OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Initial Claim Determination

Policy #:

CP-9-01

Code/Rule Reference:

R.C. 4123.511, 4123.84; O.A.C. 4123-3-08, 4123-3-36

Effective Date:

11/07/2019

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

Policy # CP-9-01, effective 11/20/15 and Procedure # CP-9-01.PR1, effective 05/06/19

History:

CP-9-01

Rev. 11/20/15, 07/01/15, 02/03/15, 09/12/14; New 08/30/13

CP-9-01.PR1

Rev.05/06/19, 09/06/18, 11/14/16, 11/20/15, 07/01/15, 02/03/15, 09/12/14; New 08/30/13

 


 

Initial Claim Determination Table of Contents

 

I.   POLICY PURPOSE

II.  APPLICABILITY

III. DEFINITIONS

Auto Claims Processing (ACP)

Fast Response

Lost Time (LT) Claim

LT Indicators

Medical (MO) Claim

Terminating Rules

Triage

IV. POLICY

A.          Investigation and Determination Time Frames for all State Fund Claims

B.          Auto Claims Processing (ACP) for Initial Claim Determination

C.         Employer Retains Appeal Rights

D.         Elective Coverage Claims

E.          Dismissal of a First Report of Injury (FROI)

F.          Claims Not Requested by the IW

G.         Employer Certification

V. PROCEDURE

A.          Claim Note Requirements

B.          ACP

C.         State Fund (SF) and Public Employer (PE) Claims Not Eligible for ACP or Fast Response

D.       Issuing an Order

E.       Re-filing a Dismissed Claim

F.          Reconsideration

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure the Ohio Bureau of Workers' Compensation (BWC) processes initial claim applications in compliance with R.C. 4123.511.

 

II. APPLICABILITY

 

This policy applies to BWC Claims Services staff.   

 

III. DEFINITIONS

 

Auto Claims Processing (ACP): the systematic evaluation of low-risk claims with little or no human intervention.  Claims systematically pass through established business rules that may prevent claims from completing the process and require claims services staff to conduct further investigation.  Terminating rules will prevent claims from being allowed via ACP. 

 

Fast Response: a program established to immediately allow specific medical conditions which have a historical record of being allowed whenever included in a claim and having low medical costs.  Claims in the program are from state-fund, private employers and public employer taxing district employers who have access to the Surplus Fund, are filed for medical treatment only, and are filed with only one (1) diagnosis code/condition.     

 

Lost Time (LT) Claim: a claim with eight or more days of lost time from work directly caused by a work-related injury, even if compensation or wages in lieu of compensation have not been paid to the injured worker (IW) or in any claim in which BWC awards compensation. 

 

LT Indicators: one type of terminating rule that presupposes an IW will, or could, miss eight or more days of work.  

 

Medical (MO) Claim: a claim with seven or fewer days of lost time from work directly caused by a work-related injury, for which the IW receives no compensation for lost wages (e.g., temporary total, salary continuation), or is not awarded any compensation during the life of the claim. 

 

Terminating Rules: any systematic red flag that presupposes a claim will, or could, be a LT claim. 

 

Triage

Systematic Triage:  the systematic review of all claims that evaluates the severity of a claim as identified by International Classification of Diseases (ICD) codes, indications of lost time, benefit applications and/or claim accident/illness type and assigns those claims not allowed by ACP to the appropriate claims office for determination. 

Claims Triage:  the manual transfer of a claim to either a claims office or particular discipline within the claims office (e.g., Intake, Return to Work, Remain at Work) based upon the severity of the condition or where the claim falls in the life cycle.  

 

IV. POLICY

 

A.    Investigation and Determination Time Frames for all State Fund Claims – Claims services staff shall investigate a claim and issue a decision: 

1.     No later than twenty-eight (28) calendar days after sending the notice of receipt of the claim; or

 

2.     No more than twenty-eight (28) calendar days after the receipt of the report for a medical examination in claims in which an examination is required by statute.

