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Policy and Procedure Name:
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PERCENTAGE OF PERMANENT PARTIAL DISABILITY OR INCREASE
OF PERMANENT PARTIAL DISABILITY COMPENSATION
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Policy #:
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CP-16-04
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Code/Rule Reference:
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R.C. 4121.32; 4121.34; 4121.63; 4123.57; 4123.511;
4123.68; 4123.84 O.A.C. 4121-3-10; 4123-3-15; 4123-3-18; 4123-10-03
IC Hearing Officer Manual Memo E7, I5
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Effective Date:
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09/28/21
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Approved:
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Ann 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-16-04, effective 09/29/17 and Procedure # CP-23-03PR.1,
effective 09/29/17
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History
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Previous versions of this policy are available upon
request
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%PP OR INCREASE OF %PP Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Accrued Compensation
Average Weekly Wage (AWW)
Daywork Payment
Disability Evaluators’ Panel (DEP)
Percentage of Permanent Partial Award
Residual Effect
Salary continuation/wages in lieu of
temporary total compensation (SC)
IV. POLICY
A. Application
B. General Policy
Statements
C. Eligibility for a C-92
D. Medical Evidence
E. Exams, File Reviews,
and Addendums Specific to %PP Requests
F. Tentative Orders for
C-92 Applications
G. Payment of a %PP Award
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. General Requirements
for a C-92
C. Application Processing
D. Exam(s) and File Review
Preparation and Scheduling
E. Exam(s) and PFR Reports
F. Failure to Appear
G. Tentative Orders and IC
Referrals
H. Wages
I. Payment of a %PP Award
The purpose of this policy is to ensure BWC correctly
determines eligibility for percentage of permanent partial (%PP) compensation
awards and bases decisions on sufficient and appropriate supporting medical
evidence from an exam or a file review.
This policy applies to BWC claims services staff.
Accrued
Compensation: The unpaid portion of an award of compensation
in an allowed claim due to the decedent at the time of his or her death,
regardless of whether the death was the result of an allowed injury or
occupational disease.
Average Weekly Wage (AWW): The basis upon
which to compute benefit payments for: temporary total disability (TT) and living
maintenance (LM) after the initial 12-week period of disability; death
benefits; permanent total disability benefits (PTD); percent of permanent
partial disability benefits (%PP); wage loss (WL) benefits; and may be used for
payment of living maintenance wage loss (LMWL) if greater than the full weekly
wage (FWW).
Daywork
Payment: Claims management system-reference to compensation
and benefit payments that cover past periods but do not extend to future
scheduled payments.
Disability
Evaluators’ Panel (DEP): A panel of physicians contracted by
BWC to perform high-quality, impartial Independent Medical Exams (IME) and
Physician File Reviews (PFR) that result in concise, timely and justifiable
reports.
Percentage
of Permanent Partial Award: Also known as a %PP or a C-92
award; compensation awarded for residual impairment, either physical or
psychological, resulting from an allowed injury or occupational disease (OD) in
state fund or self-insured (SI) claims.
Residual
Effect: An impairment granted beyond the scheduled loss award
as derived from the American Medical Association’s “Guides to the Evaluation of
Permanent Impairment, Fifth Edition” (AMA guides), unless otherwise specified.
Salary
continuation/wages in lieu of temporary total compensation (SC): Regular
full wages and benefits the employer of record (EOR) pays the injured worker (IW),
in lieu of BWC paying the IW temporary total compensation (TT) or living
maintenance (LM). This includes payment of sick leave and occupational injury
leave (OIL).
1. Application
for %PP shall be made on an Application for Determination of Percentage of
Permanent Partial Disability or Increase of Permanent Partial Disability (C-92).
2. The
employer, if it chooses to do so, must submit any proof bearing upon the
application (e.g., medical documentation) within 30 days of receipt of the initial
C-92 application or any time following BWC’s medical review of the application
for an increase of permanent partial disability.
1. BWC shall
change a claim to a lost time (LT) claim when a %PP award greater than 0% is
granted; however, BWC shall not change a claim to a LT claim based solely on
the filing of a C-92 application.
2. It is the
policy of BWC to:
a. Send to
all parties claim copies of all:
i. C-92
examination reports;
ii. Addendum
requests if applicable; and
iii. Addendum
reports.
b. Issue a
tentative order (TO) to grant, dismiss, deny or suspend a C-92 application,
except for initial C-92 applications with conflicting medical evidence, which
shall be referred to the Industrial Commission of Ohio (IC), as provided in
Section V.D.1-3 of this policy and procedure.
1. There is a
26-week waiting period to file an application for an initial %PP award. The
C-92 waiting period begins:
a. The day
after the last payment of TT, WL, or SC compensation; or
b. The day
after the date of injury (DOI) or contraction of an OD in absence of payments
of compensation.
2.
An IW is not eligible for a %PP award and the C-92 shall be dismissed
for any of the following reasons:
a. The
initial application is filed prior to the end of the waiting period;
b. Permanent
Total Disability (PTD) has been granted in the same claim;
c. The
IW fails to respond to an attempt to schedule a C92 examination or fails to
appear for a BWC scheduled C-92 examination following the Independent Medical
Exams (IME) and Physician File Reviews (PFR) policy.
d. Claims
services staff shall dismiss the C-92 request if the claim is not statutorily
open (the statute of limitations for the claim has expired).
e. The C-92
application is requesting an award for partial hearing loss or loss of vision.
f. Payment
is prohibited due to the type of OD allowance, specifically:
i.
