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Policy and Procedure Name:
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Initial Claim Determination
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Policy #:
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CP-9-01
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Code/Rule Reference:
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R.C. 4123.511, 4123.84; O.A.C. 4123-3-08, 4123-3-36
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Industrial Commission (IC) Resolution/Memo
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None
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Effective Date:
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10/4/2024
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Approved:
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Shawn Crosby, Chief Operating Officer
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Origin:
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Operational Policy and Support
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Supersedes:
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Policy # CP-9-01, effective 09/28/21
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History:
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Previous versions of this policy are available upon request
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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
National Council on Compensation
Insurance (NCCI)
Placeholder Policy
Quote number
Salary Continuation (SC)
Terminating Rules
Triage
IV. POLICY
A. Claim
Filing
B. Claim
Assignment and Reassignment
C. Initial
Claim Review and Research
D. Date
of Injury
E. Employer
Certification and Retention of Appeal Rights
F. Claim
Determination and Issuing an Order
G. Dismissal
of a FROI
H. Reconsideration
of a Previously Denied Claim- Greene Case
V. PROCEDURE
A. General
Claim Note and Documentation Requirements
B. Systematic
Claim Review and Evaluation
C. Initial
Claim Review and Investigation of Claims Not Eligible for ACP
D. Claim
Determination
E. Reconsidering
a Previously Denied Claim (Greene Case)
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.
Auto Claims Processing (ACP):
The systematic evaluation and determination of low risk claims with little or
no human intervention. Claims systematically pass through established business
rules that either allow the claim to be accepted with no human intervention, or
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 with low
treatment costs that have a record of being allowed when included in a claim.
Claims in the program are filed for medical treatment only, include only one
diagnosis code/condition, and are from state-fund, private employers and taxing
district public employers who have access to the Surplus Fund.
Lost Time (LT) Claim:
A claim is considered lost time when:
·
There are eight or more days of lost time from work directly
caused by a work-related injury; or
·
BWC awards compensation, even if the IW did not miss eight or
more days of work.
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 is considered medical only when:
·
There are seven or fewer days of lost time from work directly caused
by a work-related injury; or
·
BWC does not award compensation.
National Council on Compensation
Insurance (NCCI): An organization that gathers data,
analyzes trends, and provides objective insurance rate and loss cost
recommendations for the workers’ compensation industry. BWC uses NCCI’s
classification system, however, BWC develops its own rates.
Placeholder Policy:
An employer policy number that is created when an alleged employer has never
established a policy with BWC, BWC no longer has a record of the policy number,
or the policy is in a cancelled status and the date of injury occurred after
the policy was cancelled.
Quote number:
A temporary number used for tracking purposes in the claims management system
when an employer files an Application for Ohio Workers’ Compensation Coverage
(U-3).
Salary Continuation (SC):
Regular full wages paid to the IW by the EOR. This includes any kind of paid
leave (e.g., sick leave, paid time off, occupational injury leave (OIL), etc).
Terminating Rules:
Any systematic red flag that assumes 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. The review includes indications of lost time, benefit
applications and/or claim accident/illness type, and assigns those claims not
allowed by ACP to the appropriate claims team for determination.
Claims Triage: The transfer of a claim to either a specialty team
or a particular discipline within claims services (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.
It is the policy of BWC to process claims that are filed:
a.
Via BWC online;
b. By
BWC phone call to the contact center;
c.
Electronically by the MCO; or
d. Via
the application processing unit at BWC upon receipt of a First Report of Injury,
Occupational Disease, or Death (FROI).
2.
BWC employees are prohibited from filing any claim on behalf of the IW
or IW’s family unless the IW or IW’s family expressly requests BWC file on
their behalf.
1.
Upon receipt, BWC will assign a claim number to each initial application
for benefits and will provide the claim number to the claimant and employer.
2.
BWC will use ACP until claim determination is complete, unless one of
the terminating rules removes it and redirects the claim to the appropriate
claims team for processing.
3.
BWC will assign the claim to the appropriate claims team or specialized
unit. Claims will be assigned to a specific team based on:
a.
Benefit type (medical only or lost time);
b. Accident
type (e.g., injury, death);
c.
Severity of injury (catastrophic);
d. Multiple
claim event; or
e.
