Policy and Procedure Name:
Initial Claim Determination
R.C. 4123.511, 4123.84; O.A.C. 4123-3-08, 4123-3-36
Ann M. Shannon, Chief of Claims Policy and Support
Policy # CP-9-01, effective 11/20/15 and Procedure # CP-9-01.PR1,
Rev. 11/20/15, 07/01/15, 02/03/15, 09/12/14; New 08/30/13
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
and Determination Time Frames for all State Fund Claims
Claims Processing (ACP) for Initial Claim Determination
Retains Appeal Rights
of a First Report of Injury (FROI)
Not Requested by the IW
Fund (SF) and Public Employer (PE) Claims Not Eligible for ACP or Fast Response
a Dismissed Claim
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.
This policy applies to BWC Claims Services staff.
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.
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.
(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.
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.
Rules: any systematic red flag that presupposes a claim will, or
could, be a LT claim.
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.
1. No later
than twenty-eight (28) calendar days after sending the notice of receipt of the
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.
1. It is
BWC’s policy to consider claims for initial allowance using ACP. Claims shall
systematically with little to no manual intervention; or
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
employer retains the right to contest the allowance of a claim determined by
ACP, including Fast Response claims.
certification of a claim does not eliminate the employer’s right to appeal a
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
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;
IW is covered by federal workers’ compensation;
employer and employee are exempt from coverage because they, on religious
grounds, conscientiously object to the acceptance of workers’ compensation
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
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.
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
a. For injury
claims with a date of injury:
to 09/29/17, the statute of limitations is two (2) years; or
or after 09/29/17, the statute of limitations is one (1) year.
occupational disease claims, the statute of limitations is two (2) years.
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.
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.
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).
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and
procedure for claim note requirements; and
follow any other specific instructions for claim notes included in this
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.
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
the missing information is available, claims services staff shall enter it in
the claims management system and allow the claim to go through ACP.
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.
a. The claims
management system will set the acceptable fast response ICD codes to “accepted”
upon the acceptance of the claim in ACP.
Appendix A to OAC 4123-3-36 for a list of acceptable ICD codes.
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:
all other compensability tests under section V.C.2. below
all available claim information in the claims management system;
iii. Enter a
claim note to indicate a fast response claim;
update the claim status to “allow” in the claims management system; and
the claim in “hearing” status if an appeal is filed to the BWC Order.
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.
services staff shall ensure the claim is assigned appropriate ICD codes, in
accordance with the narrative description of the injury or disease.
services staff shall make a determination in the claim if all necessary
documentation is present.
additional information is required, claims services staff shall allow the MCO
up to three (3) days to gather the required information.
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.
services staff shall e-mail the BWC MCO Business Unit Referral e-mailbox for
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
MCO has shown a pattern of not providing the required data elements or
obtaining the required documentation.
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.
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
no employer information is available, claims services staff shall follow V.C.2.i.(i-ix.)
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
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
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).
Medical claims shall reassign forced sexual conduct claims to the appropriate
Death claims shall be reassigned to the Survivor Benefits Team, except for statutory
occupational disease death claims for specific conditions when there is no
Security Number (SSN)
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
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.
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.
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.
services staff shall review the FROI and claim documentation and make
appropriate referrals for any potential:
iii. Fraud; or
services staff shall refer to the Psychiatric
Conditions policy and procedure when a psychiatric condition is
requested on the FROI.
services staff shall review all MCO claim notes as part of his/her
services staff shall review the claim documents to determine if there is
missing documentation, including supporting medical documentation.
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.
services staff shall request the missing information from the MCO by phone and/or
e-mail during initial contact or as it is identified.
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
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.
services staff shall deny a claim for lack of supporting documentation only when
MCO notes and/or requests the required documentation from the MCO;
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
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:
right to withdraw the claim; and
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.
services staff shall review the claim to ensure the elements of the Jurisdiction,
and Employer/Employee Status, and Compensable
Injuries policies and procedures have been met
(employer/employee relationship, timeliness, etc.).
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.
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.
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;
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.);
using the Internet;
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.
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
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
all attempts to locate employer information and policy number in the claims
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.
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.
an order is issued and the EOR is out of business or in a final cancelled
status, no waiver from the EOR is required.
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.
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.
services staff shall review the FROI, MCO notes, the MEDD policy and procedure
and all available documentation to make a determination on the requested
services staff shall:
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.
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
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
Disease Claims (OD) policy procedures for additional
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.
services staff must complete all necessary clarifications, modifications, or reviews
prior to issuing a BWC Order.
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.
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
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.
The claim is compensable even if the injured worker did not seek
treatment for the injury.
Self-evident or common knowledge injury examples include, but are
not limited to:
degree burns over less than 10% of the body;
laceration (cut, open wound);
contusion (bruise, hematoma);
iv) Insect stings;
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.
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
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.
Elective Coverage – Claims services staff shall refer to the Coverage
and Employer/Employee Status policy and procedure.
D. Issuing an Order
to the Orders,
Waivers, Appeals, and Hearings policy and procedure for additional
a. When a
claim is being dismissed prior to expiration of the initial determination
appeal period, claims services staff shall:
all ICD codes in a claim before the claim application is dismissed;
a Miscellaneous Order, if BWC dismisses the claim application before an initial
determination order has been issued or within the appeal period; and
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
the claim to the IC when the IW requests dismissal of the claim; and
Stop Payment type of Indemnity on the claim to prevent any indemnity payments
from being issued.
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
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
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:
the “Change Status to” field to “Re-open Expired Claim”; and
“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
b. If the
claim has been or is currently in a final accepted or denied status, claims
services staff shall:
the “Change Status to” field to “Change Status Reason”; and
“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.”
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.
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.
services staff shall:
a claim that was previously denied by BWC Order if:
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.
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.
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
b. Enter a
claim note to acknowledge the IW’s intent to re-file the claim; and
the claim with a BWC attorney.
a Previously Denied Claim
services staff may reconsider a previously denied claim upon request from the
IW. Such request from the IW may include:
Motion (C-86) with or without a new claim application;
new claim application; or
iii. A copy of
the original claim application with written documentation of the IW’s intent to
services staff shall consult with a BWC attorney prior to issuing a decision
for a reconsideration of a previously denied claim.
the claim to be reconsidered and allowed, sufficient evidence in support of the
allowance must be submitted within the applicable statute of limitations.
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.