OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Permanent Total Disability (PTD) and Disabled Workers’ Relief Fund (DWRF) for Self-Insured Claims

Policy #:

CP-16-03.3

Code/Rule Reference:

R.C. 4123.411 through 4123.417; 4123.58; 4123.62

O.A.C. 4123-3-31; 4123-3-34

Effective Date:

11/17/21

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

Policy # CP-16-03, effective 04/20/2015 and Procedure # CP-16-03-PR.1, effective 05/06/2019

History:

Previous versions of this policy are available upon request


 

Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

Disabled Workers’ Relief Fund (DWRF)

DWRF Eligibility Amount

Permanent Total Disability (PTD)

Split PTD

Statutory PTD

IV. POLICY

A.          SI PTD

B.          DWRF

V. PROCEDURE

A.          General Claim Note and Documentation Requirements

B.          Applications for Compensation for PTD in SI Covered Claims

C.         Statutory PTD

D.         Claim Assignment

E.          Collaboration with the TPA/SI Employer

F.          Annual Contact in SI PTD Claims

G.         DWRF Annual Processing

H.         Billing and Claims Information Inquiries

I.           Settlements

 

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure BWC calculates and pays Disabled Workers’ Relief Fund (DWRF) benefits in compliance with the Ohio Revised Code and the Ohio Administrative Code when Permanent Total Disability (PTD) is granted in a covered self-insured (SI) claim.

 

II. APPLICABILITY

 

This policy applies to all claims services staff.

 

III. DEFINITIONS

 

Disabled Workers’ Relief Fund (DWRF): A fund, separate from the state fund, established to provide supplemental benefits to injured workers who are receiving PTD compensation when the total of the PTD compensation plus the social security disability (SSD) benefit is less than the DWRF eligibility amount.

 

DWRF Eligibility Amount: The threshold amount, adjusted annually based on the consumer price index, used to determine an IW’s eligibility for DWRF benefits and established by the BWC DWRF Unit and BWC’s Actuarial Department.

 

Permanent Total Disability (PTD): Compensation granted to an injured worker for the duration of his/her life when the Industrial Commission of Ohio (IC) determines that the injured worker is unable to perform any sustained remunerative employment or is statutory PTD as defined in R.C. 4123.58.

 

Split PTD: PTD compensation allocated by the IC to more than one claim for an injured worker. The percentage for each claim is used to calculate the amount payable per claim. 

 

Statutory PTD: PTD compensation payable based on the loss or loss of use of both hands or both arms, or both feet or both legs, or both eyes, or of any two thereof.

 

IV. POLICY

 

A.     SI PTD

1.     It is the policy of BWC to expeditiously process PTD matters in SI claims to help ensure applications are processed timely and awards are paid promptly by SI employers.

2.     When a covered SI claim is granted PTD, it is the policy of BWC to work with the SI employer to secure the PTD payment rate.

 

B.     DWRF

1.     It is the policy of BWC to use the PTD rate paid by the SI employer to determine if the injured worker (IW) is eligible for DWRF benefits.

2.     BWC shall proactively determine if the IW is eligible to receive DWRF benefits when PTD is granted. No application is necessary.

3.     DWRF Payments in SI Claims

a.     BWC will bill SI employers for DWRF paid in all SI claims.

b.     BWC will also bill employers in claims that were previously SF, when the employer was SF and is now SI.

 

V. PROCEDURE

 

A.     General Claim Note and Documentation Requirements

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.

 

B.     Applications for Compensation for PTD in SI Covered Claims

1.     Claims services staff shall review the Application for Compensation for Permanent Total Disability (IC-2) or Agreement As To Award for Permanent Total Disability (IC-22) imaged in a claim file to determine if the application for PTD was filed with BWC or the IC.

a.     If the application was filed with the IC and the imaged document contains an IC date stamp, claims services staff shall:

i.       Create a case in the claim; and

ii.      Update the case issue to hearing.  

b.     If the application does not have an IC date stamp, claims services staff shall:

i.       Create a case and select the event titled “Referred to the IC”;

ii.      Complete a notice of referral (NOR) to notify the IC that an IC-2 or IC-22 application has been filed; and

iii.     Update the case issue to “Hearing”.

2.     Upon receipt of an IC-2 or IC-22, claims services staff must:

a.     Send the Self-insuring Employer Notice and Request for Information for  Permanent Total Benefits Application (C-268) to the SI employer to verify IW demographics and claim information; and

b.     Set a work item for 14 days for return of the C-268 from the SI employer.

i.       If the C-268 is received, make updates as appropriate to the claims management system.

ii.      If the C-268 is not received, call the SI employer to request the completed form or send a second request.

iii.     If there is no response to the second request, file an Self Insured Complaint Form (SI-28).

 

C.    Statutory PTD

1.     If an IW files a Motion for Statutory PTD, claims services staff shall forward the request to the IC for processing via a NOR.

2.     Claims servives staff shall:

a.     Send the C-268 to the SI employer to verify IW demographics and claim information; and

b.     Set a work item for 14 days for return of the C-268 from the SI employer.

3.     If the completed C-268:

a.     Is received, claims services staff shall make updates as appropriate to the claims management system.

b.     Is not received or is missing information, claims services staff shall call the SI employer to request the completed form, or send a second request.

c.      If there is no response to the second request, claims services staff shall file an SI-28.

4.     If an SI employer files an IC-22 in response to the Motion for Stat-PTD benefits filed by the IW, claims services staff shall forward it to the IC for processing via a NOR.

