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OhioBWC - Basics: (Policy library) - File

Policy Name:

Claim Reviews

Policy #:

CP-03-09

Code/Rule Reference:

O.A.C. 4123-5-01

Effective Date:

3/21/16

Approved:

Rick Percy, Chief of Operational Policy, Analytics & Compliance (Signature on File)

Origin:

Claims Policy

Supersedes:

All Injury Management policies, directives and memos regarding claim reviews that predate the effective date of this policy.

History:

New

Review date:

3/21/19

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to provide guidance for the claim review process to ensure that field staff are accurately paying compensation and managing claims in compliance with all applicable statutes, rules and agency directives and making quality claim determinations.

 

 

II. APPLICABILITY

 

This policy applies to BWC Field Operations, particularly: Field Staff Supervisors, which includes Injury Management Supervisors, Medical Claims Specialist Supervisors and Employer Management Supervisors and to Benefits Payable staff.

 

III. DEFINITIONS

 

Batch Process: A computer program that computes a group of items together and runs it through the system at one time.

 

Claim Review Tool: An Access database used to maintain claim review records.

 

Daywork Authorized by Team Members” report: A report produced daily that indentifies batch or daywork payments.

 

Daywork payment: Claims management system-reference to compensation and benefit payments that cover past periods but do not extend to future scheduled payments.

“Miscellaneous Payment Authorized by Team Members” report: A report produced daily that identifies payments made using Miscellaneous Payment. 

 

Scheduled payment (Pension): Claims management system-reference to future compensation payments that are scheduled on a two-week basis.

 

“Scheduled Payments Authorized by Team Members” report: A report produced every two weeks to show new pension payments.

 

Warrant: Payments made by BWC, usually in the form of an electronic transfer of funds, or, in rare circumstances, by check.

 

 

IV. POLICY

 

A.    It is the policy of BWC to conduct random claim reviews to:

1.    Ensure appropriateness and accuracy of payments;

2.    Identify user and system errors;

3.    Identify trends;

4.    Monitor claims management issues; and

5.    Detect fraudulent activity.

 

B.    Claim Review outcomes are used by Service Office Managers (SOMs) and Field Staff Supervisors to:

1.    Create management reports;  

2.    Identify performance trends by office, team and/or member;

3.    Identify opportunities for coaching, mentoring and training, when appropriate.

 

C.   Types of claim reviews

1.    Import Reviews

a.    Initial determination

b.    Additional allowance

c.    Newly granted compensation

d.    On-going claims and compensation management

2.    Daily Reviews

a.    Compensation payments

b.    Claims management practices

 

D.   Claim reviews are used by field operations supervisors to:

1.    Evaluate the quality of the initial determination;

2.    Review appropriateness of:

a.    Determination of requests for an additional condition(s); 

b.    Newly initiated pending compensation payments in a claim;

c.    The accuracy of any newly initiated released compensation payment in a claim.

3.    Assess the Claims Service Specialist’s (CSS) claim management practices;

4.    Proactively detect processing errors;

5.    Provide opportunities for claims processing mentoring. 

 

E.    The Field Staff Supervisor, by using the claim review, shall:

1.    Determine how proactively and consistently the CSS is monitoring ongoing compensation and taking steps to resolve outstanding issues;

2.    Work with Benefits Payable to prevent warrants being released incorrectly;

3.    Monitor policy and procedural compliance;

4.    Identify trends and areas of improvement to share with the CSS to improve case management skills.

 

 

BWC staff may refer to the corresponding procedure for this policy entitled “Procedures for Claim Reviews” for further guidance.


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