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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, R.C. 4123.84, R.C. 109.71, R.C.
149.43(A)(1)(p); O.A.C.
4123-3-08, O.A.C.
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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07/07/2025
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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 10/4/2024
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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)
Cause of Loss/E-Codes
Fast Response
Lost-Time (LT) Claim
LT Indicators
Medical-Only (MO) Claim
National Council on Compensation
Insurance (NCCI)
Peace Officer
Placeholder Policy
Quote Number
Salary Continuation (SC)
Social Security Cross-Match
Terminating Rules
Triage
IV. POLICY
A. Claim Filing
B. Claim Assignment and
Reassignment
C. Initial Claim Review and
Research
D. Date of Injury (DOI)
E. Employer Certification
and Retention of Appeal Rights
F. Claim Determination and
Issuing an Order
G. Dismissal of a FROI
H. Refile of a Previously
Dismissed Claim
I. 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. Cause of Loss/E-Codes
E. Claim Determination
F. Processing a Refiled
Claim
G. Reconsidering a
Previously Denied Claim (Greene Case)
This policy ensures the Ohio Bureau of Workers’ Compensation
(BWC) processes initial claim applications in compliance with Ohio Revised Code
(ORC) 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
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.
Cause of Loss/E-Codes:
Specific codes available in BWC’s claims management system (originating from
the International Classification of Disease (ICD) code sets), which are
assigned to a claim and used to capture how an injury or occupational disease (OD)
occurred.
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 injured worker (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-Only (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.
Peace Officer:
An individual legally vested with law enforcement rights who generally
works for a city, county, or state public employer and can be either
“traditional” (e.g., police officer) or “non-traditional” (e.g., certain park
rangers, tax agents, or liquor agents.
Placeholder Policy:
An employer policy number that is created when an alleged employer has never
established Ohio workers’ compensation coverage, 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 employer of record. This includes any
kind of paid leave (e.g., sick leave, paid time off, occupational injury leave
(OIL), etc.).
Social Security Cross-Match:
The electronic receipt of information from the Social Security Administration
(SSA) that provides the name, date of birth, date of death (if applicable), and
any Social Security benefits paid to the individual associated with that Social
Security Number (SSN). Used by BWC to validate information in the claim file
and/or to calculate temporary total compensation (TT), permanent total
disability (PTD) and/or Disabled Workers’ Relief Fund payment rates.
Terminating Rules:
Any systematic red flag that assumes a claim will, or could, be a LT claim.
Triage: The systematic or manual 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.
1. BWC’s
policy is to process claims that are filed:
a. Via
BWC online;
b. By
calling the BWC contact center;
c. Electronically
by the managed care organization (MCO); or
d. Via BWC’s
Application Processing Unit, 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 to file on their
behalf.
3. Initial
Determination Requests for Psychiatric Conditions
a. BWC
will consider a psychiatric condition requested on a FROI signed by the IW:
i.
Concurrent with the request for a physical injury; or
ii. As a
result of forced sexual conduct without an IW declaration statement.
b. BWC
does not require an accompanying IW declaration statement for psychiatric
conditions requested as part of an initial claim determination.
c. See
the Psychiatric
Conditions policy and procedure for additional information for medical
review information.
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 (e.g., minor, 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 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. BWC
will review all documentation, claim notes, and demographic information in the
claims management system.
6. BWC
will not release the residential and familial information of peace officers as
defined in R.C.109.71 and R.C. 149.43(A)(1)(p).
7. In
compliance with federal law, BWC does not require an individual to have an SSN
to obtain workers’ compensation benefits.
8. BWC’s
policy is to pursue missing evidence to support decisions made in the claim.
1. The DOI
assigned to a claim is the date the injury occurred, regardless of when the
IW’s shift began or ended.
2. OD
claims are assigned a date of disease, not a DOI. See Occupational
Disease policy and procedure for additional information.