Firefighters and police officers with cardiovascular, pulmonary or
respiratory diseases;
ii.
Firefighters with an allowance of cancer due to the presumption in the Firefighters
with Cancer Occupational Disease policy;
iii.
Allowances for silicosis, asbestosis, or coal miners’ pneumoconiosis;
iv.
Any other OD of the respiratory tract, except berylliosis, resulting
from injurious exposure to dust; and
v.
Any psychiatric condition that results from allowances listed in Section
IV. C. 3. f. ii. and iii. above.
g. The
application is not signed by the IW or IW’s authorized representative and
claims services staff is unable to obtain the signature;
h. The IW has
already received %PP awards of 100% in all claims combined (including SI and
settled claims).
3.
The C-92 shall be denied for any of the following reasons:
a. The
application is for an increase for %PP and there is no attached medical
evidence that shows new and changed circumstances since the time of the
original or most recent %PP determination that supports an increase:
i. Claims
services staff shall contact the IW/IW Rep to request supporting medical;
ii. Claims
services staff shall not hold the claim more than 14 days for medical; and
iii. Claims
services staff shall deny the application for lack of supporting medical
evidence without waiting the 60-day hold period.
b. The date
of the medical evidence provided to support the request for an increase in
impairment is prior to the order granting the previously allowed percent of
permanent partial impairment.
c. The
medical evidence provided supports a percentage of impairment that is less than
the current percentage of impairment in the claim.
1. Medical
evidence for an initial %PP request or a %PP request for a newly allowed
condition is not required.
2. Medical
documentation is required to support an increase in %PP even when the prior
award was 0%.
3. When a BWC
scheduled impairment exam is complete, BWC shall refer an initial C-92
application to the IC without issuing a decision if any party submits
conflicting medical evidence (e.g., employer’s defense exam or IW’s impairment
exam) prior to BWC’s determination of the application.
4. A medical
report that has been rejected can never be submitted as evidence again.
a. A report
is rejected if the report was on file at the time a decision was made, and its
conclusion is contrary to the finding of a hearing officer;
b. Example:
IW filed for Permanent Total Disability (PTD) based on a report finding 66 %PP
and indicating the IW is PTD. The report was rejected when the SHO denied
PTD. A C-92 increase was filed after the PTD hearing relying on the same
physician’s report. That report can no longer be used as evidence.
1. It is the
policy of BWC to ensure examining physicians consider previous impairment
awards for the same part(s) of body in any of the IW’s claims.
2. Exams
a. The
employer may schedule an exam at any time during the C-92 process at the
employer’s expense.
b. It is the
policy of BWC to schedule the C-92 examination to obtain an opinion on the
whole person percentage of impairment (WPI) for an allowance for the IW based
on the 5th edition AMA Guides unless otherwise specified, pursuant to R.C.
4123.57(A).
c. BWC
may schedule an exam based on the age of the claim or impairment percentages
previously allowed.
d. A DEP exam
report or file review may be used as evidence for one year after the date of
the exam or review even if the DEP indicates a 0%, unless:
i. The
report was previously used and rejected by the IC; or
ii. New
and changed circumstances render the report irrelevant.
e. When exam
availability has not been provided on the C-92 application and the IW cannot be
reached by phone, a “Percent Permanent Partial Notice of Application” letter shall
be sent to the IW (copy to the IW representative) upon receipt of a C-92
application:
i. The
letter explains the purpose of the exam;
ii. The
letter requests IW availability for scheduling the exam;
iii. If the
letter is returned due to an incorrect address, BWC shall attempt to obtain the
correct address.
f. BWC
shall consider and request an examination on all conditions allowed at the time
the physician notice letter is sent unless instructed otherwise by the IW/IW
Rep.
g. BWC shall
schedule and pay for %PP examinations, file reviews, addendums and related
travel expenses.
i. Exam
expenses for state fund claims are charged to the surplus fund;
ii. Exam
expenses for SI employer claims are charged to the SI surplus fund;
iii. State of
Ohio employers pay dollar for dollar and are billed for all IME expenses.
h. Residual
Effects – BWC may grant a %PP award for residual effects over and above a
scheduled loss impairment award if a loss of use or amputation produces a residual
impairment. The examining physician may consider the impact of disability
factors to the IW. This includes, but is not limited to, the impact of current
symptoms and limitations or difficulty caused by the disability to the IW.
1. Parties
objecting to the TO may:
a. File the Objection
to Tentative Order Determining the Percentage of Permanent Partial Disability
Compensation (IC-167-T) (or equivalent); or
b. Electronically
utilize the IC’s online appeal process (ICON) located on the IC website.
2. If the
last decision of the IC was to allow a claim or a condition and that decision
is appealed to the court by the employer:
a. A C-92
requesting a %PP for the conditions under appeal shall be suspended until a
decision is issued;
b. A C-92
requesting a %PP for conditions previously allowed in the claim and not under
appeal may be processed without waiting for a decision from the court;
c. If
the decision of the IC to allow a condition is appealed by the employer and the
IW subsequently dismisses the complaint with the consent of the employer, the
C-92 application can be processed until such time as the complaint is re-filed
by the IW and is considered pending by the court.