 

B.     Auto Claims Processing (ACP) for Initial Claim Determination

1.     It is BWC’s policy to consider claims for initial allowance using ACP.  Claims shall be:

a.     Allowed systematically with little to no manual intervention; or

b.     Directed to the appropriate claims office to process.

2.     The claim will remain in ACP until it is determined or one of the terminating rules removes it from ACP.

 

C.    Employer Retains Appeal Rights

1.     The employer retains the right to contest the allowance of a claim determined by ACP, including Fast Response claims.

2.     Employer certification of a claim does not eliminate the employer’s right to appeal a BWC Order. 

 

D.    Dismissal of a First Report of Injury (FROI)

1.     It is BWC policy to dismiss a claim prior to issuance of a BWC Order or during the BWC Order appeal period when:

a.     The IW voluntarily withdraws his/her claim application without prejudice; or

b.     An IW/IW representative requests dismissal of a claim either verbally or in writing. 

2.     BWC shall not dismiss an initial claim application if the appeal period has expired. 

3.     BWC may dismiss a claim at any time during the twenty-eight (28) day determination period when:

a.     The IW has filed a claim for a psychological condition which did not arise out of forced sexual contact and there is no physical condition alleged following the Psychiatric Conditions policy and procedure;

b.     The IW has signed a sports waiver, which BWC has on file;

c.      The IW is covered by federal workers’ compensation;

d.     The employer and employee are exempt from coverage because they, on religious grounds, conscientiously object to the acceptance of workers’ compensation benefits; or

e.     Claims services staff has received approval from a supervisor for dismissing the claim prior to the end of the twenty-eight (28) day determination period for other good cause. 

4.     Once a claim is dismissed, BWC can take no further action in the claim, except updating claim notes, unless a party re-files the claim application.

5.     The dismissal and subsequent re-filing of a claim application for the same injury and same injury date will not change the statute of limitations in which the IW must file.

a.     For injury claims with a date of injury:

i.       Prior to 09/29/17, the statute of limitations is two (2) years; or

ii.      On or after 09/29/17, the statute of limitations is one (1) year.

b.     For occupational disease claims, the statute of limitations is two (2) years. 

 

E.     Claims Not Requested by the IW

1.     BWC employees are prohibited from filing any claim on behalf of the IW or IW’s family if there are any indications that the IW or the IW’s family does not want a claim filed.

2.     BWC employees may file on behalf of the IW or IW’s family when the IW or IW’s family expressly requests BWC file on their behalf. 

 

F.     Employer Certification

1.     Certification may be written or verbal. 

2.     When the claim is certified, the employer has accepted the validity of the IW’s claim.  Specifically, certification only means the employer acknowledges that a work-related injury occurred.

3.     State fund and public employers cannot certify a claim in part (i.e., certification cannot be specific to allowing medical costs, but denying lost-time benefits).

 

 

V. PROCEDURE

 

A.     Claim Note 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.     ACP

1.     If the claim does not meet the ACP eligibility rules, the claims management system will generate a “new claim-ineligible for ACP” work item and claims services staff shall process the claim per sections C and D below. 

2.     If the claim meets the ACP eligibility rules, the claims management system systematically places the claim in “accepted” status and assigns the claim to the ACP group. 

3.     If additional information is needed to determine if the claim meets the ACP eligibility rules, claims services staff shall receive a “new claim pending ACP” work item after three (3) days from the date the claim is filed.

a.     Claims services staff shall ensure the claim is assigned an appropriate ICD code(s), in accordance with the narrative description of the injury or disease.

b.     Within two (2) business days of receipt of the work item, claims services staff shall review all available information and attempt to obtain the missing data elements.

i.       If the missing information is available, claims services staff shall enter it in the claims management system and allow the claim to go through ACP.

ii.      If the missing information is not available, claims services staff shall contact the managed care organization (MCO) to obtain the information. 

iii.     If, after three (3) calendar days, the missing information is still not available, claims services staff shall make one more attempt to obtain it. 

iv.    After fourteen (14) days, the system will generate a “no claim decision” work item if the claim is still undetermined.  Claims services staff shall continue to manage the claim and the claims management system will continue to evaluate the claim using the ACP eligibility rules. 