1. BWC’s
policy is 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-insuring
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 possible:
a. No
later than 28 calendar days after BWC received notice of the claim and provided
notification to the IW and employer; or
b. No
more than 28 calendar days after receiving 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 the body affected; and
b. Basis
of the decision.
3. BWC
will not allow or deny a symptom on an order.
1. BWC
will dismiss a claim prior to issuance of an 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. The
investigation of the claim is complete, the claim does not meet the minor
injury guidelines outlined in the Medical
Evidence for Diagnosis Determinations policy, and no medical
documentation was submitted;
c. An
employer is an elective coverage person who did not elect coverage for
themselves; or
d. An
employer cannot be identified after a thorough investigation.
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
Ohio Industrial Commission for hearing.
4. Once
a claim is dismissed, BWC can take no further action in the claim, except
updating claim notes, unless a party refiles the claim application.
5. The
dismissal and subsequent refiling of a claim application will not change the
statute of limitations for filing the claim.
1. BWC
will consider refiled claims within one year of the DOI.
2. BWC
will accept notice of refile:
a. Verbally;
or
b. In
writing. Written notice of refile may be in the form of a written statement,
but any written indication of the intent to refile is also acceptable (e.g.,
writing “Refile” at the top of newly submitted medical evidence).
1. BWC’s
policy is 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:
a. The
previously requested missing information has been submitted;
b. The
IW or IW’s representative requests that BWC reconsider the claim in writing;
and
c. BWC
receives the request 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
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 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 employer certifies the claim, both the claim and ICD statuses are updated
to “Accepted.”
iii. If the employer
does not certify the claim, 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 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 the required ACP
eligibility rules, the claims management system will generate an Initial 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.
i.
Claims Services staff will receive a “new claim pending ACP” work item.
ii. Within
two business days of receiving 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 OD.
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.
iii. If the
information is not on file, Claims Services staff will contact the MCO for missing
medical documentation (e.g., supporting documentation, statement of causality),
or the appropriate party to obtain the missing evidence.
a) If,
after three calendar days, the information is still not on file, Claims
Services staff will make one more attempt to obtain it.
b) 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 an 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 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, DOI, 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 clarify an MCO note when conflicting information is on file
or received.
v. Claims
Services staff will email 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 without good cause; 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 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.
The claims management system will systematically verify SSNs with the
SSA.
ii. When
the correct SSN is entered, it will generally verify upon entry into the claims
management system. Once the SSA has verified the SSN, staff does not need to
take further action.
iii. Claims Services
staff will promptly investigate an issue regarding an SSN when:
a) Verification
of the SSN through the SSA fails; or
b) They are
notified of a conflict or error with a customer’s SSN.
iv. If an IW
does not have an 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.
v. For
additional instructions regarding an unverified SSN, see the Social
Security Number policy.
c. Enter
a customer information block, if applicable. See Claim
Confidentiality and Information Requests policy and procedure
for further detail.
d. 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
that there is an employee/employer relationship.
i.
If the employer identity and an employer/employee relationship have not
been verified, Claims Services staff will:
a) Gather
additional information from the IW; and
b) Staff with
a supervisor and BWC Legal, if necessary.
ii. If
the employer identity and an employer/employee relationship have 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 email 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 email 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 email.
vi) The BWC RTS
Manual Classification Unit will transition the quote to a placeholder policy number
and notify the CSS and ECD via email upon completion of the process.
vii) If the correct policy number
is not identified and a placeholder policy is not appropriate, the CSS will
staff the claim with a supervisor and dismiss it against a no insured found
risk.
e. Search
the claims management system to determine if a quote number is listed for the
employer. A quote number indicates that the employer recently applied for
coverage, and the Manual Classification Unit will transition it to a policy
number when the policy goes into effect.
f.
Verify each element of jurisdiction, coverage, and compensability by
investigating all facts of the accident. Staff must:
i.