– BWC shall not issue a payment until the administrative
decision that grants the award is final.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Shall
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. When
claims services staff receive an application for %PP (typically filed on a C-92),
claims services staff shall create a Case Management case and shall review the
application to determine if the IW is requesting:
a. Option 1 -
Initial %PP – all allowed conditions at the time of the exam will be considered
unless the IW specifically requests only specific conditions be examined;
b. Option 2 -
%PP for a newly allowed condition – only the newly allowed condition(s) will be
considered, and all other conditions will be assumed to have no change in %PP;
or
c. Option
3 - An increase in the %PP – only those conditions for which evidence of new
and changed circumstances has been submitted will be considered; all other
conditions will be assumed to have no change in %PP.
2. Claims
services staff shall ensure:
a. The C-92
request is signed by the IW or the IW’s authorized representative.
i.
If the C-92 request is not signed, claims services staff shall attempt
to obtain the signature by contacting the IW/IW representative.
ii.
If the IW is represented, claims services staff shall make one attempt with
the IW representative to obtain a signed C-92. Two attempts are required if the
IW is not represented.
iii.
Claims services staff shall also accept electronic signatures of the
IW/IW representative on C-92 applications filed electronically through www.bwc.
ohio.gov.
b. The appropriate
waiting period has been met.
i.
The claims management system will set a task if the appropriate waiting
period has not been met.
ii.
The 26-week calculator is available on COR to assist claims staff.
c. The
percentage of impairment across all claims is accurate.
i.
A %PP of 90% or greater entitles the IW to a total percentage of 100%;
ii.
IW does not need to request the additional percentage;
iii.
If the IW has already received 90% or greater in all claims, including
settled and Self-Insured (SI) claims, claims services staff shall grant the
current application;
iv.
Claims services staff shall not request an exam or physician file review
(PFR) to grant the additional percentage;
v.
The %PP needed to bring the IW up to 100% shall be granted by TO in the
claim where the %PP granted brought the IW up to 90% or greater;
vi.
If the claim in which the IW was granted the %PP award that brought them
to 90% or greater is out of statute, the additional percentage shall be granted
in another claim.
d. The
descriptions found on the claims management system match allowances as
described in BWC and IC Orders.
e. A review of
all claims for other active %PP requests is completed.
i.
Applications may be processed in multiple claims;
ii.
One exam or PFR may be scheduled to address all claims; and
iii.
Each claim included in the examination must have supporting medical
evidence when an increase in %PP was requested even if only one exam or PFR is
scheduled.
f. The
claims management system has been updated to reflect any percentage award
granted per an Agreement as to Compensation for Permanent Partial Disability
(ICGC1).
g. A copy of
the C-92 and any supporting documentation is forwarded to the EOR and employer
representative upon receipt of a C-92 application and document completion of
this in claim notes.
3. Claims
services staff shall ensure a %PPD Worksheet (C-123) query (203 - %PPD
Worksheet/10 Year Check) is generated and imaged into the claim file.
a. Claims
services staff shall ensure all claims and the allowed conditions are included
on the worksheet.
b. Claims
services staff shall ensure the percentages reflected on the claims management
system for all claims for the IW is correct.
c. Claims
services staff shall note any previous impairment award for pain.
d. For SI
claims, previous %PP awards and names of providers previously seen by the IW in
the current claim may need to be obtained from the SI employer or the SI
bankrupt team.
1. 60-Day
Hold for C-92 Applications Requesting an Award on a Newly Allowed Condition or
an Increase in %PP
a. Claims
services staff shall hold the request for an award on a newly allowed condition
or an increase over a previous award for sixty (60) days from the date a copy
of the request is mailed to the employer/employer representative.
b. The 60-day
hold may not be waived. However, claims services staff shall not mail the
request and may process the request without waiting the 60 days if the EOR is
out of business.
2. Claims
services staff shall verify the following when speaking to the IW:
a. IW’s
mailing address;
b. Availability
should an exam be necessary.
3. Claims
services staff shall review the claimant’s customer record looking for both the
IW’s name and the IW’s social security number to look at the history of all
allowed claims and look for similar allowances.
4. Claims
services staff shall not hold an application an additional 26 weeks if the IW
met the waiting period requirement when the application was initially filed,
but TT, WL, or SC was subsequently paid. For additional information on payments
see section V.I.1-7 below.
5. When a %PP
application and a request for additional allowance(s) are both pending in the
claim, claims services staff shall:
a. Contact
the IW/IW Rep to ask if they would like to:
i. Include
the additional allowance(s) in the %PP application if the additional allowances
are determined to be compensable in the claim; or,
ii. Process
the application for %PP for the currently allowed conditions only; or
iii. Dismiss
the application for %PP and proceed with processing the additional allowance
only.
b. Document
in claim notes the instructions provided by the IW/IW Rep after contact has
been completed.
c. Process
the additional allowance(s) request prior to processing the %PP application if
the IW/IW Rep does not provide direction on the order of processing after at
least 2 attempts at contact are made.
d. Notify the
DEP physician that there are pending conditions that should not be considered
in the evaluation if the IW/IW Rep wants to proceed with the application for
%PP for the currently allowed condition(s) only.
e. Note in
the TO that any conditions not addressed by the DEP physician were not
considered at the request of the IW/IW Rep, as they were not in an allowed
status at the time of the exam or PFR.
6. Claims
services staff shall process a C-92 if the IW is receiving living maintenance
(LM) or living maintenance wage loss (LMWL). For additional information on
payments see section V.I.10.a below.
