OhioBWC - Basics: (Policy library) - File

Catastrophic Claims

Policy and Procedure Name:

Catastrophic Claims and Extremely Severe Injuries

Policy #:


Code/Rule Reference:

R.C. 4123.511; R.C. 4121.121(B)(3)

Effective Date:



Shawn Crosby, Chief Operations Officer


Claims Policy


Policy # CP-03-14, effective 04/01/21


Previous versions of this policy are available upon request


Table of Contents





Catastrophic (CAT) Claim

Extremely Severe Injury Claim


A.          Claim Review and Referral

B.          Claim

C.         MCO Role in CAT Claims and Collaboration with BWC


A.          General Claim Note and Documentation Requirements

B.          Claim Review and Referral

C.         CAT Claim Determination Process

D.         CAT and Extremely Severe Injury Claim Handling by Special Claims II Team





The purpose of this policy is to ensure that BWC claims services staff identify and manage catastrophic claims appropriately during initial claim determination.




This policy applies to BWC claims services staff.




Catastrophic (CAT) Claim: A claim in which there is a serious injury or occupational disease resulting in limited mobility and/or cognition related to the allowed conditions in the claim that severely limits the ability of the injured worker (IW) to perform activities of daily living and has a high probability of resulting in permanent disability.


Extremely Severe Injury Claim: A claim in which there is an injury that, while not deemed to meet the definition of a CAT claim, is significant enough that it may include multiple significant conditions, involvement of multiple body parts, high risk of complications, or extended projected length of disability, and thus requires special handling.




A.     Claim Review and Referral

1.     It is BWC’s policy that CAT claims may include, but are not limited to:

a.     Brain injuries, moderate to severe;

b.     Amputations, fractures, or crush injuries of a major extremity, or loss of use of one or more limbs;

c.      Spinal cord injuries such as paraplegia, quadriplegia, hemiplegia or diplegia;

d.     Total occupational blindness;

e.     Severe burns, including second-or third-degree burns on more than 25 percent of the body;

f.       Actual and anticipated hospitalization in excess of four weeks, (i.e., ventilators, intensive care unit, psychiatric hospitalization);

g.     Severe occupational diseases and bloodborne pathogens (not end stage);

h.     Toxic exposure with long term complications; and

i.       Any other medical diagnoses identified by the managed care organization (MCO) and CAT nurse.

2.     It is the policy of BWC that claims services staff refer claims with the indicators outlined above to the CAT nurse for determination of catastrophic claim status.


B.     Claim


1.     It is the policy of BWC that CAT claims and claims involving extremely severe injuries are handled by a specialized team called Special Claims II.

2.     A CAT nurse decides whether a claim meets the appropriate criteria to be deemed a CAT claim.

3.     Claims not deemed CAT will be reviewed by a supervisor to decide whether they meet the criteria of an extremely severe injury to be handled by the Special Claims II team.


C.    MCO Role in CAT Claims and Collaboration with BWC

1.     The MCO, not the CAT nurse, is responsible for providing case management for all CAT claims including, but not limited to, on-site visits.

2.     The BWC CAT nurse provides oversight and assists the MCO with issues that may arise during the case management process.

3.     For additional details on MCO management of CAT claims, please refer to the Catastrophic Claims portion of the MCO Policy Reference Guide.




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 requirements; and

2.     Shall follow any other specific instructions for claim notes included in this procedure.


B.     Claim Review and Referral

1.     Claims services staff will monitor their assigned claims for indicators or changes in the IW’s condition that would suggest that the claim is or may become catastrophic. If there is insufficient medical evidence on file to make this determination, claims services staff must work with the MCO to ensure that it has been requested.

a.     If claims services staff is unsure whether a claim should be referred to the CAT nurse for CAT claim determination, they will staff the claim with a supervisor.

b.     Claims services staff will refer a claim meeting the criteria listed in this policy to the CAT nurse within three business days of receipt of the claim.

2.     Upon referral to a CAT nurse, claims services staff will:

a.     Enter a note in the claim indicating the reasoning for the need for the referral being made to the CAT nurse.

b.     Create a work item in the claim.

i.       From the task template drop down select “Review for Possible Catastrophic Claim;”

ii.      Select the Assign to team radio button;

iii.     From the Team drop down select ‘Nurse – Catastrophic;’

iv.    Enter the name of the MCO in the Description box; and

v.      Click the finish button.

3.     When a new claim is referred to the CAT nurse for review, a referral should not also be made to a medical services specialist (MSS).


C.    CAT Claim Determination Process

1.     Upon receipt of a claim referred for CAT claim determination, the CAT nurse will use the medical evidence on file to assist with making a determination within two business days, whenever possible.

2.     If the CAT nurse receives a claim referral without medical or other relevant evidence, the CAT nurse will review claim notes to ensure that the evidence has been requested.

a.     If evidence has been requested, the CAT nurse will use their discretion to determine the CAT status or to leave the referral open and wait until the evidence is received to make a determination.

b.     If  the CSS is unsuccessful at obtaining missing documentation, the CAT nurse will contact the MCO to obtain the evidence.

3.     If the CAT nurse determines that the claim is catastrophic:

a.     The CAT nurse will:

i.       Review and determine the appropriate allowances and obtain a physician review, if indicated;

ii.      Enter a claim note documenting the decision, using the appropriate note template.

iii.     Place the ICD-10 code recommendations into the claims management system and request modifications, if necessary;

iv.    Update the claims management system to designate the claim as a CAT claim (for information on this process, refer to the CoreSuite – Catastrophic Advocate Nurse (CAT) Group manual); and

v.      Notify the claims services specialist (CSS), injury management supervisor (IMS) of the Special Claims II team, and MCO that:

a)     The claim will be handled as a CAT claim (including the information contained in the claim note template referenced in Section V.C.3.a.ii above); and

b)     ICD modification is complete, if applicable.

b.     The IMS of the Special Claims II team will reassign the claim to a CSS on Special Claims II.

4.     If the CAT nurse determines that the claim is NOT catastrophic:

a.     The CAT nurse will:

i.       Enter a claim note documenting the decision, using the appropriate note template;

ii.      Send an email to the referring CSS, IMS of the Special Claims II team, and the MCO informing them of the decision; and

iii.     Ensure that the Catastrophic Injury box is unchecked in the claims management system.

b.     The IMS of the Special Claims II team will review the claim to determine whether the claim will be considered an extremely severe injury.

i.       If so, the claim will be reassigned to the Special Claims II Team for handling.

ii.      If not, the claim will remain with the referring CSS.


D.    CAT and Extremely Severe Injury Claim Handling by Special Claims II Team

1.     Claims managed by the Special Claims II team will be staffed by a multidisciplinary team (including BWC Legal and Policy) as needed.

2.     In general, these claims will remain with the Special Claims II team for the life of the claim. Claims will be reassigned to another team in cases:

a.     Of statutory occupational disease;

b.     Where the IW is found permanently and totally disabled; and

c.      When the IW dies and BWC receives an application for death benefits.

3.     The CSS will establish communication with the IW. If the CSS is unable to speak to the IW because the IW is unreachable due to hospitalization or incapacitation, the CSS will attempt to contact the following individuals to obtain necessary information:

a.     The IW’s attorney of record, if applicable;

b.     The IW’s guardian or health care power of attorney, if applicable;

c.      The IW’s family member(s) or other individuals that have knowledge of the IW; or

d.     The IW’s employer of record.