4.     Fast Response Claims

a.     The claims management system will set the acceptable fast response ICD codes to “accepted” upon the acceptance of the claim in ACP.

b.     See Appendix A to OAC 4123-3-36 for a list of acceptable ICD codes. 

c.      When the diagnosis code(s) is one which can be allowed through fast response, but the claim does not meet the ACP eligibility criteria, claims services staff shall:

i.       Verify all other compensability tests under section V.C.2. below

ii.      Update all available claim information in the claims management system;

iii.     Enter a claim note to indicate a fast response claim;

iv.    Immediately update the claim status to “allow” in the claims management system; and

v.      Place the claim in “hearing” status if an appeal is filed to the BWC Order.   

 

C.    State Fund (SF) and Public Employer (PE) Claims Not Eligible for ACP or Fast Response

1.     General Requirements:

a.     Claims services staff shall review all MCO notes in the claims management system to determine what information has already been gathered and what additional information is necessary.

b.     Claims services staff shall ensure the claim is assigned appropriate ICD codes, in accordance with the narrative description of the injury or disease.

c.      Claims services staff shall make a determination in the claim if all necessary documentation is present.

d.     If additional information is required, claims services staff shall allow the MCO up to three (3) days to gather the required information. 

e.     Claims services staff shall contact the MCO after three (3) days if additional information is needed to make the claim determination, but shall not contact the MCO solely to validate the information in claim notes.

f.       Claims services staff shall e-mail the BWC MCO Business Unit Referral e-mailbox for assistance when:

i.       After supervisory staffing with the MCO, the MCO fails to provide the required data elements and/or necessary medical documentation to make a determination on the claim and fails to establish good cause for that failure; or

ii.      An MCO has shown a pattern of not providing the required data elements or obtaining the required documentation. 

g.     Claims services staff shall request certification information, verify the manual number, also referred to as the National Council on Compensation Insurance (NCCI) manual classification number, and, if appropriate, request necessary wage information in addition to any other missing information, including interstate jurisdiction information from the employer of record (EOR) after the MCO has completed their initial contacts.  If certification has not already been established and contact with the EOR is unsuccessful, claims services staff shall send the “Employer Certification Request” letter.

h.     If wages are still needed, claims services staff shall follow the Wages policy and procedure.

i.       Claims services staff shall document verbal certification information in claim notes.  The notes must reflect the name and title of the person providing certification.  Claims services staff shall also note employer certification information in the claims management decision note when issuing an initial BWC Order. 

j.       If no employer information is available, claims services staff shall follow V.C.2.i.(i-ix.) below.

k.      Claims services staff shall ensure that an initial contact has been made on or before seven (7) days from the date of filing.  If contact has not been made, staff shall immediately call the necessary party(ies) to the claim to complete the initial contacts.

l.       When claim applications are received more than seven (7) days after the filing date, claims services staff shall immediately contact the MCO if additional information is required to make a determination.  If the MCO does not provide the necessary information within three (3) days, claims services staff shall contact the appropriate party for missing information.  If claims services staff is unsuccessful in the attempted phone contact, claims services staff shall send an Additional Information Request (C-63) to the party. 

2.   Claim Investigation

a.     Claims services staff shall investigate the claim to ensure the claim is assigned to the appropriate claims office.  Claims may need to be reassigned to a claims office based on benefit type (medical only or lost time), accident type (injury, occupational disease, death), and/or requested condition (psychiatric or forced sexual conduct).

i.       Example:  Medical claims shall reassign forced sexual conduct claims to the appropriate claims office.

ii.      Example:  Death claims shall be reassigned to the Survivor Benefits Team, except for statutory occupational disease death claims for specific conditions when there is no existing claim. 

b.     Social Security Number (SSN)

i.       When a new application has been entered, the claims management system will identify if there are any possible duplicate claims.  The indexer shall review any identified claims to determine if the new claim could be a duplicate of an existing claim.   

a)     If the application is an exact duplicate, the indexer shall not create a new claim and image the application to the existing claim. 

b)     If it is unclear or not a duplicate, the indexer shall move forward with creating a claim number. 