Requested condition.
1.
BWC will complete a systematic evaluation of every claim entered into
the claims management system to determine if the claim is eligible to be
considered for immediate determination.
2.
Claims that meet all of the required eligibility rules will be
immediately determined.
3.
Claims that may meet the eligibility requirements will continue to be
systematically reviewed for three days before being assigned to claims services
staff.
4.
Claims that fail to meet the eligibility requirements are assigned to
claims services staff for review and processing.
5.
Claims services staff will review all documentation, claim notes, and
demographic information in the claims management system.
6.
It is the policy of BWC to pursue missing evidence to support decisions
made in the claim.
1.
The date of injury assigned to a claim is the date the injury occurred,
regardless of when the IW’s shift began or ended.
2.
Occupational Disease (OD) claims are assigned a date of disease, not a
date of injury (DOI). See Occupational
Disease policy and procedure for additional information.
1.
It is the policy of BWC to attempt to obtain certification or rejection
of the claim from the employer.
a.
When the claim is certified, the employer has only acknowledged that the
IW’s work-related injury occurred.
b. An
employer’s certification of a claim does not automatically mean that BWC will
allow the claim.
2.
Certification may be written or verbal.
a.
State fund and public employers can only certify or reject the claim.
b. Self-insured
employers can certify, reject, or clarify their certification.
3.
Only a sole-proprietor who has elected coverage for themselves can
certify their own claim.
4.
Employers who have certified the claim retain the right to appeal a
decision.
1.
BWC must issue the most complete order:
a.
No later than 28 calendar days after BWC received notice of the claim
and provides notification to the injured worker and employer; or
b. No
more than 28 calendar days after the receipt of the report for a medical
examination in OD claims in which examination is required by statute.
2.
At a minimum, the order must contain the:
a.
Description of the condition or conditions for which the claim is being
allowed and parts of body affected; and
b. Basis
of the decision.
1.
BWC will dismiss a claim prior to issuance of a BWC Initial Allowance
Order or during the appeal period when an IW/IW representative requests
dismissal of a claim either verbally or in writing.
2.
BWC may dismiss a claim at any time during the 28-day determination
period when:
a.
The investigation of the claim is complete, the claim allowance is not
supported, and there is no signed FROI on file;
b. No
medical documentation was available;
c.
An employer is an elective coverage person that did not elect coverage
for themselves;
d. An
employer cannot be identified after a thorough investigation; or
e.
It is requested by the IW/IW representative.
3.
BWC will not dismiss an initial claim application if the appeal period
has expired. Requests to dismiss after the appeal period has expired must be
referred to the IC for hearing.
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 will not
change the statute of limitations for filing the claim.
1.
It is the policy of BWC to reconsider a previously denied claim if the
original claim was denied due to a lack of specific information that was
requested, but never received.
2.
BWC will only reconsider the claim if the missing information has been
submitted with the IW’s intent, in writing, for BWC to reconsider the claim
within the statute of limitations.
1.
BWC staff will refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2.
Must follow any other specific instructions for claim notes and
documentation included in this procedure.
1.
Upon receipt, all claims filed are systematically evaluated to determine
if they can potentially be allowed by automated processing. If the claim does
not meet the ACP eligibility rules:
a.
The claims management system will generate a “new claim-ineligible for
ACP” work item;
b. The
claim will be assigned to the appropriate team (e.g. medical only, lost time,
special claims); and
c.
Claims services staff from the appropriate team will process the claim
per sections V.C. and V.D. below.
2.
All claims that potentially meet ACP eligibility rules will be
systematically evaluated for determination.
a.
If, upon initial evaluation, the claim meets all required ACP
eligibility rules, the claims management system generates an Initial Allowance Order.
i.
If the claim meets the fast response requirements, both the claim and
ICD statuses will be updated to accepted.
ii.
If the claim is certified by the employer, both the claim and ICD
statuses are updated to accepted.
iii. If the
claim is not certified by the employer, the claim status is updated to
accepted, but the ICD status is placed in accepted/appeal. The ICD status will
remain in accepted/appeal and will be updated to:
a) Accepted
status at the end of the appeal period; or
b) Hearing
status if an appeal is filed.
b. Claims
that do not initially meet all of the required ACP eligibility rules will
continue to be systematically evaluated for three days. During the three days:
i.
