OhioBWC - Basics: (Policy library) - File

Insurance Services Office - ISO

Policy and Procedure Name:

Insurance Service Office

Policy #:


Code/Rule Reference:


Effective Date:



Kevin R. Abrams, Chief Operating Officer


Claims Policy


CP-09-04 effective 04/19/19



Rev. 04/19/19; 11/14/16; New 07/10/13


Rev. 08/09/13; New 07/10/13


Insurance Service Office Table of Contents





Insurance Services Office (ISO)


A.          Investigation Tool

B.          Disclosing ISO Report Information

C.         ISO Impact on Claim Decisions


A.          Standard Claim File Documentation

B.          ISO Report Requests

C.         Utilization of ISO Reports

D.         Reviewing the ISO Report

E.          Confidentiality and Using the Information from ISO

F.          Communications with ISO Members

G.         BWC Job Aid






The purpose of this policy is to ensure that BWC staff properly obtain and utilize Insurance Services Office information during the life of a claim.




This policy applies to all BWC staff.




Insurance Services Office (ISO): A confidential data bank that contains bodily injury claim information on automobile, workers’ compensation, homeowner, general liability, product liability and disability insurance injury claims for the last ten (10) years.




A.     Investigation Tool - It is the policy of BWC to use ISO as an investigative tool to combat fraud, recognize and pursue subrogation rights and reduce the overall cost of workers’ compensation claims.


B.     Disclosing ISO Report Information - Information from the ISO report will not be disclosed to any individual or entity other than BWC staff involved in investigating the claim, or the insurance company, or other entities that provided the information.


C.    ISO Impact on Claim Decisions - A claim will not be denied based solely on the information received from ISO, although BWC will consider all evidence in the file to determine eligibility and compensability.


D.  It is the policy of BWC to run ISO reports on state fund and bankrupt self-insured claims only.




A.     Standard Claim File Documentation

1.     BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note requirements; and

2.     Shall follow any other specific instructions for claim notes included in this procedure.


B.     ISO Report Requests

1.     Types of ISO Report Requests

a.     Automated request – An ISO cross-match search that starts automatically once a new claim is entered in the claims management system.

b.     Manual request – An ISO report request that is submitted manually in the claims management system by BWC staff on a pre-existing claim.

c.      Requested ISO reports are automatically indexed into the claim document folder, under “doc type confidential” in the document management system.

2.     Timeframes for Receipt

a.     ISO reports are viewable in the claim management system on the fourth (4th) day after the request.

Example: If claims services staff requests an ISO report on Monday, claims services staff will not see the ISO report and work item in the claims management system until the following Friday.

b.     ISO report timeframes include weekends.

Example: If claims staff requests an ISO report on Friday, claims services staff will see the ISO report and work item in the claims management system the following Tuesday.

3.     Storing of Requested ISO Reports

a.   The ISO report will be automatically imaged into the confidential file of the claim; and

i.    If ISO detects a hit, a work item will generate to the claims services staff member assigned to the claim at the time of the hit; or

ii.   If there is not a hit, the ISO report will be imaged into the claim without a work item being generated.

b.   Claims services staff may also review “Interface Requests” in the claims management system to determine if an ISO report was generated.


C.    Utilization of ISO Reports

1.   Initial Determination - During the initial investigation, claim services staff may review the automatically generated ISO report to further investigate incidents that may impact the claim such as duplicate claims filed in other jurisdictions, separate accidents with related medical conditions, or potential third-party involvement.

2.   Additional Allowance or Claim Reactivation – For a request for an additional allowance or for claims reactivation, claims services staff may request an ISO report when:

a.   There has been no recent activity in the claim;

b.   The medical evidence or other documentation in the claim file identifies intervening injuries that may not be related to the current worker’s compensation claim; or

c.   The severity of the additional condition being requested appears to be greater than what could have been caused by the current claim.

3.   Lump Sum Settlement (LSS)

a.   The LSS claims services staff may request an ISO report whenever LSS claims services staff determines it may be useful in valuing and negotiating the settlement agreement.

b.   Please refer to the Lump Sum Settlement policy and procedures on COR for additional information.