ii.      Upon release of the claim, the claims management system creates a work item if the IW has any previous claims.  Claims services staff shall review for any potential duplicates or claims in which the same/similar body part(s) is allowed.

a)     If a duplicate claim is identified, claims services staff shall refer to the Duplicate Claims and Customers policy and procedure for processing instructions. 

b)     If a duplicate claim is not identified, claims services staff shall continue processing the claim.

c)     If there are same or similar body parts allowed in other claims, claims services staff shall investigate to determine if the recently filed claim is a new claim or an aggravation of a condition allowed in an existing claim.    

iii.     Claims services staff shall look up the IW by name only if the SSN is not known or the IW does not have one.

iv.    Claims services staff shall document any changes to SSN, name, and/or date of birth in claim notes and customer level notes. 

v.      Claims services staff shall not update a SSN until the update has been verified.

vi.    If an IW does not have a SSN or a visa number, claims services staff shall check the “Tax ID unavailable” box in the claims management system so that compensation may be released to the IW when appropriate.

c.      Claims services staff shall review the FROI and claim documentation and make appropriate referrals for any potential:

i.       Employer management issue;

ii.      Subrogation;

iii.     Fraud; or

iv.    Safety trending. 

d.     Claims services staff shall refer to the Psychiatric Conditions policy and procedure when a psychiatric condition is requested on the FROI.

e.     Claims services staff shall review all MCO claim notes as part of his/her investigation.

f.       Claims services staff shall review the claim documents to determine if there is missing documentation, including supporting medical documentation. 

i.       Claims services staff shall refer to the Medical Evidence for Diagnosis Determination (MEDD) Coding Reference Guide ICD-10 for additional information about what supporting medical documentation may be required. 

ii.      Claims services staff shall request the missing information from the MCO by phone and/or e-mail during initial contact or as it is identified. 

iii.     Claims services staff shall document in claim notes what information was requested.

iv.    If required documentation is not received from the MCO within three (3) days of making the request or the MCO requests assistance from BWC to obtain the required documentation, claims services staff shall call the appropriate party to the claim (IW, IW representative, employer, or employer representative) to obtain missing documentation.

v.      If claims services staff is unable to reach the appropriate party to the claim by phone, he/she shall send a C-63 and continue attempts at phone contact.

vi.    If documentation is not received within seven (7) calendar days from the phone call to the party to the claim, claims services staff shall make a second call to the IW only if he/she is unrepresented.

vii.   Claims services staff may contact the provider of record for supporting documentation if the MCO is unable to obtain it.

viii. Claims services staff shall deny a claim for lack of supporting documentation only when he/she:

a)     Reviews MCO notes and/or requests the required documentation from the MCO;

b)     Attempts at least one (1) phone call to obtain the required documentation and the IW/IW representative does not respond;

c)     Sends the C-63 if unable to reach the IW/IW representative by phone and the IW does not respond to the C-63; and

d)     Attempts one (1) final phone call to the IW if the IW is not represented and the IW fails to respond to the C-63 within 10 days. 

g.     If a claim will be denied due to lack of supporting documentation, claims services staff should call the IW to explain:

i.       IW’s right to withdraw the claim; and  

ii.      How to re-file with the necessary supporting documentation within the applicable statute of limitations.

h.     If a claim is withdrawn at the IW’s request, claims services staff shall dismiss the claim (See section V.D.2. below.

i.       Claims services staff shall review the claim to ensure the elements of the Jurisdiction, Coverage and Employer/Employee Status, and Compensable Injuries policies and procedures have been met (employer/employee relationship, timeliness, etc.).

i.       Correcting the Employer and/or Policy Number – Upon receipt of an initial application that lists incomplete or incorrect employer information or is missing employer information, or upon notice from the MCO or a party to the claim alleging an incorrect employer, claims services staff shall determine the correct employer information, policy number and the NCCI manual classification number prior to making the claim determination.

ii.      Claims services staff shall use one or more of the following methods to investigate and obtain correct employer information, including the correct policy number:

a)     Call the IW or assigned employer to request evidence (e.g., W-2, paystub for the date of injury that includes the employer’s federal identification number as part of the printed form i.e., the ID number is computer-generated and not hand written) to help identify the correct employer. 

