R.C. 4123.511; O.A.C. 4123-3-08, 4123-3-36
Rick Percy, Chief
of Operational Policy, Compliance and Analytics
(Signature on File)
All policies and
procedures, directives or memos regarding initial claim determination that
predate the effective date of this policy.
Rev 11/20/15; 07/01/15;
02/03/15; 09/12/2014; New 08/30/13
I. POLICY PURPOSE
purpose of this policy is to ensure BWC processes initial claim applications in
compliance with R.C. 4123.511.
policy applies to BWC Field Operations.
Auto Adjudication: Auto adjudication (AA) is
the systematic allowance of low-risk claims with little or no human
intervention. Claims systematically pass through established business rules
that may prevent claims from completing the AA process and require field staff
to conduct further investigation. Terminating rules, such as lost time (LT)
indicators, will exclude claims from AA.
Fast Response: a program established to
immediately allow specific medical conditions which have a historical record of
being allowed whenever included in a claim and having low medical costs.
Lost Time (LT) Claim: a claim with eight
or more days of lost time from work directly caused by a work-related injury,
even if compensation or wages in lieu of compensation have not been paid to the injured worker (IW) or in any claim in which
BWC awards compensation.
Lost Time Indicators: one type of terminating rule
that presupposes that an IW will or could, miss eight or more days of work.
Medical Only (MO)
a claim with seven or fewer days of lost time from work directly caused by a
work-related injury, for which the IW receives no compensation for lost wages
(e.g., temporary total, salary continuation), or is not awarded any
compensation during the life of the claim.
Terminating Rules: any systematic red flag that presupposes a
claim will or could be LT.
triage: the systematic review of all claims that
evaluates the severity of a claim as identified by ICD codes, indications of
lost time, benefit applications and/or claim accident/illness type and assigns
those claims not allowed by auto adjudication (AA) to the appropriate service
office for determination.
triage: the transfer of a claim to either a service
office or particular discipline within the service office (e.g., Intake, Remain
at Work, Return to Work) based upon the severity of the diagnosis/condition or
where it falls in the life cycle of the claim.
is the policy of BWC to investigate and make an initial claim determination on
all State Fund claims no later than twenty-eight (28) calendar days after
sending the notice of receipt of the claim, or no more than twenty-eight (28)
calendar days after the receipt of the report for a medical examination in
claims in which an examination is required by statute.
uses an AA process for initial claim determination
are systematically triaged based on pre-determined criteria built into the
claims management system for AA and are either:
systematically with little to no manual intervention; or
to the appropriate Central Service Office or Field Service Office to process.
claim automatically terminates from the AA process after ten (10) calendar days
and is assigned to field staff for processing.
Response Claims that can be allowed immediately are:
claim allowances filed with specific ICD codes/narrative conditions that
historically are not disputed and have low medical costs;
with only one (1) diagnosis code/condition;
for medical treatment only; and
from State Fund-Private employers and Public Employer- Taxing District
employers who have access to the Surplus Fund.
employer retains the right to contest the allowance of an AA or Fast Response
claim. If the employer contests the allowance of the claim, BWC will follow the
Medical Recovery-Medical Bill Adjustments
policy, if needed.
the claim is an elective coverage claim, it is the policy of BWC to wait until
at least the 16th of the month to issue a claim determination to
ensure that there is active coverage and that the
policy did not lapse during the grace period.
of a First Report of Injury (FROI)
will dismiss a claim any time prior to issuance of a BWC Order or during the
BWC Order appeal period when:
a. The IW voluntarily
withdraws his/her claim application without prejudice; or
b. An IW/IW rep requests
to dismiss a claim either verbally or in writing.
will not dismiss an initial claim application If the
appeal period has expired.
may dismiss a claim at any time during the twenty-eight (28) day determination
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
IW has signed a sports waiver, which we have 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
staff has received approval from a supervisor for dismissing the claim prior to
the end of the twenty-eight (28) day determination period for other good cause.
a claim is dismissed, BWC can take no further action in the claim, except
updating 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 two-year statute of limitations in
which the injured worker must file, as addressed in R.C. 4123.84.
Not Requested by the IW:
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.
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.
does not eliminate the employer’s right to appeal a BWC order.
fund and public employers cannot certify a claim in part, (i.e., certification
cannot be specific to allowing the medical but denying the lost time benefits).
certification can be written or verbal.
shall refer applications for a previously denied claim in which the appeal
period has expired to the Industrial Commission (IC) who has original
staff may refer to Procedure CP-9-01.PR1 for further guidance on initial