OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Motions

Policy #:

CP-19-02

Code/Rule Reference:

R.C. 4123.511(A); O.A.C. 4123-3-16; 4123-3-09(C)

Effective Date:

12/17/20

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

Policy # CP-19-02, effective 09/06/18 and Procedure # CP-19-02.PR.1, effective 05/06/19

History:

Previous versions of this policy are available upon request


 

Motions Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

Application

Motion

Parties to a claim

Physician file review (PFR)

Preponderance of the evidence

IV. POLICY

A.          Requirements

B.          Applicant Responsibilities

V. PROCEDURE

A.          General Requirements

B.          Review and Investigation

C.         Processing the Motion

 

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that the Ohio Bureau of Workers’ Compensation (BWC) consistently and appropriately processes motions received. 

 

II. APPLICABILITY

 

This policy applies to BWC claims services staff.

 

III. DEFINITIONS

 

Application:  A form or other means of communicating to BWC a request, authorization, or agreement.

 

Motion:  For purposes of this policy, a written request, typically submitted on BWC form Motion (C-86), requesting an action from BWC or the Ohio Industrial Commission (IC). 

 

Parties to a claim: The injured worker (IW), IW representative, employer, employer representative and BWC. 

 

Physician file review (PFR): A review and evaluation of the medical documentation in a claim by a qualified medical specialist who has met BWC credential ing requirements to conduct independent medical exams. 

 

Preponderance of the evidence: A standard of proof which is met when a party’s evidence on a fact indicates that it is “more likely than not” that the fact is as the party alleges it to be. 

 

 

IV. POLICY

 

A.     Requirements

1.     A motion shall be submitted in writing;

2.     By a party to the claim;

3.     To request an action on a claim; and

4.     On any matter that is not otherwise addressed by statute or rule with its own procedure and/or form requirements (e.g., an application for approval of a lump sum settlement; motions for drug related issues).

 

B.     Applicant Responsibilities

1.     The applicant shall not use a motion as a substitute for a timely filed appeal;

2.     The motion shall clearly and fully state the issue and the requested action;

3.     The applicant shall include with the motion substantial competent proof to support the request;

4.     The motion shall include citations to any legal authority relied upon;

5.     The motion shall be signed by the applicant or the applicant’s authorized representative;

6.     The motion shall establish entitlement to the request by a preponderance of the evidence; and

7.     Unless the issue addressed in the motion does not affect the rights of the non-filing party, the applicant shall mail a copy of the motion to the non-filing party and provide acknowledgement to BWC or the IC that a copy has been so mailed.    

 

V. PROCEDURE

 

A.     General Requirements

1.     BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note and documentation requirements;

2.     Follow any other specific instructions for claim notes and documentation included in this procedure;

3.     Refer to the:

a.     Jurisdiction (Statute of Limitations, Statutory life of a claim) policy and procedure to determine if a claim is statutorily open; and

b.     Specific subject-matter policy for additional information, including due process requirements, for motions and other applications filed requesting a particular action in a claim (e.g., Additional Allowance; Scheduled Loss Compensation; Psychiatric Conditions). 

 

B.     Review and Investigation

1.     When a motion is submitted, claims services staff shall review it to ensure all necessary information has been provided and:

a.     It has been signed by a party to the claim or the party’s authorized representative;

b.     The filing party has certified by signature and date that a copy of the motion has been provided to all parties and representatives in the claim;

c.      It clearly and fully states the issue and what action is being requested;

d.     Legal citations have been provided for any authority the request relies on;

e.     It is not being used to substitute for a timely filed appeal;

f.       It is not a request that is required by law to be submitted on a different form or in some other manner (e.g., an application for a lump sum settlement);

g.     Supporting evidence has been submitted with the motion or is specifically referenced and contained in the claim; and

h.     All legal requirements and procedures have been complied with if it is requesting allowance of a psychiatric condition. See the Psychiatric Conditions policy and procedure for more information.

2.     As necessary, claims services staff shall: 

a.     Contact the filing party to advise the filing party of the specific evidence needed to support the motion (if known) (e.g., earnings statements to support a request to adjust the average weekly wage) and request that it be submitted; and

b.     Contact the managed care organization (MCO) for assistance in obtaining any needed medical evidence. 

3.     After receipt of any additional medical evidence, claims services staff shall consider whether a physician file review (PFR) or independent medical exam (IME) is needed to further clarify the medical issues or develop the evidence necessary in considering the request.  Claims services staff shall refer to the Independent Medical Exams and Physician File Reviews and/or Additional Allowance policy and procedure as necessary for additional information.  

 

C.    Processing the Motion

1.     When a motion is received, claims services staff shall create the appropriate case in the claims management system. 