7. When
scheduling an exam, claims services staff shall:
a. Create an
exam scheduling case prior to sending for a PFR or scheduling an exam;
b. Schedule
the exam or obtain a PFR as appropriate following the Independent Medical
Exams (IME) and Physician File Reviews (PFR) policy and procedure;
c. Inform
the DEP physician that IW is currently receiving TT, WL, SC, LM, LMWL when
appropriate;
d. Include
any temporary or permanent restrictions in the exam packet when IW is receiving
TT, WL, SC, LM or LMWL; and
e. Ask the
DEP physician how much of the current impairment is permanent by answering the
“Is the Injured Worker currently receiving compensation?” question in the
profile tab in the Exam Scheduling Case.
f. Claims
services staff shall not suspend an application for medical instability.
8. SI Claims
a. Claims
services staff shall send the Self-Insuring Employer Notice and Request for
Information for C-92/C-92A Application (C-256) to the SI employer.
b. Claims
services staff shall forward a copy of the application and any supporting
documentation to the EOR and employer representative.
c. If
the employer does not respond within 14 days, claims services staff shall:
i. Verify
the employer contact information is correct;
ii. Contact
the employer to request any missing information;
iii. Initiate a
complaint using the Allegation Against a Self-Insured Employer (SI-28)
form found on COR or on www.bwc.ohio.gov. if
the C-256 is not returned and the attempt to contact the employer was
unsuccessful;
iv. Claims services
staff shall not dismiss a C-92 due to lack of response from the employer.
d. Claims
services staff shall schedule the %PP examinations or obtain a PFR for all SI
employer claims.
9. Procedures
Specific to an Application for a %PP of a Newly Allowed Condition:
a. When a
C-92 application is filed for %PP of a newly allowed condition in a claim,
claims services staff shall ensure the IW checked the box “Determination in the
%PPD for a newly allowed condition in this claim (no new medical required).”
b. Claims
services staff shall verify that the IW has been previously awarded a %PP,
including an award of 0%, in that claim.
c. Claims
services staff shall determine if an exam is necessary:
i. Claims
services staff shall schedule an exam to support the request for a %PP for a
newly allowed condition for a new body part;
ii. A
PFR, rather than an exam, may be appropriate if:
a) The newly
allowed condition is for the same body part that was included in a previous %PP
award and supporting medical evidence was submitted with the request, or
b) The IW is
deceased.
d. Claims
services staff shall refer to the “C92A Physician Review vs Exam Criteria” job
aid for additional guidance.
10. Procedures Specific to an
Application for an Increase of %PP with Supporting Medical Evidence
Demonstrating New and Changed Circumstances:
a. Claims
services staff shall verify:
i. That
the IW has been previously awarded a %PP, including an award of 0%, in that
claim; and
ii. That
the request is accompanied by medical evidence that shows that new and changed
circumstances have developed since the time of the original or most recent %PP
determination;
a) A medical report
indicating an increase in %PP will suffice as evidence of new and changed
circumstances.
b) Medical evidence
submitted by the IW to support an increase does not have to be based on AMA
guides.
c) Claims
services staff shall contact the IW/IW rep to request supporting medical
documentation if documentation was not provided to support an increase in the
%PP.
b. Claims
services staff shall verify the medical evidence attached to the request was
not previously used and rejected.
c. Claims
services staff shall verify that the percentage of increase stated in the
supporting medical documentation is higher than that which was previously
granted.
d. Claims
services staff shall verify that the medical evidence submitted by the IW is
dated after the date of the TO for the previously granted %PP.
e. When a
C-92 is filed that requests an increase of 20% or greater, claims services
staff shall:
i. Automatically
schedule an exam or,
ii. If
the IW is deceased and a spouse or dependent requests an increase in %PP and
supplies supporting medical documentation dated within one year of the date of
death, send for a PFR.
f. If
medical evidence is not dated after the previous %PP award, or the supporting
documentation states the %PP is lower than previously awarded, claims services
staff shall:
i. Contact
the IW/IW rep requesting appropriate medical evidence; and
ii. If
insufficient medical evidence or no medical evidence is submitted, deny the
request for increase of %PP for not meeting the burden of proof because there
are no new and changed circumstances; and
iii. Issue a TO
denying the C-92.
g. Claims
services staff shall dismiss the request for increase of %PP if no medical
evidence is submitted unless an additional condition has been allowed in the
claim and the request is for an increase in %PP based solely on that additional
condition.
h. If medical
evidence is present claims services staff shall follow the procedures below in
section V.D.1-5.
1. Scheduling
a Percentage of Permanent Partial Medical Exam(s)
a. Claims
services staff shall schedule all IWs requesting an initial determination of
%PP for an exam;
b. Claims
services staff shall contact the IW or IW Rep and schedule the C-92 exam
following the C92 Independent Medical Exams (IME) and Physician File
Reviews (PFR) policy and procedure.
c. Claims
services staff shall use the appropriate C-92 exam-question inserts located in
the case tool. Any prior pain awards should be noted in the Profile Tab of the
Exam Scheduling Case.
d. Claims
services staff shall refer to the “C92A Physician Review vs Exam Criteria” job
aid for additional guidance when determining if a PFR or an exam is
appropriate.
e. Claims
services staff shall request a PFR for all requests for an increase of %PP
except when:
i. There
is a newly allowed condition(s) for a new part of body;
ii. There
are highly complex injuries;
iii. A
psychological exam is necessary for an initial psychological condition;
iv. IW is requesting
an increase of 20% or greater;
v. The
DEP reviewer requests the IW be examined.