b)     Contact the provider’s office initially filing the claim for the name of the employer;

c)     Perform a person customer search by name and SSN for the IW on the claims management system to determine if there is a duplicate claim or previous claim that may list the employer information;

d)     Investigate the employer in BWC systems, which will include a business customer search or consult with Employer Management (EM) staff for assistance with investigating the correct employer (Claims services staff may refer to the EM Policy #EP-05-04, entitled Employer of Record Change.);

e)     Investigate using the Internet;

f)       Investigate the claims documents, including hospital information, to determine if employer information has been included in any of them;

g)     Staff the issue with the local Account Examiner 2 (AE2) or supervisor; and/or

h)     Run a system report or query to assist in locating the correct policy number. 

iii.     If claims services staff obtains the correct employer information and policy number, a claim number must be assigned, and the pertinent information must be scanned and indexed into the claim. 

iv.    Claims services staff shall notify the original employer that the employer named in the claim is being corrected, and the claim in question will not be assigned to the original employer’s policy number. 

v.      Claims services staff shall notify the correct employer of the claim assignment.

vi.    If claims services staff cannot obtain employer information, including the policy number, the issue shall be staffed with the local AE2, Employer Services Specialist (ESS) or supervisor. 

vii.   If all attempts to obtain employer information and policy number are unsuccessful, claims services staff shall:

a)     Add “No Insured Found” as the insured customer;

b)     Assign a claim number to the initial application;

c)     Scan and index claim documents into the file; and

d)     Document all attempts to locate employer information and policy number in the claims management system.

viii. The claim will default to the assigned claims services staff’s worklist, so the contact person shall complete a brief review of the information, and reassign the claim to the claims specialist based on case leveling or employer policy assignment.

ix.    If claims services staff is able to determine the correct employer, but the employer has no policy number or coverage, claims services staff shall refer to the Coverage and Employer/Employee Status policy and procedure.

3.     Claim Determination

a.     If the EOR certified the claim, compensation and medical benefits are payable once the BWC Order is issued for the initial determination.  Claims services staff shall not hold payment for a waiver or the 14-day appeal period.  However, the EOR still has the right to appeal the BWC Order.

b.     If the EOR and IW submit a waiver in writing or electronically during the appeal period, compensation and medical benefits can be paid without waiting for the appeal period to expire.

c.      If an order is issued and the EOR is out of business or in a final cancelled status, no waiver from the EOR is required.

d.     Claims services staff shall assign an E-code based on the accident description.  If claims services staff is unable to determine the correct E-code, he/she shall discuss the issue with the supervisor or Medical Services Specialist (MSS), or send an e-mail to BWC Claims Policy Field Techs.

e.     Claims services staff shall follow the Temporary Total Compensation policy and procedure when a request for an initial award of temporary total compensation is being decided at the same time as the initial claim allowance.

f.       Claims services staff shall review the FROI, MCO notes, the MEDD policy and procedure and all available documentation to make a determination on the requested condition(s). 

i.       Claims services staff shall:

a)    Follow the ICD Modification policy and procedure if any condition(s) cannot be accurately coded or if clarification is necessary;

b)     Use the encoder and copy and paste the International Classification of Diseases (ICD) code to the diagnosis window in the claims management system when claims services staff is otherwise unable to obtain the correct ICD code. 

ii.      Claims services staff shall send the claim to the MSS for medical review if the claim falls outside the MEDD guidelines for CSS determination or he/she is unable to interpret the medical documentation or determine the accuracy of the requested condition(s).

iii.     The CSS must attempt to obtain all medical documentation including exam results or testing reports from the MCO prior to sending the issue for medical review.

iv.    The MSS must obtain a physician file review or schedule an independent medical exam if necessary, but an exam does not extend the 28-day time frame to issue a decision as required by law, except for occupational disease claims that require an exam prior to determination.  Claims services staff must refer to the Occupational Disease Claims (OD) policy procedures for additional information.