If information is received that causes the claim to be ineligible for
the ACP process, the claim is automatically reassigned to the appropriate area
for manual processing (e.g., information is received that indicates the claim
is lost time).
ii.
If information is received that causes the claim to meet all of the
required ACP eligibility rules, the claims management system will generate an
allowance order and assign the claim to the ACP group. See V.B.3.a.i-iii above
for further status update information.
c.
If additional information is still needed to determine if the claim
meets the ACP eligibility rules, the claim will be assigned to claims services
staff for processing. Claims services staff will receive a “new claim pending
ACP” work item.
i.
Within two business days of receipt of the work item, claims services
staff must review and verify all available information has been entered into
the claims management system correctly.
a) Claims
services staff must ensure the claim is assigned an appropriate ICD code(s), in
accordance with the narrative description of the injury or disease.
b) If
the information is available in claim documents or notes, claims services staff
will enter or correct it in the claims management system and:
i)
Allow the claim to go through ACP; or
ii) Pull
the claim from the ACP process if the claim does not meet the ACP criteria.
c)
If the information is not available, claims services staff will contact
the managed care organization (MCO) for medical documentation (e.g., supporting
documentation, statement of causality) or the appropriate party to obtain the
missing evidence.
d) If,
after three calendar days, the information is still not available, claims
services staff will make one more attempt to obtain it.
e) After
14 calendar days, the system will generate a “no claim decision” work item if
the claim is still undetermined. Claims services staff will continue to
investigate the claim and the claims management system will continue to
evaluate the claim using ACP eligibility rules.
3.
Fast Response Claims
a.
When the diagnosis code is one that can be allowed through fast
response, but the claim does not meet ACP eligibility criteria, claims services
staff must:
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. Issue
a BWC order;
v.
Immediately update the claim and ICD statuses to accepted in the claims
management system; and
vi. Place
the claim in hearing status if an appeal is filed to the BWC order.
b. See
Appendix A to OAC 4123-3-36 for a list of acceptable codes.
1.
Claims services staff will review the claim in totality to determine
what information has already been received and what additional information is
necessary for claim processing. The medical claims specialist (MCS)/claims
services specialist (CSS) must:
a.
Review and confirm demographics submitted with the claim, FROI, job
description, MCO and other notes, mechanism of injury, date of injury and compare
the medical documentation on file to what the Medical Evidence for Diagnosis
Determination (MEDD) guidelines or other medical evidence resources (e.g.,
WebMD) state should be present to make an appropriate determination.
i.
If medical documentation (e.g., supporting documentation, statement of
causality) or clarification of medical information is required, claims services
staff must contact the MCO to request the specific information needed.
ii.
If the MCO does not respond to the request after three business days,
claims services staff must make a second request for the information.
iii. If the MCO
fails to respond to the second request, claims services staff must report the
issue to their supervisor. The BWC supervisor must call the MCO supervisor to
discuss the issue.
iv. Claims
services staff must contact the MCO after three days if additional information
is needed to make the claim determination, but will not contact the MCO solely
to validate the information in claim notes. Claims services staff may only
contact the MCO to confirm validation of an MCO note when conflicting
information is on file or received.
v.
Claims services staff will e-mail the BWC MCO Business Unit
Referral box for assistance when:
a) The
BWC supervisor and MCO supervisor have discussed the issue and 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
failure; or
b) The
MCO has shown a pattern of not providing the required data elements or
obtaining the required documentation.
b. Confirm
the IW’s social security (SSN) is entered into the claims management system
correctly and there are no duplicate claims or customer records by searching
the customer’s name and address.
i.
When a new application has been entered, the claims management system
will identify if there are any possible duplicate claims.
ii.
If an IW does not have a SSN or visa number, claims services staff will
check the “Tax ID unavailable” box in the claims management system so that
compensation may be released to the IW when appropriate.
c.
Verify that the employer policy number listed in the claims management
system matches the employer information documented in the file and that the
evidence supports there is an employee/employer relationship.
i.
If the employer identity and an employer/employee relationship has not
been verified, claims services staff will:
a) Gather
additional information from the IW; and
b) Staff
with a supervisor and legal, if necessary.
ii.