f. Claims
services staff may request an exam after consulting with the IMS or BWC
attorney based on the age of the claim or impairment percentages previously
allowed.
g. Claims
services staff shall:
i. Request
the DEP physician consider all relevant conditions allowed at the time the
physician notice letter is sent.
ii. Ensure
the DEP physician is informed when a condition allowed for substantial
aggravation is included as an allowed condition but is in a non-payable status
and shall not be considered in the determination of the percent of impairment.
iii. Provide
the DEP physician with the review and any exam findings and awards made in
another claim if it is for the same body part/condition.
iv. Ask the DEP physician
to compare the findings and results of any previous examination(s) to the
current claim examination for the increase over the previously allowed percent.
v. Request
the DEP physician consider the percentage of impairment granted in the previous
claims and determine what portion of the percentage granted in previous
claim(s) impacts the current claim when the previously granted %PP involved
multiple body parts.
vi. Obtain the %PP
previously granted by any SI employer from the SI employer(s) or SI bankrupt team.
vii. Notify the DEP physician
if IW is medically unstable (currently receiving TT, etc.).
h. Claims
services staff shall ensure the exam packet contains the documents as outlined
in the “Exam Packet Content” document found on COR including related information
from other claims as appropriate.
2. Claims
services staff shall request any missing medical documentation from the MCO via
phone, fax, email or correspondence.
3. Claims
services staff shall discuss all requests by a C-92 DEP physician for
additional diagnostic testing with a medical service specialist (MSS).
4. When %PP
requests require multiple exam types, claims services staff shall:
a. Schedule
each exam with the appropriate DEP physician;
b. Schedule
exams simultaneously; and
c. Refer
to an MSS for a combined effects review to determine the WPI for all exams.
5. Scheduling
Increase of Percentage of Permanent Partial PFR(s)/Exam(s)
a. Claims
services staff shall refer to the “C92A Physician Review vs Exam Criteria” job
aid for additional guidance in determining if a PFR or exam is appropriate.
b. Claims
services staff shall request a PFR to determine if an increased percentage of
impairment is indicated by the medical evidence attached to the request.
c. Claims
services staff shall complete form Report of %PPD Increase Medical File Review
(C-253) noting all allowed conditions for that claim.
d. Claims
services staff shall provide the C-253 to the DEP file reviewer and ensure it
is imaged in the claim file.
1. Claims
services staff shall review the report upon receipt to ensure:
a. The DEP
physician has:
i. Used
the AMA Guides unless otherwise specified;
ii. Considered
prior impairment examinations and previous impairment awards;
iii. Based
opinion of impairment percentage on the AMA Guides, unless otherwise specified;
iv. Cited page
number or Tables used in the AMA Guides, unless otherwise specified;
v. Addressed
all conditions;
vi. Stated that
he/she has reviewed the relevant records and accepted the findings.
b. That a WPI
for the claim was provided;
c. That
the percentage of increase (as applicable) is indicated on the Report of %PP
Increase Medical File Review (C-253); and
d. That a
percentage of disability has been identified:
i. If
no percentage of disability has been identified (i.e., only states medical
instability), claims services staff shall ask the DEP physician to submit an
addendum providing a percentage even though instability exists;
ii. If
the DEP physician still does not provide a percentage of impairment in the
addendum report, a TO is issued awarding 0%;
iii. If the DEP
physician acknowledges the previous percentage of impairment and provides a new
percentage of impairment but does not specifically provide the amount of the
increase, the MSS may deduce the % increase is the new WPI minus the previous
WPI. For example, the DEP physician states IW had a WPI of 32% and now has a
WPI of 35%, the MSS may assume the IW has a WPI increase of 3%.
2. Claims
services staff shall review the report to determine if a residual pain
impairment was recommended.
a. Pain
impairment can be awarded without other impairment;
b. Claims
services staff shall only allow a maximum of 3% for pain for all the IW’s
claims combined.
3. Claims
services staff shall enter a note in the claims management system indicating:
a. The report
has been reviewed;
b. All
conditions have been addressed;
c. No
addendums are needed;
d. No
referrals for additional exams are needed;
e. If a
percentage was awarded for pain; and,
f. Amount
of the WPI award.
4. If there
is a conflict in the medical evidence, claims services staff shall:
a. Accept the
recommendation of the DEP file reviewer if the request is for an increase in
%PP or for a %PP for a newly allowed condition.
b. Refer the
claim to the IC if the request is for an initial %PP award.
5. Addendums
a. Claims
services staff shall ensure:
i. Requests
for addendums to a DEP %PP examination report are sent to all parties in the
claim.
ii. Addendum
reports are attached to and processed with the original %PP examination report.
