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OhioBWC - Basics: (Policy library) - File

Crisis Event - Multiple Claims Occureence

Policy Name:

Crisis Event/Multiple Claims Occurrence

Policy #:

CP-03-05

Code/Rule Reference:

R.C. 4123.511

Effective Date:

12/21/17

Approved:

Kevin R. Abrams, Chief Operating Officer

Origin:

Claims Policy

Supersedes:

CP-03-05, effective 08/20/13 and CP-03-05.PR1, effective 11/14/17

History:

CP-03-05

Rev. 12/21/17; New 08/20/13

CP-03-05.PR1

Rev. 12/21/17; 11/14/16; New 08/20/13

Review date:

12/21/20

 

 

I.     POLICY PURPOSE

 

The purpose of this policy is to ensure crisis events are properly identified, and to ensure consistent injury management:

1.    Within BWC using crisis event teams; and,

2.    Through collaboration between BWC and the Managed Care Organizations (MCOs).

 

II.    APPLICABILITY

 

This policy applies to all BWC and MCO staff.

 

III.  DEFINITIONS

 

Catastrophic claim: a claim in which there is a serious injury resulting in limited mobility and/or cognition related to the allowed conditions in the claim and that severely limits the ability of the injured worker (IW) to perform activities of daily living.

 

Crisis Event: an incident resulting in:

1. At least two workers being severely injured or hospitalized; and,

2. The nature of the event could involve death claims, long-term treatment, the inability to return to work and psychological issues.

3. Examples of a crisis event include:

a. Natural disasters;

b. Industrial accidents;

c. Workplace violence; or,

d. Terrorism.

 

IV.  POLICY

 

A.    General Policy Statement: It is the policy of BWC to evaluate reports of potential multiple claim occurrences and to determine if the event meets the criteria set forth in the crisis event definition in this policy.

 

B.    Crisis Event Teams

1.    When BWC has categorized an event, it is the policy of BWC to proactively assist the IWs and facilitate injury management services through the crisis event teams. The regional core crisis event teams and the claims offices and/or claim types they service are as follows:

a.    Columbus team:

i.      Columbus;

ii.     Cambridge;

iii.    Mansfield;

iv.   Portsmouth;

v.     Self-insured bankrupt employers;

vi.   Out of state IWs;

vii.  Special Claims/COEMP;

viii. Out of state employer claims; and,

ix.   Death claims.

b.    Dayton team:

i.      Dayton;

ii.     Cincinnati-Governor’s Hill;

iii.    Lima; and

iv.   Toledo.

c.     Youngstown team:

i.      Youngstown;

ii.     Canton;

iii.    Cleveland; and

iv.   Garfield Heights.

2.    BWC will not utilize a crisis event team for claims managed by a self-insuring employer.

3.    The regional core crisis event teams will be responsible for managing claims throughout the initial determination process.

 

V.   PROCEDURE

 

A.    Claim-note Requirements: BWC staff shall refer to the Standard Claim File Documentation policy and procedure for claim-note requirements and shall follow any other specific instructions included in this procedure.

 

B.    Crisis Event Team Members and Responsibilities: Claims Services Division shall maintain regional crisis event teams whose members participate in staffings as needed and consist of the following:

1.    An injury management supervisor (IMS) who:

a.    Is the team lead;

b.    Oversees the efforts of the team through the closure of the crisis event;

c.     Assigns tasks to the crisis event team members;

d.    Coordinates the transfer of claims to the responsible regional claims service specialist (CSS) as needed; and,

e.    Coordinates completion of the initial crisis management summary document.

f.      Communicates information to claims director (CD) for dissemination to senior staff.

2.    A claims service specialist (CSS) who:

a.    Creates the event in the Multiple Claim Occurrence window in PowerSuite (PS);

b.    Ensures the  information remains current by updating PS according to staffing outcomes; and,

c.     Manages all aspects of the injury in accordance with all applicable policies and procedures.

3.    A medical service specialist (MSS) who acts as a primary resource for medical issues regarding non-catastrophic claims.

4.    A BWC catastrophic nurse advocate (CNA) who is the primary resource for issues regarding catastrophic claims.

5.    An employer management supervisor (EMS) who:

a.    Decides in what capacity employer services needs to be involved; and,

b.    Notifies the Safety Violation Investigation unit (SVIU) or the Public Employment Risk Reduction Program unit (PERRP) when a fatality is part of the crisis event.

6.    An MCO catastrophic claim program coordinator (MCO CAT Coordinator) who:

a.    Is the point of contact for the responsible regional crisis event team;

b.    Obtains medical documentation for his/her respective employer(s); and,

c.     Disseminates information within the MCO as needed.

7.    A survivor benefits coordinator (SBC) who:

a.    Manages death claims that result from the crisis event; and,

b.    Makes the initial confirmation and notification contact to the employer(s).

 

C.   Reporting an event

1.    Upon becoming aware of a potential crisis event, BWC staff or MCO staff shall report the incident by sending an email to catevent-notification@bwc.state.oh.us.

2.    Staff shall title the email “Potential Crisis Event” and note the location of the event in the subject line of the email (e.g., Potential Crisis Event – Dayton).

3.    BWC staff shall include all known information on the initial crisis management summary document and attach the document to the email.

4.    MCO staff shall include all known information in the body of the email (e.g., location of event, employer(s) involved, number of injured workers (IWs), and extent of injuries).

 

D.   Establishing the responsible crisis event team

1.    The IMS of the region identified in the subject line of the email shall direct a member of the regional crisis event team (generally the CSS) to enter the available event information into the Multiple Claims Occurrence window in PS.  

2.    The IMS shall then either, within one business day:

a.    Coordinate an initial staffing with the responsible regional crisis event members, notifying the appropriate MCO CAT coordinator(s) of the event and staffing via email and phone call; or

b.    If the event involves multiple regions, staff with the IMS and Claims Directors of each involved region to determine the responsible crisis event team; and,

                                          i.    Notify the responsible crisis event team members;

                                         ii.    Notify appropriate MCO CAT coordinator(s); and,

                                        iii.    Notify the appropriate BWC CNAs.

 

E.    Crisis event determination   

1.    If, after the initial staffing, BWC has determined that the event does not meet the definition of a crisis event as defined by this policy, a member of the responsible regional crisis event team shall:

a.    Enter a staffing note;

b.    Update the multiple claim occurrence screen in PS; and

c.     Reassign the claim to the appropriate regional service office and CSS who shall then process the claim(s) in accordance with the Initial Determination or Occupational Disease policy and procedure in the appropriate claims office.

2.    If, after the initial staffing, BWC has determined that the event does meet the definition of a crisis event as defined by this policy:

a.    All claims related to the event, even if previously filed, shall be reassigned to the regional multiple claims occurrence CSS;

b.    The multiple claim occurrence screen in PS shall be updated by the CSS;

c.     A crisis event action plan created by the IMS; and

d.    Each claim associated with the event is processed in accordance with the Initial Claim Determination policy and procedure.

 

F.    The action plan

1.    A designee of the responsible regional event team shall create an action plan by using the template located on the Crisis Event policy page on COR.

2.    Claims staff shall document each action step and utilize the action plan to capture tasks and outcomes associated with claims occurring from an event.

3.    Staff shall close an action plan when the team agrees that all major claim and employer issues have been addressed.

4.    Claims remain assigned to the crisis event office throughout the life of the claim.

5.    The closure of a CAT event action plan results in closure of the multiple claims occurrence event.

6.    Upon closure of the CAT event action plan, involved claims shall be processed in accordance with all applicable policies and procedures.

 

 


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