Ensure that:
a) The
claim is within Ohio’s jurisdiction;
b) The claim
was timely filed;
c) An
employer/employee relationship exists;
d) The injury
was accidental (unexpected);
e) The
accident/injury occurred while in the course of and arising out of employment;
ii. Review
the evidence for possible coverage issues (e.g., trucking industry
owner/operator issue, subcontractors with no coverage, construction, etc.); and
iii. Staff with a
supervisor and BWC Legal, if necessary.
g. Review
the claim for subrogation and determine if a referral should be made to the Subrogation
Unit. See the Subrogation
policy and procedure for additional information.
h. 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, enter a note with the reason why.
i.
Ensure the claim is assigned the appropriate ICD code(s), in accordance
with the narrative description of the injury or OD.
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 the employer has specifically
requested contact be made via email.
b. The
MCS will make contact via letter, however, the MCS is expected to make contact
by phone when necessary.
c. During
these contacts, Claims Services staff will:
i.
Document the responses to the three-point contact questions;
ii. Request
new or missing information that is necessary for the 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 to contact any party to the claim.
e. If
the initial contact attempt was unsuccessful, Claims Services staff must make a
second contact attempt. A successful contact is when Claims Services staff has:
i.
Spoken with the necessary party and verified claim details;
ii. Sent
an email with no bounce back;
iii. Left a detailed
message for the correct person; or
iv. Sent the Request
for Information.
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 certification or rejection. If the
CSS is unable to obtain this over the phone and the MCO has not already secured
the information, 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 make disability payments.
See the 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
the name and address of the employer, if the information on file needs to be
clarified;
d. Request
that the IW provide a verbal description of their job duties to aid in the selection
of the correct NCCI classification code, if necessary;
e. Explain
what specific evidence the IW needs to provide for BWC to determine the claim;
f.
Make the IW aware of any missing medical documentation BWC has asked the
MCO to obtain from the treating physician;
g. Request
wages for all employers for the 52 weeks prior to the DOI. See the Wages
policy and procedure for additional information.
h. Confirm
whether 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. For
every new claim, Claims Services staff must enter a cause of loss code into the
claims management system.
2. If the
MCO or provider have identified a cause of loss code, Claims Services staff will
verify the code for appropriateness based on the accident description.
a. If
the cause of loss code provided by the MCO or provider is appropriate, Claims Services
staff will enter it into the claims management system.
b. If
the cause of loss code is not appropriate, or if the MCO or provider did not
provide one, Claims Services staff must determine the appropriate code and
enter it into the claims management system.
3. If
multiple events occurred simultaneously resulting in a claim, Claims Services
staff will code the event that caused the most serious diagnosis.
4. Claims
Services staff must not enter new cause of loss codes or change cause of loss
codes after the claim is initially allowed.
5. If Claims
Services staff is unsure of the appropriate cause of loss code, they must staff
the claim with their supervisor.
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 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 are unable to interpret the medical documentation or determine
the accuracy of the requested condition(s).
ii.
Conditions listed on an unsigned FROI or in the claim file must have
supporting medical documentation and a statement of causality 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) are 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 have 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 statutorily
require an exam prior to determination. Claims Services staff may 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 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 cannot be allowed or denied under BWC guidelines.
h. Claims
Services staff must never allow or deny a symptom on an order. Instead, Claims
Services staff must:
i.
Remain silent on all symptoms listed on a FROI or within the medical; or
ii. If
compelled to address a symptom on the order, use the following language: “Your
treating physician diagnosed you with (insert symptom). This diagnosis is one
that BWC does not allow, either because it is a symptom, or it is a condition BWC
does not recognize. If your physician submits either a diagnosis of a condition
causing the symptoms, or a diagnosis BWC recognizes, we will review further.”
i.
Claims Services staff must deny the claim when only one condition that
cannot be allowed is listed on a signed FROI, and the supporting medical
evidence does not include any other allowable conditions.
j.
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 the supporting
medical evidence does not include any other allowable conditions.
k. For
the initial determination only, Claims Services staff may allow a condition
that is identified in medical documentation, but not specifically requested by
the IW. Staff will not deny any conditions that were not specifically
requested.
l.