If the employer identity and an employer/employee relationship has been
verified, claims services staff will:
a) Confirm
that the employer has active coverage;
b) Check
that the NCCI code in the claims management system matches the job description;
and
c)
Identify the correct employer policy number by completing a thorough
investigation and documenting in claim notes all attempts to locate the correct
identifier.
i)
If, after investigation the policy number cannot be identified, the CSS
will initiate an EM Referral using the EM Referral Tracker and copy their team
leader.
ii) The
referral will be assigned to the Employer Compliance Department (ECD) for
further review by inserting ECD Rush in the EM Referral Office field of the
referral.
iii) If the
correct policy number is identified, ECD will notify the CSS by e-mail and the
referral will be complete.
iv) If the
correct policy number is not identified, ECD will create a quote number in the
claims management system.
v)
ECD will e-mail the quote number to the BWC RTS Manual Classification
Unit and request the quote number be transitioned to a placeholder policy
number. ECD will copy the CSS on the e-mail.
vi) The BWC
RTS Manual Classification Unit will transition the quote to a placeholder
policy number and notify the CSS and ECD via e-mail upon completion of the
process.
vii) If the correct policy
number is not identified and a placeholder policy is not appropriate, the claim
should be staffed with a supervisor and dismissed against a no insured found
risk.
d. If
the employer recently applied for coverage, the claims management system may
show a quote number for the employer. A search can be conducted in the claims
management system similar to a search for a claim.
e.
Verify each element of jurisdiction, coverage, and compensability by
investigating all facts of the accident. Staff must ensure that:
i.
The claim is within Ohio’s jurisdiction;
ii.
The claim was timely filed;
iii. An
employer/employee relationship exists;
iv. The
injury must have been accidental (unexpected);
v.
The accident/injury occurred while in the course of and arising out of
employment;
vi. Review
the evidence for possible coverage issues (e.g., trucking industry
owner/operator issue, subcontractors with no coverage, construction, etc.); and
vii. Staff with a supervisor
and legal, if necessary.
f.
Review the claim for subrogation and determine if a referral sould be
made to the subrogation unit. See Subrogation
policy and procedure for additional information.
g.
Determine if a referral to EM is needed. If a referral is:
i.
Appropriate, send the referral through the existing tracker and enter a
corresponding note in the claims management system.
ii.
Not appropriate, the CSS should enter a note with the reason why.
h. Ensure
the claim is assigned the appropriate ICD code(s), in accordance with the
narrative description of the injury or disease.
i.
Request modification of the narrative description, if necessary, and
ii.
Wait to create the order until the narrative modification is complete.
2.
Claims services staff will make initial contacts to all parties within three
business days of the assignment of the claim, regardless of whether the claim
is lost time or medical only.
a.
The CSS must make the contact by phone unless an employer has
specifically requested contact be made via e-mail.
b. The
MCS will make contact via letter, however, the MCS is expected to make a
contact by phone when necessary.
c.
During these contacts, claims services staff will:
i.
Complete the 3-point contact questions in the claims management system;
ii.
Request new or missing information that is necessary for determination
of the claim;
iii. Set
expectations for IWs and employers during the claim process; and
iv. If
necessary, leave a detailed message asking the customer to return the call and
leave a call back number.
d. Claims
services staff must enter a detailed note in the claims management system after
each contact or attempt at contact with any party to the claim.
3.
When contacting the employer, the CSS must:
a.
Verify the IW is their employee;
b. Verify
the policy number and NCCI classification code or job description;
c.
Verify the accident description and request claim cerfication or
rejection. If the CSS is unable to obtain this over the phone and the
information has not already been secured by the MCO, the CSS must send the Employer
Certification Request letter;
d. Request
any missing information;
e.
Ask if the employer intends to pay salary continuation or pay disability
payments. See Salary
Continuation policy and procedure for additional information.
f.
Discuss availability of modified/light duty work; and
g.
Request the IW’s wages for the 52 weeks prior to the DOI. Refer to the
Wages
policy and procedure for additional information.
4.
When contacting the IW, the CSS must:
a.
Clarify all conflicting demographic information (e.g., date of birth,
SSN, address, etc.);
b. Verify
conflicting accident description and parts of body injured;
c.
