4123.511; O.A.C. 4123-3-08, 4123-3-36
Percy, Chief of Operational Policy, Compliance and Analytics
policies and procedures, directives or memos regarding initial claim
determination that predate the effective date of this policy.
11/20/15; 07/01/15; 02/03/15; 09/12/2014; New 08/30/13
purpose of this policy is to ensure BWC processes initial claim applications in
compliance with R.C. 4123.511.
policy applies to BWC Field Operations.
Auto adjudication (AA) is the systematic allowance of low-risk claims with
little or no human intervention. Claims systematically pass through established
business rules that may prevent claims from completing the AA process and
require field staff to conduct further investigation. Terminating rules, such
as lost time (LT) indicators, will exclude claims from AA.
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.
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
one type of terminating rule that presupposes that an IW will or could, miss
eight or more days of work.
Only (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.
any systematic red flag that presupposes a claim will or could be LT.
the systematic review of all claims that evaluates the severity of a claim as
identified by ICD codes, indications of lost time, benefit applications and/or
claim accident/illness type and assigns those claims not allowed by auto
adjudication (AA) to the appropriate service office for determination.
the transfer of a claim to either a service office or particular discipline
within the service office (e.g., Intake, Remain at Work, Return to Work) based
upon the severity of the diagnosis/condition or where it falls in the life
cycle of the claim.
A. It is the policy of BWC
to investigate and make an initial claim determination on all State Fund claims
no later than twenty-eight (28) calendar days after sending the notice of
receipt of the claim, or 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. BWC uses an AA process
for initial claim determination
1. Claims are
systematically triaged based on pre-determined criteria built into the claims
management system for AA and are either:
a. Allowed systematically
with little to no manual intervention; or
b. Directed to the
appropriate Central Service Office or Field Service Office to process.
2. The claim automatically
terminates from the AA process after ten (10) calendar days and is assigned to
field staff for processing.
C. Fast Response Claims
that can be allowed immediately are:
1. Initial claim
allowances filed with specific ICD codes/narrative conditions that historically
are not disputed and have low medical costs;
2. Filed with only one (1)
3. Filed for medical
treatment only; and
4. Claims from State
Fund-Private employers and Public Employer- Taxing District employers who have
access to the Surplus Fund.
D. The employer retains
the right to contest the allowance of an AA or Fast Response claim. If the
employer contests the allowance of the claim, BWC will follow the Medical
Recovery-Medical Bill Adjustments policy, if needed.
E. If the claim is an
elective coverage claim, it is the policy of BWC to wait until at least the 16th
of the month to issue a claim determination to ensure that there is active
coverage and that the policy did not lapse during the grace period.
F. Dismissal of a First
Report of Injury (FROI)
1. BWC will dismiss a claim
any time prior to issuance of a BWC Order or during the BWC Order appeal period
a. The IW voluntarily
withdraws his/her claim application without prejudice; or
b. An IW/IW rep requests
to dismiss a claim either verbally or in writing.
2. BWC will 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 we have 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. Field 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 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 injured worker
must file, as addressed in R.C. 4123.84.
a. For injury claims with
a date of injury:
to 9/29/2017, the statute of limitations is two (2) years; or
or after 9/29/2017, the statute of limitations is one (1) year.
b. For occupational
disease claims, the statute of limitations is two (2) years.
G. Claims Not Requested by
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.
H. Employer Certification
1. 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.
2. Certification does not
eliminate the employer’s right to appeal a BWC order.
3. State fund and public
employers cannot certify a claim in part, (i.e., certification cannot be
specific to allowing the medical but denying the lost time benefits).
4. Employer certification
can be written or verbal.
I. BWC shall refer
applications for a previously denied claim in which the appeal period has
expired to the Industrial Commission (IC) who has original jurisdiction.
staff may refer to Procedure CP-9-01.PR1 for further guidance on
initial claim determination.