
iv. When
denying a claim, claims services staff shall update the claim to a disallowed
status when the fourteen (14) day appeal period has expired and no appeal has
been filed. For additional information regarding the appeal period, refer to
the Mailbox Rule policy or the Jurisdiction policy and procedure.
v.
Claims services staff shall refer the claim to the IC if the IW or
employer appeals the BWC Order during the appeal period and shall place the
claim in hearing status so no benefits are paid.
vi. If
an appeal is filed after the appeal period expires, claims services staff shall
refer the claim to the IC and keep the claim in the determined status so
benefits will continue.
i.
A BWC Modified Order shall be sent if the correct employer information
is discovered prior to expiration of the initial appeal period as long as no
appeal has been filed. See V.C.2.i (i-x) above for information regarding
correcting the employer and/or policy number.
4.
Elective Coverage – Claims services staff shall refer to the Coverage
and Employer/Employee Status policy and procedure.
D. Issuing an Order
1. Refer to the Orders,
Waivers, Appeals, and Hearings policy and procedure for additional
information.
2.
Dismissing a Claim
a.
When a claim is being dismissed prior to expiration of the initial
determination appeal period, claims services staff shall:
i.
Dismiss all ICD codes in a claim before the claim application is
dismissed;
ii.
Issue a Miscellaneous Order, if BWC dismisses the claim application
before an initial determination order has been issued or within the appeal
period; and
iii. Complete
any correspondence before updating the status to “Expire Occurrence” and
choosing the claim status reason of “Dismissed.”
b.
When a claim is being dismissed after expiration of the initial
determination appeal period and the claim is in a final accepted or denied
status, claims services staff shall:
i.
Refer the claim to the IC when the IW requests dismissal of the claim;
and
ii.
Place Stop Payment type of Indemnity on the claim to prevent any
indemnity payments from being issued.
E. Re-filing a Dismissed Claim
1.
When the claim is re-filed, the claims management system will indicate a
duplicate claim and will notify the MCO that the application is a
duplicate.
2.
If the claim is refiled hard copy, the application shall be imaged into
the original claim.
3.
Claims services staff shall manually activate the original claim if the
claim is re-filed and change the filing date to the date the current
application was received.
a.
If the claim has never been in a final accepted or denied status and is
currently in a status of “Expire Occurrence” with a status reason of “Dismissed,”
claims services staff shall:
i.
Update the “Change Status to” field to “Re-open Expired Claim”; and
ii.
Select “Coverage Verified” as the claim status reason. The claims
management system will update the claim status to “Pending” and the MCO’s
outbound interface will be “alleged.”
b.
If the claim has been or is currently in a final accepted or denied
status, claims services staff shall:
i.
Update the “Change Status to” field to “Change Status Reason”; and
ii.
Select “Refile” as the claim status reason. The claims management
system will retain the previous claim status, but the MCO’s outbound interface
will be “alleged.”
4.
Claims services staff shall move the claim from a dismissed status to
any appropriate status when the claim is re-filed. A claim can be moved
from dismissed to a pending status of allow/appeal or disallow/appeal.
5.
Claims services staff shall investigate the claim and review additional
information if received on the re-filed application or a substantial period of
time has elapsed since the initial contacts were originally made.
F. Reconsideration
1.
Claims services staff shall:
a.
Reconsider a claim that was previously denied by BWC Order if:
i.
The original claim was denied due to a lack of specific information that
was requested, but never received and that information has been submitted with
the IW’s intent to re-file the claim; or
Example:
A claim was previously filed for allowance of a broken tibia and an x-ray
report to support allowance of the claim was requested, but not submitted;
therefore, the claim was denied. Six months later, x-ray results from the
date of injury showing the injured worker suffered a broken tibia are submitted
by the hospital and a letter from the IW stating his/her intent to re-file the
claim is filed with the documentation. The claim shall be reconsidered
because the specific information that caused denial of the initial claim was
submitted with the IW’s intent to re-file the claim.
ii.
The original claim was denied due to a lack of supporting documentation
and a new request or medical/factual documentation requesting allowance of the
claim is filed by the IW or with the IW’s intent to re-file the claim.
Example: A
claim was previously filed for allowance of a herniated disc at L4-5; however,
sufficient medical evidence to support allowance of the claim was not submitted
and the claim was denied due to lack of supporting medical documentation.
Three months later, a MRI report from the date of injury showing the injured
worker suffered a herniated disc at L4-5 is submitted by the hospital. A
letter from the IW stating his/her intent to re-file the claim is filed with
the documentation. The claim shall be reconsidered because supporting
medical evidence was submitted with the IW’s intent to re-file the
claim.
b.
Enter a claim note to acknowledge the IW’s intent to re-file the claim;
and
c.
Review the claim with a BWC attorney.
2.
Reconsidering a Previously Denied Claim
a.
Claims services staff may reconsider a previously denied claim upon
request from the IW. Such request from the IW may include:
i.
A Motion (C-86) with or without a new claim application;
ii.
A new claim application; or
iii. A
copy of the original claim application with written documentation of the IW’s
intent to file.
b.
Claims services staff shall consult with a BWC attorney prior to issuing
a decision for a reconsideration of a previously denied claim.
c.
For the claim to be reconsidered and allowed, sufficient evidence in
support of the allowance must be submitted within the applicable statute of
limitations.
d.
If sufficient evidence is not submitted to justify allowing the refiled
claim, claims services staff shall deny, dismiss, or refer the claim consistent
with BWC’s Initial Claim Determination policy and procedure.