A copy of the exam report(s), addendums, corrections, etc. are mailed to the
IW, the EOR and the representatives.
b. An
addendum request may be used in the following situations:
i. No
WPI is provided, even if it is implied to be zero;
ii. The
physician fails to grant an impairment percentage when an impairment is
indicated based on specific diagnosis impairment criteria. For example,
an award of 0% for an IW who has had a meniscectomy;
iii. The
physician submits a medical report stating medical instability and does not
provide a percentage;
iv. The physician
has failed to address the allowed conditions of the claim.
a) If a
condition is omitted but the exam covers other allowed conditions for the same
body part, claims services staff shall ask for an addendum.
b) For
example, if the allowances are lumbar strain, herniated disc and spinal
stenosis, and the report did not include the spinal stenosis as an allowed
condition, it is assumed that the physician can opine on an additional
condition not previously considered if the condition involves the same body
part as previously examined.
v. The
report appears to have been altered, such as whiteout or cross-outs. An
addendum shall be requested even though the altered items are initialed;
vi. The physician
may have inappropriately applied the AMA Guides, 5th Edition, unless otherwise
specified, such as use of wrong table(s);
vii. The physician may have
failed to follow guidance as provided in the DEP Manual;
viii. The results may have been
calculated incorrectly;
ix. To clarify ambiguous
or contradictory statements, such as location of body (right versus left);
x. The
conclusion of the DEP physician differs by more than 5% from the result of the
IW’s physician using the same medical records, physical findings and impairment
method;
xi. When requested
by the IC.
6. %PP Exam
Quality Assurance (QA) Review
a. Claims
services staff shall complete the %PP Exam QA reviews.
b. The MSS
shall perform QA reviews when the:
i. Exam
is on the audit list;
ii. Exam
involves combined effects;
iii. CSS
requests the QA;
iv. The MSS, in
his/her professional opinion, finds it appropriate to do so.
c. Claims
services staff shall refer to the review process documented on the “%PP Exam
Quality Review Workflow” on COR.
7. Combined
effects evaluation
a. Claims
services staff shall have a combined effects evaluation done when:
i. Multiple
body parts are involved with multiple exams or reviews; or
ii. The
IW has multiple allowed conditions (i.e., psych and physical) but is only
requesting an additional percentage for one of the conditions (either psych or physical);
or
iii. A new
condition was allowed for a new part of body.
b. Claims
services staff shall ensure:
i. Combined
effect evaluations are done by an MSS;
ii. The
MSS report reflects the combined WPI; and
iii. The MSS
completes the C-251 Report of %PP Combined Effects Review form.
c. A
combined effects evaluation is not necessary when one of the impairment exams
recommends 0%.
1. Claims
services staff shall dismiss the C-92 application following the failure to
appear process in the C92 Independent Medical Exams (IME) and
Physician File Reviews (PFR) policy and procedure when an IW fails to
appear for a BWC scheduled exam without explanation.
2. Claims
services staff shall refer to the IC any Motion (C-86) filed by the employer
requesting a claim be suspended or dismissed due to an IW’s failure to appear
for an employer scheduled exam.
1. Claims
services staff shall build the benefit type for both State Fund and SI claims
following the “Percentage of Permanent Partial Impairment in PowerSuite” job
aid.
2. Claims
services staff shall issue an order to grant, deny, dismiss or suspend a C-92
application.
3. Claims
services staff shall issue a TO for the percentage indicated by the IME or PFR.
4. Claims
services staff shall:
a. Hold the
TO for a 20-day objection period plus mailing time;
b. Waive the
objection period if a written waiver signed by the employer and IW is received;
and
c. Refer
objections to a TO to the IC.
5.
Awards for pain:
a. If a BWC
%PP exam finds a specific percentage for pain should be awarded and the TO
granting that award is uncontested, BWC shall update the claims management
system with that specific percentage for pain.
b. If the IC
issues an order that grants a specific percentage for pain, BWC shall update
the claims management system with that percentage.
c. If
the IC grants a C92 award based solely on one doctor’s report that indicates a
specific percentage for pain, BWC shall update the system with the %PP for pain
identified in the exam.
d. If the IC grants
a C92 award that relies on multiple exams that don’t address pain in a
consistent manner, then no pain award shall be added to the claim management
system.
1. Claims
services staff shall ensure wages have been set at the time the C-92
application is received and if not, request earnings following the Wages
policy and procedures.
2. Claims
services staff shall not set wages in order to pay a %PP award without evidence
of actual earnings.
3. If the %PP
request is granted and earnings information is available, but wages have not
been set:
a. The wage
team shall set wages; and
b. Claims
services staff shall:
i. Issue
a TO that grants the %PP award; and
ii. Issue
a BWC order setting wages.
iii. Both
orders may be issued at the same time.
4. If the %PP
request is granted but earnings information is not available, claims services
staff shall issue a TO indicating that the %PP has been granted but is not
payable until earnings information is received.
5. Claims
services staff may refer to the Orders, Waivers, Appeals, Hearing
policies and procedures for further guidance on TO’s.
1. Claims
services staff shall pay %PP awards at the lesser of 2/3 of the IW’s AWW or 1/3
of the statewide average weekly wage (SAWW).
2. Claims
services staff shall not pay a %PP award until the appeal period for the order
setting wages has expired.
3. Claims
services staff shall only pay the %PP award prior to the end of the wage
setting appeal period when the IC issues an order granting a %PP award and the
order has expired.
4. Claims
services staff shall ensure that any authorization to receive payment by a
third-party (usually the IW’s attorney) has been signed by the IW.
a. Claims
services staff shall not honor the authorization to receive payment that is
part of the C-92 application unless the IW files the C92 application online
that gives authorization or provides a hard copy signature indicating
authorization to receive payment.
b. A
separate, signed Authorization to Receive Workers’ Compensation Payment (C-230)
may also be used for the purpose of directing payment.
5. Claims
services staff shall deduct from the %PP award any temporary partial (TP)
payments in claims with dates of injury before August 22, 1986.
a. Claims
services staff shall dismiss a %PP application when the IW has received TP in
excess of the maximum allowed as described in the Temporary Partial (TP) Compensation
– Change of Election policy and procedures;
b. Additional
information regarding TP is available on COR under the Temporary Partial
Disability (TP) Compensation – Change of Election policy and
procedures.