If an additional allowance has been requested on a properly signed Motion
(C-86) and BWC has not published an initial claim decision yet, Claims Services
staff must include the newly requested allowance in the initial decision, even
though it is not listed on the FROI, because the C-86 is a formal request.
m. If an additional
allowance has been recommended on a Request for Medical Service
Reimbursement or Recommendation for Additional Conditions for Industrial Injury
or Occupational Disease (C-9) and BWC has not published an initial claim
decision yet, the condition is treated as a condition found in the medical
evidence (e.g., the condition 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.
n. If a
subsequently requested condition is filed during the appeal period of the
initial decision, Claims Services staff will pend the request. Claims Services
staff may refer to the Additional
Allowance policy and procedure.
o. Claims
Services staff must issue an order to accept or deny the claim based on the
claim investigation and the evidence in the file. Claims Services staff will
note the documentation and rationale used to make the claim determination in
the “add text” section of the order.
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 otherwise
be denied, but a signed FROI is not on file and cannot be obtained at the end
of the 28-day determination period, 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 injuries/abrasions.
b) The claim
is compensable even if the IW 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.
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.
iii) If the IW or
employer appeals the 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 “Accepted” status so benefits will
continue. Once the notice of hearing is received, Claims Services staff must
update the claim status to “Hearing”.
v) For
additional information regarding the appeal period, refer to the Mailbox
Rule policy and procedure.
p. Claims
Services staff will send a modified Initial Allowance Order if the
correct employer information is discovered prior to expiration of the initial
appeal if 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;
c. Include
the following language in the order: “The required
evidence to determine if this is a compensable claim was not received. Should a
verbal request or documentation be received that indicates a request to refile,
additional information may be requested, and a full investigation will be
completed to determine the claim’s compensability. Please contact your assigned
CSS to see what information is needed.”
d. Complete any correspondence before updating the claim status;
e. Enter a claim note indicating that the claim is dismissed
and cite the specific reason why;
f.
Update the claim status to “Expired occurrence,”
and choose the claim status reason of “Dismissed”; and
g. Reassign the claim to the Remain
at Work team when the appeal period has expired.
3. Once a claim is dismissed, Claims Services staff can take no
further action in the claim, except updating claim notes, until the claim is
refiled.
4. If 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:
a. Refer the claim to the IC; and
b. Place a stop payment on indemnity in the claim management
system to prevent any indemnity payments from being issued.
1. Upon
receipt of any information that indicates or implies that it is the intention
of the IW to refile the claim, the assigned claim owner will:
a. Review
all claims documents, correspondence, and notes to determine why the claim was
originally dismissed; and
b. Determine
if new or missing evidence has been submitted.
2. Once
the review and assessment are complete, Claims Services staff will:
a. Look
for an explicit statement that the claim is being refiled, either on the FROI
or accompanying documents.
i.
If a clear statement that the intention is to refile the claim is
present, document this in notes and continue to process the claim. The assigned
Claims Services Specialist does not need to contact the IW to confirm the
intent is to refile the claim.
ii. If
there is no explicit indication the IW is refiling the claim, contact the IW or
their representative to confirm that their intent is to refile the claim and
document this in notes.
a) If
the IW or their representative states their intent is to refile, staff will
reassign the claim to Intake and continue to process the claim.
b) If Claims
Services staff cannot reach the IW or their representative, the claim will
remain dismissed until it is confirmed, and no further action is needed.
b. Review
the evidence on file and ensure the previously missing information has been
submitted; and
c. Change
the status of the claim in the claims management system.
3. After
a thorough investigation, Claims Services staff will publish an order to allow,
deny, or dismiss the claim.
4. If
the intent is to refile the claim and new information was not submitted to BWC,
Claims Services Staff will deny the claim.
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) 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 BWC Legal 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 was not submitted to justify allowing the reconsidered
claim; or
iii. Dismiss. If
sufficient evidence was 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 DOI 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.