Verify name and address of the employer, if information on file needs to
be clarified;
d. Request
that the IW provide a verbal description of their job duties in order to aid in
selection of the correct NCCI classification code, if necessary;
e.
Explain what specific evidence the IW needs to provide in order for BWC
to determine the claim;
f.
Make the IW aware of any missing medical documentation BWC has requested
the MCO obtain from the treating physician;
g.
Request wages for all employers for the 52 weeks prior to the
DOI. See Wages
policy and procedure for additional information.
h. Confirm
whether or not the IW is working anywhere (e.g., a second job);
i.
Verify if the IW is receiving any type of wage replacement from another
source (e.g., SSR, salary continuation, disability, etc.);
j.
Discuss return to work goals and expectations (e.g., participating in
light/modified duty work, if available); and
k.
Review the Better You Better Ohio program.
1.
Claims services staff must review the FROI, MCO & BWC claim notes, MEDD
guidelines, and all available documentation to make a determination on the
requested condition(s).
a.
Claims services staff must follow the
ICD Modification policy and procedure if any condition(s) cannot be
accurately coded or if clarification is necessary.
b. When
claims services staff is otherwise unable to obtain the correct International
Classification of Diseases (ICD) code, they may use the encoder or the online ICD-10
look up and enter the ICD code in the diagnosis window in the claims management
system.
c.
Claims services staff must attempt to obtain all medical documentation
including exam results or diagnostic test(s) and a statement of causality from
the MCO prior to sending the issue for medical review.
i.
Claims services staff must send the claim to the MSS for medical review
if:
a) The
claim falls outside the MEDD guidelines; or
b) Claims
services staff is unable to interpret the medical documentation or determine
the accuracy of the requested condition(s).
ii.
A condition(s) listed on an unsigned FROI or in the claim file must have
supporting medical documentation and a statement of causality for the condition(s)
on file prior to sending the claim to the MSS for medical review. The
condition(s) will not be sent for physician file review if supporting medical
documentation and a statement of causality for the condition(s) is not on file.
d. If
all jurisdiction, coverage, and compensability elements are met and the claim
appears to be non-controversial but the only diagnosis provided is a symptom,
claims services staff may refer the claim to the MSS for medical review once
all attempts to secure a condition has been exhausted.
e.
If necessary, the MSS will obtain a physician file review or schedule an
independent medical exam, but an exam does not extend the 28-day time frame to
issue a decision as required by law, except for OD claims that statuatorily require
an exam prior to determination. Claims services staff must refer to the Occupational
Disease Claims policy and procedure for additional information.
f.
The MSS will enter notes in the claims management system detailing the
findings of the physician reviewer and listing the documentation used to form
that opinion.
g.
Claims services staff must address all conditions listed on the FROI signed
by the IW. If a condition(s) listed on the FROI signed by the IW cannot be
allowed or denied, claims services staff must:
i.
Explain in the add text section of the order if additional documentation
is needed to make a determination; or
ii.
Indicate that the requested condition(s) cannot be allowed or denied
under BWC guidelines.
h. Claims
services staff must deny the claim when only one condition that cannot be
allowed is listed on the signed FROI and there is not another condition(s)
within the supporting medical that can be allowed.
i.
Claims services staff must deny the claim for the no injury code A00.00
when there are no codes listed on a signed FROI and there is not another
condition(s) within the supporting medical that can be allowed.
j.
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 will not deny a condition(s) not specifically
requested.
k.
If an additional allowance(s) has been requested on a properly signed C-86
and BWC has not published an initial claim decision yet, claims services staff
must include the newly requested allowance(s) in the initial decision, even
though it is not listed on the FROI because the C-86 is a formal request.
l.