6. Claims
services staff shall adhere to the following rules when making payment of %PP:
a. An IW is
awarded two weeks of %PP for each percent of impairment. For example, an
IW who receives a 5% award will receive 10 weeks of compensation;
b. Claims
services staff shall build separate benefit types when pain is identified in a
BWC IME or PFR.
c. The
%PP award cannot be made until after the last payment of compensation is paid
to the IW. This includes TT, WL, SC, LM and LMWL. However, if TT, WL, or SC is
currently being paid into the future and a %PP is awarded and there is a broken
period of compensation in the past, the %PP plan can start during the broken
period, beginning on the first date when there is a break in compensation. Payment
does not have to wait until the TT, WL, or SC has concluded;
d. If the IW
is receiving living maintenance (LM) or living maintenance wage loss (LMWL), the
%PP request may be processed, but payment cannot be made until the LM or LMWL
ends.
e.
If there are no open periods where compensation was not paid, the %PP
plan begins after the conclusion of the compensation being paid. Claims
services staff shall:
i. Issue
a TO but shall not issue payment; and
ii. Use
the add text section in the order to state the actual period for payment of the
compensation will be determined when the IW is no longer receiving TT, WL, SC,
LM, or LMWL;
iii. This may
result in the payment going into scheduled payments for the future.
f. When
an increase in %PP is being paid, there are no options except to continue
paying from the last date the prior %PP was paid, even if this results in
payment over other types of compensation.
g. BWC shall
pay %PP beginning the day after the DOI or DOD in a claim where no other
compensation has been paid, and to continue, subject to the limitations
outlined below in Section V.I.10.
h. Claims
services staff may refer to the job aid “Percentage of Permanent Partial
Percentage in PowerSuite” for additional information.
7. Public
Works Relief Employees (PWRE) – A %PP award is payable after:
a. Six (6)
months of receiving compensation directly out of the fund from which the
employee was receiving relief; or,
b. After the
employer’s funds to compensate the IW have been exhausted.
8. Claims
services staff shall recoup overpayments as outlined in the Overpayment of
Compensation policy and procedures.
9. Family
Support Collection from %PP Awards
a. Claims
services staff shall treat %PP payments issued through an initial ‘catch-up’ (daywork)
payment as a lump sum payment subject to attachment for family support
arrearages.
b. Scheduled
payments into the future are subject to weekly family support deductions.
c. If
there is a family support obligation on file requiring a notice be sent to the
attorney but wages have not been previously set, the claims management system
will not send the “Notice to Attorney of Lump Sum Payment” letter until:
i. Wages
have been set;
ii. All
appeal periods have expired; and
iii. The %PP
award is payable and scheduled.
10. %PP and Concurrent Payments
– In addition to the below information, staff shall refer to the Concurrent
Payments Chart on COR.
a. LM/LMWL
and %PP
i. Claims
services staff shall not pay %PP and LM awards or %PP and LMWL awards
concurrently in the same claim.
ii. Claims
services staff may pay %PP and LM or LMWL concurrently in different claims when
the claims involve different conditions/body parts.
iii. Claims
services staff shall not consider past or ongoing LM/LMWL payments when
determining if a %PP application is timely filed and shall process the request
for a %PP.
iv. Additional
information regarding LM and LMWL is available on COR under the Living
Maintenance and the Living Maintenance Wage Loss policies and
procedures.
b. WL and %PP
i.
Claims services staff shall pay a %PP award and WL over the same period
in the same claim if the %PP award becomes final prior to the WL being
awarded.
ii. Claims
services staff may pay %PP and WL concurrently in different claims.
iii. Additional
information regarding WL is available on COR in the Wage Loss policy.
b.
c. SC
and %PP
i. Claims
services staff shall pay a %PP award and SC over the same period in the same
claim if the %PP award becomes final prior to the SC being awarded.
ii. Claims
Services staff may pay %PP and SC concurrently in different claims.
iii. Additional
information regarding SC is available on COR in the Salary
Continuation/Wages in Lieu of Temporary Total Compensation policy.
d. TT and %PP
i. Claims
services staff may pay TT and a %PP over the same period in the same claim when
the %PP was paid first, and the IW later is awarded TT compensation over the
period the %PP is paid.
ii. Claims
services staff may pay TT and a %PP over the same period in different
claims.
iii. Before TT
and %PP are paid over the same period, claims services staff shall staff with
the local BWC attorney to determine if the court decision of Advantage Tank
Lines v Industrial Commission (2005) 107 Ohio St. 3d 16 applies.
iv. Additional
information regarding TT payments is available on COR under the Temporary
Total Compensation policy and procedure.
e. PTD and
%PP
i. Claims
services staff shall continue processing a %PP application when the %PP
application was filed on or before the date the PTD application was filed.
ii. Once
PTD has been awarded in a claim, the IW is ineligible to receive a new award of
%PP benefits in the same claim.
iii. Claims
services staff shall refer the PTD application to the IC for processing and
suspend the %PP application when the PTD application was filed prior to the
filing of the %PP application; if PTD is granted the %PP application shall be
dismissed.
iv.