4.   Death Benefits

a.   When claims services staff receives a request or recommendation for death benefits, claims services staff may request an ISO report, if a previous non-work-related injury appears to be related to the IW’s death.

b.   Example: A person has a car accident on a Thursday and is diagnosed with a concussion. The car insurance covers the accident and injury treatment costs. The person goes back to work the following Monday and hits his/her head on a desk while falling on the floor at work. The person dies immediately afterwards. The family of the deceased files for workers’ compensation death benefits. In this case, claims service staff may need an ISO report to uncover information about the car accident and whether it was related to the ultimate death of the IW.

5.   Fraud

a.   Special Investigations Department staff may manually request and receive ISO reports when investigating:

i.    Workers’ compensation claims fraud;

ii.   Medical provider fraud; and

iii.   Premium fraud.

b.   Please refer to the Fraud Special/Investigations policy and procedures on COR for additional information.

6.   Subrogation

a.   Claims services staff may request an ISO report after the initial determination of the claim if subsequent questions regarding potential subrogation issues are identified in the claim.

b.   Claims services staff shall review any ISO reports received to identify any potential for subrogation and make a referral to the Subrogation Department, if appropriate.

c.   Please refer to the Subrogation policy and procedures on COR for additional information.

7.   Other – Claims services staff may request an ISO report at any other time it is determined that such report could provide useful information for claims management. Example: sudden or significant increase in treatments has occurred that appear unrelated to the claim.


D.    Reviewing the ISO Report

When an ISO report reflects a match, claims services staff responsible for managing the claim shall review the report and:

1.   Determine if there are potential patterns to the types of claims filed by the IW;

a.   Are there multiple reported injuries?

b.   Is there a pattern to the type of injuries reported?

c.   What types of claims are reported?

2.   Evaluate the information to determine if the matched data does or could have an impact on a current or past BWC claim;

a.   If there is an injury listed in ISO with a date of injury that could be reasonably related to the workers’ compensation claim: Is the IW submitting medical bills for the same injury to BWC and the other ISO member?

b.   The body parts affected in each claim: If the claims involve related body parts, the claims services staff shall advise the managed care organization (MCO) of the related accident date and injuries so the MCO may inform the provider.

3.   Evaluate the information to determine if there are red flags that warrant a fraud referral (See the Fraud Special/Investigations policy and procedure);

4.   Evaluate the information to determine if there are indicators that warrant a referral to the BWC Subrogation Unit (See the Subrogation policy and procedure); and

5.   Consider whether other information on the report may be relevant to a claim including, but not limited to:

a.   Workers’ compensation claims in another state;

b.   Insurance claims through other policies (i.e., auto, homeowners, liability, workers’ compensation or medical claims);

c.   Causes of other injuries and liability for those injuries; and

d.   Treating providers and/or representatives in the IW’s other claims.


E.     Confidentiality and Using the Information from ISO

1.   Claims services staff shall not share the ISO report itself with any party or entity outside of BWC staff involved in investigating the claim.

2.   Claims services staff shall not deny a claim based solely on the information received from ISO. Claims services staff shall weigh all the evidence in the claim when determining eligibility and compensability.

3.   Claims services staff shall refer to the Sensitive Paper Record Handling policy on how to protect confidential hard copy ISO reports received via email, files, printouts, electronic copy, etc.


F.     Communications with ISO Members

1.   Claims services staff may contact other ISO members to obtain basic information regarding a claim filed with that member. For general inquiries, claims services staff may also email ISO at njsupport@iso.com or call 1-800-888-4476.

2.   As applicable, claims services staff shall ask the ISO member:

a.   What is the current status of the ISO member’s claim and what type of claim is being handled (e.g., auto, homeowner, workers’ compensation)?

b.   Is the claim still open? If the claim is open, has the IW recently requested an additional allowance?

c.   What is the name of the doctor, hospital and attorney associated with the claim?

d.   If the claim is closed, how and when did it close? Was the claim closed through settlement or due to the statute of limitations?

e.   Was the claim denied and if so, for what reason?

3.   If claims services staff is contacted by an ISO member for information, claims services staff shall obtain a signed release from the IW before sharing any BWC claim information.

4.   Claims services staff shall direct any questions regarding the use of ISO information to a BWC attorney.


G.    BWC Job Aid - BWC staff shall refer to the ISO Claims Match Job Aid located on Claims Online Resources (COR) for outlined processes to manually request an ISO report.