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OhioBWC - Basics: (Policy library) - File

Initial Claim Determination Policy 11-20-2015

Policy Name:

INITIAL CLAIM DETERMINATION

Policy #:

CP-9-01

Code/Rule Reference:

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

Effective Date:

11/20/15

Approved:

Rick Percy, Chief of Operational Policy, Compliance and Analytics

(Signature on File)

Origin:

Claims Policy

Supersedes:

All policies and procedures, directives or memos regarding initial claim determination that predate the effective date of this policy.

History:

Rev 11/20/15; 07/01/15; 02/03/15; 09/12/2014; New 08/30/13

Review date:

11/20/2020

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure BWC processes initial claim applications in compliance with R.C. 4123.511.

 

II. APPLICABILITY

 

This policy applies to BWC Field Operations.

 

III. DEFINITIONS

 

Auto Adjudication:  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.

 

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.

 

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.

 

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

 

Medical 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.

 

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

 

Triage: 

Systematic triage:  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.

Claims triage:  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.

 

IV. POLICY

 

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) diagnosis code/condition;

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 when:

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.

3.    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;

4.    The dismissal and subsequent re-filing of a claim application for the same injury and same injury date will not change the two-year statute of limitations in which the injured worker must file, as addressed in R.C. 4123.84.

 

G.   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.

 

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.

 

Internal staff may refer to Procedure CP-9-01.PR1 for further guidance on initial claim determination.


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