5.     Upon receipt of an IC Tentative Order (TO) for statutory PTD, the assigned PTD/DWRF CSS must verify that the order:

a.     Includes the PTD start date; and

b.     Limits the retroactive payment, if any, to no more than two years before the request for statutory PTD. 

c.      If the TO does not contain the required information, the PTD/DWRF CSS shall:

i.       Contact the parties to the claim and their representatives to discuss the error; and,

ii.      Document which party is going to request a corrected TO.

 

D.    Claim Assignment

1.     Upon receipt of an IC order granting PTD, claims services staff shall enter the claim’s information on the PTD Reassignment SharePoint site.

2.     If the SI employer settles the DWRF liability, the claim remains assigned to the SI PTD/DWRF CSS.

3.     If the SI employer settles the DWRF liability and the PTD indemnity, the claim is reassigned to the assigned claims assistant (CA).

 

E.     Collaboration with the TPA/SI Employer

1.     Upon the granting of PTD benefits in an SI claim, the PTD/DWRF CSS shall collaborate with the TPA/SI employer as needed.

2.     Initial steps when PTD is granted:

a.     The SI PTD/DWRF CSS shall:

i.       Send the Self-Insuring Employer Notice and Request for Information for Injured Worker Who Has Been Granted PTD Benefits (C-269), which provides notification to the SI employer of the DWRF rate to be paid by BWC based on the AWW information the SI employer previously provided and the Social Security (SS) information BWC has on file; and

ii.      Set a work item for 14 days for return of the C-269 from the SI employer.

b.     If the C-269:

i.       Is received, the SI PTD/DWRF CSS shall make updates as appropriate to the claims management system.

ii.      Is not received, the PTD/DWRF CSS shall call the SI employer to request the completed form, or send a second request.

c.      The SI PTD/DWRF CSS must work with the SI employer to resolve any discrepancies, if necessary.

3.     Ongoing management of the claim(s):

a.     If the SI PTD/DWRF CSS receives any SS crossmatch work items that indicate, after review, that the PTD rate should be updated, the PTD/DWRF CSS must contact the SI employer regarding the SS change.

b.     The SI PTD/DWRF CSS will send the SI employer an updated PTD rate calculation worksheet along with the effective date of the change.

c.      The SI PTD/DWRF CSS shall contact the SI employer if notification of the IW’s death is received.

 

F.     Annual Contact in SI PTD Claims

1.     When the annual contact work item is posted in the claim, the SI PTD/DWRF CSS shall contact the SI employer or their designee annually via the “DWRF Annual Contact – SI Insured” letter (found in the claims management system) to request:

a.     The AWW, if not previously submitted;

b.     The PTD declared and paid rates; and

c.      Any LSAs or other offsets affecting the rate.

2.     The SI PTD/DWRF CSS shall document in claim notes all efforts to obtain information from an SI employer or their designee.

3.     If the SI employer or their designee fails to respond to the first letter:

a.     The SI PTD/DWRF CSS shall send a second letter requesting the information.

b.     If there is no response to the second letter, the SI PTD/DWRF CSS must make an attempt to contact the SI employer or their designee by phone or email.

c.      If the phone or email contact is not successful, the SI PTD/DWRF CSS shall file an SI-28 documenting that the SI employer or their designee has not been responsive to BWC’s request for information. The notification shall include:

i.       Dates that the letters were sent; and

ii.      Information regarding phone calls or emails, including date and person contacted.

d.     The SI PTD/DWRF CSS shall work with the SI auditors to obtain contact information for the employer if necessary.

4.     When the response is received, the SI PTD/DWRF CSS shall work with the SI employer or designee to resolve any discrepancies if information previously reported has changed. If necessary, the SI PTD/DWRF CSS shall staff the issue with the PTD/DWRF Injury Management Supervisor (PTD/DWRF IMS).

5.     Once the discrepancy has been resolved, the SI PTD/DWRF CSS shall image a copy of the revised PTD rate calculation worksheet indicating the change in the PTD declared rate. 

6.     If any changes occur, the SI PTD/DWRF CSS must make the appropriate updates in the system. 

7.     The SI PTD/DWRF CSS must build a PTD-SI plan based on the PTD rate calculation worksheet.

8.     If DWRF is impacted due to the change, the SI PTD/DWRF CSS must issue a DWRF order addressing the new rate.

 

G.    DWRF Annual Processing

1.     The SI PTD/DWRF CSS must issue a DWRF order during the DWRF annual process when an IW becomes newly entitled to DWRF benefits.

2.     Please see the PTD/DWRF training document for detailed information regarding the SI DWRF annual process procedures.

 

H.    Billing and Claims Information Inquiries

1.     If the PTD/DWRF CSS receives an inquiry from an SI employer about a DWRF billing, the PTD/DWRF CSS shall inform the SI employer that the billing information can be found on www.bwc.ohio.gov.

2.     Excess Carrier Requests

a.     Excess Carriers may periodically request information regarding a SI backrupt claim by emailing Excessinsurance@bwc.state.oh.us. The request may include:

i.       The amount of medical benefits and compensation payments;

ii.      Authorizations; and

iii.     Invoices.

b.     If the request is claims related, the SI department will contact the PTD/DWRF CSS to respond. The PTD/DWRF CSS must respond to these requests as soon as possible, as a delay in response may result in BWC becoming permanently responsible for the payment of the claim.

c.      The PTD/DWRF CSS or PTD/DWRF IMS must forward all email inquiries they receive directly to Excessinsurance@bwc.state.oh.us for review and assignment.

 

I.       Settlements

1.     When the SI PTD/DWRF CSS receives notification from the Industrial Commission that a SI settlement has been approved, the PTD/DWRF CSS shall update the claim to the appropriate settled status (e.g., settled medical, settled indemnity, settled both).

2.     If the PTD indemnity or both the medical and indemnity are settled, the PTD/DWRF CSS must stop DWRF payments.