v.      The MSS shall enter notes in the claims management system detailing the opinion of the physician reviewer and listing the documentation used to form that opinion.

vi.    Claims services staff must address all conditions listed on the FROI.  If conditions cannot be allowed or denied, claims services staff must explain in the “add text” section of the order if additional documentation is needed to make a determination or if the requested condition(s) cannot be allowed under BWC guidelines.  Claims services staff shall indicate in the order that the condition(s) is neither allowed nor denied but can be addressed upon submission of additional evidence or that BWC will not consider the condition(s) based on BWC guidelines.

vii.   Claims services staff shall deny the claim when only one condition that cannot be allowed is listed on the FROI and there is not another condition(s) within the supporting medical that can be allowed.

viii. For the initial determination only, claims services staff may allow a condition(s) that is identified in medical documentation but not specifically requested by the IW.  Staff shall not deny a condition(s) not specifically requested.

ix.    If an additional allowance(s) has been requested on a C-86 or recommended on a C-9 and BWC has not published an initial claim decision yet, claims services staff shall include the newly requested or recommended allowance(s) in the initial decision, even though it is not listed on the First Report of Injury (FROI). For more information regarding additional allowances, refer to the Additional Allowance policy and procedure.   

x.      If a subsequent request is filed during the appeal period of the initial decision, claims services staff shall refer to the Additional Allowance or Motions policy and procedure.

g.     Claims services staff must complete all necessary clarifications, modifications, or reviews prior to issuing a BWC Order.

h.     Claims services staff shall issue a BWC Order to accept or deny the claim based on the claim investigation and the evidence in the file.  Claims services staff shall note in the add text section of the BWC Order the documentation and rationale used to make the claim determination.     

i.       If a FROI is not signed by the IW, the claim may be allowed, but staff cannot deny a claim solely because the FROI is not signed.  If the claim would be denied and a signed FROI is not on file at the end of the 28-day determination period and cannot be obtained, claims services staff shall dismiss the claim by Miscellaneous Order. 

ii.      Claims services staff may allow a claim for a minor injury without supporting medical documentation if the injury is “self-evident” or a “common knowledge” injury.

a)    The claim is compensable even if the injured worker did not seek treatment for the injury. 

b)    Self-evident or common knowledge injury examples include, but are not limited to:

i)       First degree burns over less than 10% of the body;

ii)      Superficial laceration (cut, open wound);

iii)    Superficial contusion (bruise, hematoma);

iv)    Insect stings; or

v)     Blisters. 

iii.     When allowing a claim, claims services staff shall update the claim to an allowed status when the fourteen (14) day appeal period has expired and no appeal has been filed.  Benefits are then payable, and the claims management system will update the claim status.

iv.    When denying a claim, claims services staff shall update the claim to a disallowed status when the fourteen (14) day appeal period has expired and no appeal has been filed. For additional information regarding the appeal period, refer to the Mailbox Rule policy or the Jurisdiction policy and procedure. 

v.      Claims services staff shall refer the claim to the IC if the IW or employer appeals the BWC Order during the appeal period and shall place the claim in hearing status so no benefits are paid.

vi.    If an appeal is filed after the appeal period expires, claims services staff shall refer the claim to the IC and keep the claim in the determined status so benefits will continue.   

i.       A BWC Modified Order shall be sent if the correct employer information is discovered prior to expiration of the initial appeal period as long as no appeal has been filed.  See V.C.2.i (i-x) above for information regarding correcting the employer and/or policy number. 

4.  Elective Coverage – Claims services staff shall refer to the Coverage and Employer/Employee Status policy and procedure.

 

D.  Issuing an Order

      1.  Refer to the Orders, Waivers, Appeals, and Hearings policy and procedure for additional information.

2.     Dismissing a Claim

a.     When a claim is being dismissed prior to expiration of the initial determination appeal period, claims services staff shall:

i.       Dismiss all ICD codes in a claim before the claim application is dismissed;

ii.      Issue a Miscellaneous Order, if BWC dismisses the claim application before an initial determination order has been issued or within the appeal period; and

iii.     Complete any correspondence before updating the status to “Expire Occurrence” and choosing the claim status reason of “Dismissed.”

b.     When a claim is being dismissed after expiration of the initial determination appeal period and the claim is in a final accepted or denied status, claims services staff shall:

i.       Refer the claim to the IC when the IW requests dismissal of the claim; and

ii.      Place Stop Payment type of Indemnity on the claim to prevent any indemnity payments from being issued.