Claims services staff shall not pay a %PP for the same period in the
same claim that a PTD award has been granted. If a %PP award is granted prior
to the PTD decision, the award is payable as long as it does not cover a
concurrent period with the PTD award
v. Claims
services staff shall deduct the %PP from the PTD award if PTD is awarded for a
back period that overlaps with the period in which %PP was awarded. Claims
services staff shall refer to “Scheduled Loss with Offset” in PowerSuite.
vi.
Claims services staff may pay a %PP award in one claim(s) even when PTD
has been granted in other claim(s) if the injuries affect different parts of
body or are conditions not included in the PTD claim(s). Example: The
IW is awarded PTD in one claim which was allowed for chondromalacia of the left
knee, L5-S1 disc herniation, and degenerative disc disease of the L5-S1. The IW
now files for a %PP in another claim (cervical strain, lumbar strain, left knee
contusion). The IW is not PTD in the latter claim. The IW may
receive %PP, but only for the condition of cervical strain, because the IW’s
PTD award was limited to a claim which included the left knee and lumbar back,
but not the cervical area. Claims services staff shall:
a) Inform the
examining DEP to examine only the allowed condition for body parts not included
in any PTD claims if a %PP application is received;
b) Refer all
PTD claims for that IW if the TO is appealed;
c) Notify the
local attorney so a BWC attorney can attend the hearing.
vii. Claims services staff
may pay a %PP award in one claim when one of the allowed conditions is the same
as an allowed condition in a settled PTD claim:
a) Any
previous %PP awards in any settled claim must be considered if there are
overlapping conditions.
b) The
settled PTD claim cannot be used as the basis to deny the %PP request because
the IW is no longer considered PTD due to the settlement;
c) Claims
services staff may staff these situations with a local BWC attorney.
viii. Claims services staff shall refer
to the Permanent Total Disability policy and procedure for additional
information.
f. Lump
Sum Settlement (LSS) and %PP
i. Claims
services staff shall suspend a pending %PP application when a signed LSS
agreement is filed as detailed in the Lump Sum Settlement policy and
procedure.
ii. The
C-92 application will remain suspended until:
a) The IW
withdraws the C-92 application; or
b) The LSS is
approved and the C-92 application can be dismissed; or
c) The LSS is
denied and claims services staff moves forward with processing the C-92
application.
iii. Claims
services staff shall update the status of the C-92 to “Dismissed” in the claims
management system but shall not issue a TO to dismiss the application.
iv. Claims services
staff shall consider the total WPI percentage in the settled claim when:
a) IW was
granted and paid a %PP award prior to the settlement,
b) Subsequent
C-92 applications are received and under consideration in the other non-settled
claims.
g. Violation
of Specific Safety Requirement (VSSR) and %PP
i. Claims
services staff shall pay VSSR and %PP concurrently.
ii. Claims
services staff shall not pay more than the maximum VSSR award on a %PP award of
33 1/3% of the SAWW.
iii. Additional
information regarding VSSR is available on COR under the Violation of
Specific Safety Requirements policy and procedures.
h. SL and %PP
i. Claims
services staff shall request an IME or PFR to determine how much, if any, of
the previously awarded %PP is for the loss and how much, if any, is for
residual effects when a %PP award is made prior to a SL award.
ii. Claims
services staff shall deduct any previous %PP award for the same part of body or
condition (not the residual) from a SL award; any subsequent %PP award should
not attribute any part of the percentage to that which has been covered by the
SL award
iii. Claims
services staff shall not vacate the %PP plan if any of the previously awarded
%PP is for the same part of body or condition and is being deducted from the
SL.
a) Claims
services staff shall offset the amount of money awarded, not the %PP awarded;
BWC has no jurisdiction to modify a previous order which is not under
appeal.
b) Claims
services staff shall not reduce or eliminate any %PP awarded by BWC or IC
Order.
c) Claims
services staff shall indicate that a reduction will be made for a previously
paid %PP award on the order which grants the SL.
d) Claims
services staff shall staff these with the local BWC attorney and/or supervisor.
iv. Claims services
staff shall refer to “Scheduled Loss with Offset” in PowerSuite.
i. Residual
effects
i. Claims
services staff shall ensure the DEP physician’s report documents: the symptoms,
including severity, frequency, treatment, and other important factors regarding
the loss addressed by the IW; an examination of the IW; and an impairment
percentage for these symptoms.
ii. Claims
services staff shall not grant a %PP award for partial hearing loss; however,
the IW may be eligible for a SL award if there is a total loss of hearing.
iii. Claims
services staff shall not grant a %PP award for loss of vision; however, the IW
may be eligible for a SL award if there is a 25% or greater loss of vision.
iv. A %PP may be
granted if there are conditions over and above the loss of hearing or loss of
vision.
j. Death
and %PP
i. Claims
services staff shall take the following steps when there’s a request for
accrued compensation for %PP:
a) Claims
services staff shall review the claim to determine if the IW had been examined
and a percentage established prior to death and if the examining physician
designated a whole person impairment for the IW;
b) If no independent
medical examination was performed prior to the IW’s death, claims services
staff shall request a file review and include recent medical that the doctor
can rely upon in the review;
c) Claims
services staff shall issue a TO based on the BWC exam or PFR;
d) Claims
services staff shall manually mail a copy of the TO to all parties in the
claim;
ii.
Claims services staff shall pay %PP awards for dependent(s) or estates
of the IW through the claims management system as accrued compensation in
Miscellaneous Payments.
iii. Claims
services staff shall refer to the Death Claims and the Accrued
Compensation policies and procedures for additional information.