If an additional allowance(s) has been recommended on a C-9 and BWC has
not published an initial claim decision yet, the condition(s) is treated as a
condition(s) found in the medical evidence (e.g., the condition(s) can be
allowed, but cannot be denied because it was not requested by the IW). C-9
recommendations received prior to initial determination are not treated as an
additional allowance request.
m. If a subsequently
requested condition(s) is filed during the appeal period of the initial
decision, claims services staff will pend the request. Claims services staff must
refer to the Additional
Allowance policy and procedure.
n. Claims
services staff must issue a BWC order to accept or deny the claim based on the
claim investigation and the evidence in the file. Claims services staff will
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 must 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) Self-evident
or common knowledge injury examples include, but are not limited to:
i)
First degree burns to less than 10% of the body;
ii) Superficial
lacerations (e.g., cut, open wound);
iii) Superficial
contusions (e.g., bruise, hematoma);
iv) Insect
stings;
v)
Minor animal or human bites;
vi) Superficial
foreign body in the eye;
vii) Corneal abrasions;
viii)
Conjunctivitis (also known as pink eye);
ix) Dermatitis;
x)
Blisters; and
xi) Superficial
injury/abrasion.
b) The
claim is compensable even if the injured worker did not seek treatment for the
injury.
i)
When allowing a claim, claims services staff must update the claim to an
allowed status when the appeal period has expired, and no appeal has been
filed. Benefits are then payable, and the claims management system will update
the claim status. For additional information regarding the appeal period, refer
to the Mailbox
Rule policy and procedure.
ii) When
denying a claim, claims services staff must update the claim to a denied status
when the appeal period has expired, and no appeal has been filed. For
additional information regarding the appeal period, refer to the Mailbox
Rule policy and procedure.
iii) If the IW
or employer appeals the BWC order during the appeal period, claims services
staff must check that the appeal was filed with the IC and place the claim in
hearing status so no benefits are paid.
iv) If an
appeal is filed after the appeal period expires, claims services staff must
refer the claim to the IC and keep the claim in the determined status so
benefits will continue. Once the notice of hearing is received, the claim
status must be updated to hearing.
o. A
modified BWC initial allowance order must be sent if the correct employer
information is discovered prior to expiration of the initial appeal as long as
no appeal has been filed.
2.
If claim dismissal is appropriate, claims services staff must:
a.
Update all ICD codes in the claims management system to dismissed before
the miscellaneous order is created;
b. Issue
a miscellaneous order, if BWC dismisses the claim application before an initial
determination order has been issued or within the appeal period of the initial
determination order; and
c.
Include the following language in the order: “The
required evidence to determine if this is a compensable claim was not received.
Should a signed FROI be filed, additional information may be requested, and a
full investigation will be completed to determine the claim’s compensability.
Please reach out to your assigned CSS to see what information is needed.”
d. Complete any correspondence before updating the claim
status.
e.
Update the claim status to expired occurrence
and choose the claim status reason of dismissed.
f.
Once a claim is dismissed, claims services
staff can take no further action in the claim, except updating claim notes,
until the claim is re-filed.
g.
When the IW requests dismissal of the claim
after expiration of the initial determination appeal period and the claim is in
a final accepted or denied status, claims services staff must:
i.
Refer the claim to the IC; and
ii.
Place Stop Payment type of indemnity on the
claim to prevent any indemnity payments from being issued.
1.
Upon receipt of an IW’s written request to have their previously denied
claim reconsidered:
a.
Claims services staff will ensure that:
i.
The request is submitted via a:
a) Motion
(C-86) with or without a new claim application;
b) New
claim application; or
c)
Copy of the original claim application with written documentation of the
IW’s intent for BWC to reconsider the claim.
ii.
The evidence that was previously requested but never received has been
submitted; and
iii. The
request was submitted within the applicable statute of limitations.
b. Claims
services staff must enter a claim note to acknowledge the IW’s intent for BWC
to reconsider the claim.
c.
Claims services staff will then staff with a BWC attorney to determine
whether there is sufficient evidence to reconsider the claim.
d. Following
staffing, claims services staff will vacate the previous order and either:
i.
Allow, if sufficient evidence in support of the allowance was submitted
within the applicable statute of limitations;
ii.
Deny, if sufficient evidence is not submitted to justify allowing the
reconsidered claim; or
iii. Dismiss.
If sufficient evidence is not submitted to justify allowing the reconsidered
claim, claims services staff must deny or dismiss the claim consistent with
this policy and procedure.
2.
Example:
a.
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.
b. Six
months later, the IW files a letter stating their intent for BWC to reconsider
the claim. The IW includes x-ray results from the date of injury showing they
suffered a broken tibia.
c.
The claim will be reconsidered because the specific information that
caused denial of the initial claim was submitted with the IW’s intent for BWC
to reconsider the claim.