 

E.  Re-filing a Dismissed Claim

1.     When the claim is re-filed, the claims management system will indicate a duplicate claim and will notify the MCO that the application is a duplicate. 

2.     If the claim is refiled hard copy, the application shall be imaged into the original claim.

3.     Claims services staff shall manually activate the original claim if the claim is re-filed and change the filing date to the date the current application was received. 

a.     If the claim has never been in a final accepted or denied status and is currently in a status of “Expire Occurrence” with a status reason of “Dismissed,” claims services staff shall:

i.       Update the “Change Status to” field to “Re-open Expired Claim”; and

ii.      Select “Coverage Verified” as the claim status reason.  The claims management system will update the claim status to “Pending” and the MCO’s outbound interface will be “alleged.”

b.     If the claim has been or is currently in a final accepted or denied status, claims services staff shall:

i.       Update the “Change Status to” field to “Change Status Reason”; and

ii.      Select “Refile” as the claim status reason.  The claims management system will retain the previous claim status, but the MCO’s outbound interface will be “alleged.”

4.     Claims services staff shall move the claim from a dismissed status to any appropriate status when the claim is re-filed.  A claim can be moved from dismissed to a pending status of allow/appeal or disallow/appeal.

5.     Claims services staff shall investigate the claim and review additional information if received on the re-filed application or a substantial period of time has elapsed since the initial contacts were originally made.

 

F.     Reconsideration

1.     Claims services staff shall:

a.     Reconsider a claim that was previously denied by BWC Order if:

i.       The original claim was denied due to a lack of specific information that was requested, but never received and that information has been submitted with the IW’s intent to re-file the claim; or

Example:  A claim was previously filed for allowance of a broken tibia and an x-ray report to support allowance of the claim was requested, but not submitted; therefore, the claim was denied.  Six months later, x-ray results from the date of injury showing the injured worker suffered a broken tibia are submitted by the hospital and a letter from the IW stating his/her intent to re-file the claim is filed with the documentation.  The claim shall be reconsidered because the specific information that caused denial of the initial claim was submitted with the IW’s intent to re-file the claim.   

ii.      The original claim was denied due to a lack of supporting documentation and a new request or medical/factual documentation requesting allowance of the claim is filed by the IW or with the IW’s intent to re-file the claim. 

Example:  A claim was previously filed for allowance of a herniated disc at L4-5; however, sufficient medical evidence to support allowance of the claim was not submitted and the claim was denied due to lack of supporting medical documentation.  Three months later, a MRI report from the date of injury showing the injured worker suffered a herniated disc at L4-5 is submitted by the hospital.  A letter from the IW stating his/her intent to re-file the claim is filed with the documentation.  The claim shall be reconsidered because supporting medical evidence was submitted with the IW’s intent to re-file the claim.   

b.     Enter a claim note to acknowledge the IW’s intent to re-file the claim; and

c.      Review the claim with a BWC attorney. 

2.     Reconsidering a Previously Denied Claim

a.     Claims services staff may reconsider a previously denied claim upon request from the IW.  Such request from the IW may include:

i.       A Motion (C-86) with or without a new claim application;

ii.      A new claim application; or

iii.     A copy of the original claim application with written documentation of the IW’s intent to file. 

b.     Claims services staff shall consult with a BWC attorney prior to issuing a decision for a reconsideration of a previously denied claim. 

c.      For the claim to be reconsidered and allowed, sufficient evidence in support of the allowance must be submitted within the applicable statute of limitations. 

d.     If sufficient evidence is not submitted to justify allowing the refiled claim, claims services staff shall deny, dismiss, or refer the claim consistent with BWC’s Initial Claim Determination policy and procedure.