2.     Due Process

a.     Claims services staff shall provide notification of receipt of a request for action by motion and provide an opportunity to respond as may be required by any applicable subject-matter specific policy and procedure.

b.     If the subject matter of the motion and/or the required due process is not addressed in a subject-matter specific policy or procedure:

i.       Claims services staff shall attempt to contact the non-filing party as notification that a motion has been filed and offer an opportunity to submit additional information. 

a)     The first attempt shall be made by phone.

b)     When the party cannot be contacted by phone, but claims services staff leaves a message for the party:

i)       They have three full business days to return the call. 

ii)      Claims services staff shall set a work item for four business days. 

c)     When the party cannot be contacted by phone and leaving a message is not an option, claims services staff shall send the applicable letter by mail, fax, or e-mail. 

i)       When the letter is sent by fax or e-mail, the non-filing party has three full business days to respond.  Claims services staff shall set a work item for four business days.    

ii)      When the letter is sent by mail, the non-filing party has seven calendar days (plus four additional days per the Mailbox Rule policy) to respond.  Claims services staff shall set a work item for 12 calendar days.   

iii)    The response time frames may be extended, not to exceed 18 calendar days.

iv)    The non-filing party’s authorized representative shall be copied on the letter.

v)     The filing party shall not be copied on the letter sent to the non-filing party.   

d)     Do not continue considering the request until the waiting period has expired or evidence has been received.

ii.      Claims services staff may direct the non-filing party to www.bwc.ohio.gov to view the motion and accompanying evidence.  However, if requested, claims services staff shall provide the non-filing party a copy of the motion and any accompanying evidence.

iii.     Claims services staff must make a decision on a motion: 

a)     Within 28 days of receipt of the motion; or

b)     If a physician file review or independent medical examination has been requested, within 14 days of receipt of the report.    

3.     Motion Filed Prior to the Final Initial Determination of the Claim

a.     When a motion is filed after an initial determination order is issued but prior to it becoming final (i.e. during the appeal period with no appeal filed), claims services staff shall:

i.       Review the request included in the motion; and

ii.      Consider the most expedient and efficient course of action, taking into account any impact on timely payment of compensation and benefits to the IW.

b.     After careful review of the motion, claims services staff shall take one of the following actions:

i.       Vacate the initial order and issue a new order to issue a decision on the motion; or

ii.      Suspend acting on the motion until final determination of the claim.

c.      If the motion is suspended, claims services staff shall send the “Suspension Letter” to all parties in the claim.

i.       If the claim is subsequently allowed, once it is in final allowed status and all appeal periods have expired, claims services staff shall proceed with processing the motion. 

ii.      If the claim is subsequently disallowed, claims services staff shall send the “Moot Issue Letter” to the filing party and copy the non-filing party. 

4.     Suspending a Motion Pending Resolution of a Related Issue

a.     Upon reviewing a motion, if claims services staff determines the request cannot be addressed until a related issue is resolved, claims services staff shall: 

i.       Send the filing party the “Application/Request Pending Letter” to advise that the motion will not be acted on until there is a final decision on the related matter;

ii.      Update the case to “suspend”; and

iii.     Set a work item to address the motion.

b.     Claims services staff shall begin to consider the request when the related issue is resolved.

5.     Referral to the MCO

a.     Upon reviewing the motion, if claims services staff determines the request is for medical treatment or vocational services, claims services staff shall refer the motion to the MCO.

i.       Claims services staff shall ensure the description of the request is clearly stated on the referral letter.

ii.      Claims services staff shall mail a copy of the letter to the IW and copy the MCO.

b.     If claims services staff determines the request is for medical treatment or vocational services as well as other issues, claims services staff shall refer the medical or vocational issues to the MCO and address the remaining issues. 

6.     Dismissing and Reinstating a Motion

a.     Claims services staff shall dismiss a motion when:

i.       There is no evidence to support the request, even after reasonable attempts to obtain evidence;

ii.      The requested action is not clear, despite reasonable attempts to clarify the request;

iii.     The filing party requests to withdraw the motion; or

a)     The filing party may request withdrawal in writing or verbally (a verbal request must be documented in claim notes).

b)     The dismissal shall be issued via Miscellaneous Order.

c)     If the filing party requests to withdraw the motion after a decision has been issued and during the appeal period with no appeal filed, claims services staff shall vacate the order and issue a new Miscellaneous Order to dismiss the motion.

d)     If the filing party requests to withdraw the motion after an order has become final, claims services staff shall send the filing party the “No Dismissal Letter” indicating the motion cannot be withdrawn or dismissed.

e)     If the filing party requests to withdraw the motion after it has been referred to the IC, see the Notice of Referral to the Industrial Commission (IC) policy and procedure for instructions related to withdrawing a notice of referral.  

iv.    The requested action must be pursued on a mandated form and/or by some other mandated means (e.g., request for settlement must be filed on a C-240 form, Settlement Agreement and Application for Approval of Settlement Agreement.

b.     Claims services staff shall reinstate a dismissed motion when the filing party submits a new motion.

7.     Issuing an Order

a.     If the request contained in the motion is within BWC’s jurisdiction and there is no conflict of evidence, claims services staff shall issue an order to address the request.

b.     Claims services staff shall refer to the Orders, Waivers, Appeals and Hearings policy and procedure for more information. 

8.     Referring to the IC

a.     Claims services staff shall refer the motion to the IC when:

i.       The requested action is not within the jurisdiction of BWC;

ii.      There is a conflict of evidence; or

iii.     Multiple issues have been presented in one motion and one or more of the issues are not within the jurisdiction of BWC.

b.     Claims services staff shall refer to the Notice of Referral to the IC policy and procedure for more information.