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OhioBWC - Basics: (Policy library) - File

Policy Name:

Multiple Claims Occurrence

Policy #:

CP-03-05

Code/Rule Reference:

R.C. 4123.511

Effective Date:

08/20/13

Approved:

Rick Percy, Chief of Operational Policy, Analytics & Compliance (Signature on File)

Origin:

Claims Policy

Supersedes:

All policies and procedures, directives or memos regarding catastrophic events that predate the effective date of this policy.

History:

New 08/20/13

Review date:

08/20/18

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure multiple claims occurrences are properly identified, and to ensure consistent injury management:

1.    Within BWC using multiple claims occurrence teams; and,

2.    Between BWC and the Managed Care Organizations (MCOs) through collaboration.

 

II. APPLICABILITY

 

This policy applies to all BWC and MCO staff.

 

III. DEFINITIONS

 

Activity of Daily Living (ADL): a personal or self-care task that enables an individual to meet basic life needs (e.g., eating, dressing, bathing, toileting, transferring in and out of a bed/chair and walking).

 

Catastrophic claim: a claim in which there is a serious injury resulting in limited mobility and/or cognition related to the allowed conditions in the claim and that severely limits the ability of the injured worker (IW) to perform activities of daily living.

 

Multiple claims occurrence: an incident resulting in:

1. At least two workers being severely injured; and,

2. At least two workers requiring treatment at a medical facility; and

3. The nature of at least two of the workers’ injuries makes a return to the position held at the time of injury improbable (e.g., severity of  injury or death).

 

IV. POLICY

A.    It is the policy of BWC to evaluate reports of potential multiple claim occurrences and to determine if the event meets the criteria set forth in the multiple claims occurrence definition in this policy.

 

B.    When BWC has categorized an event as a multiple claims occurrence, it is the policy of BWC to proactively assist the IWs and facilitate injury management services through the multiple claims occurrence teams.

 

C.    BWC maintains the following  regional core multiple claims occurrence  teams in service offices that assist the listed offices and/or areas:

1.    Columbus team:

a.    Columbus;

b.    Cambridge;

c.    Mansfield;

d.    Portsmouth;

e.    Self-insured bankrupt employers;

f.     Out of state IWs;

g.    Special Claims/COEMP;

h.    Out of state employer claims; and

i.      Death claims associated with a multiple claims occurrence.

2.    Dayton team:

a.    Dayton;

b.    Governor’s Hill;

c.    Lima; and

d.    Toledo.

3.    Youngstown team:

a.    Youngstown;

b.    Canton;

c.    Cleveland; and

d.    Garfield Heights.

 

D.   The regional multiple claims occurrence teams are responsible for managing claims through the initial determination process.

 

E.    The multiple claims occurrence process is:

1.    The initial reporting of a potential multiple claims occurrence event;

2.    Assignment of the event to a responsible multiple claims occurrence event team;

3.    Determination if the event is a multiple claims occurrence; and

4.    If it is a multiple claims occurrence, the development of an action plan utilized through the initial determination phase of the involved claims.

 

F.    BWC does not utilize the multiple claims occurrence process for self-insured claims, unless the self-insured employer is bankrupt.

 

 


 

Procedure Name:

Procedure for Multiple Claims Occurrence

Procedure #:

CP-03-05.PR1

Policy # Reference:

CP-03-05

Effective Date:

11/14/16

Approved:

Rick Percy, Chief of Operational Policy, Analytics & Compliance (Signature on file)

Supersedes:

Procedure for Multiple Claims Occurrence CP-03-05.PR1 dated 08/20/13

History:

New 08 /20/13; Rev. 11/14/16

Review date:

8/20/18

 

 

I.      BWC staff shall refer to the Standard Claim File Documentation policy and procedure for claim-note requirements and shall follow any other specific instructions included in this procedure.

 

II.    BWC shall maintain regional multiple claims occurrence teams whose members participate in staffings as needed and consist of the following:

 

A.  An injury management supervisor (IMS) who:

1.    Is the team lead;

2.    Oversees the efforts of the team through the closure of the multiple claims occurrence;

3.    Assigns tasks to multiple claims occurrence team members; and

4.    Coordinates the transfer of claims to the responsible regional claims service specialist (CSS) as needed.

 

B.  A claims service specialist (CSS) who:

1.    Creates the event in the Multiple Claim Occurrence screen in the claims management system;

2.    Ensures the  information remains current by updating the claims management system according to staffing outcomes; and,

3.    Manages all aspects of the injury in accordance with all applicable policies and procedures.

 

C. A medical service specialist (MSS) who acts as a primary resource for medical issues regarding non-catastrophic claims.

 

D. A BWC catastrophic nurse advocate (CNA) who is the primary resource for issues regarding catastrophic claims.

 

E.  An employer management supervisor (EMS) who:

1.    Decides in what capacity employer services needs to be involved; and,

2.    Notifies the Safety Violation Investigation unit (SVIU) or the Public Employment Risk Reduction Program unit (PERRP) when a fatality is part of the multiple claims occurrence event.

 

F.  An MCO catastrophic claim program coordinator (MCO CAT Coordinator) who:

1.    Is the point of contact for the responsible regional multiple claims occurrence team;

2.    Obtains medical documentation for his/her respective employer(s); and,

3.    Disseminates information within the MCO as needed.

 

G. A death benefits coordinator who:

1.    Manages death claims that result from the multiple claims occurrence; and,

2.    Makes the initial confirmation and notification contact to the employer(s).

 

III.   Initial reporting and investigation of a potential multiple claims occurrence event

 

A.  Reporting an event

1.    Upon becoming aware of a potential multiple claims occurrence, BWC or MCO staff shall report the incident by sending an email to catevent-notification@bwc.state.oh.us.

2.    Staff shall title the email “Potential Multiple Claims Occurrence” and note the location of the event in the subject line of the email (e.g., Potential Multiple Claims Occurrence – Grove City).

3.    Staff shall include all known information in the body of the email (e.g., location of event, employer(s) involved, number of injured workers (IWs), and extent of injuries).

 

B.  Establishing the responsible multiple claims occurrence team

1.    The IMS of the identified region in the subject line of the email shall direct a member of the regional multiple claims occurrence team (generally the CSS) to enter available information regarding the event into the Multiple Claims Occurrence screen.

2.    Multiple claims occurrence team leads shall then either:

a.    Coordinate an initial staffing with the responsible regional multiple claims occurrence team members within one business day, notifying the appropriate MCO CAT coordinator(s) of the event and initial event staffing via email and phone call; or,

b.    If the event involves multiple regions, staff within one business day with the IMS staff and SOMs of each involved region to determine the responsible multiple claims occurrence event team and primary region assignment; and,

                                          i.    Notify the responsible multiple claims occurrence team members; and,

                                         ii.    Notify appropriate MCO CAT coordinator(s).

 

IV.  Multiple claims occurrence determination

 

A.  If, after the initial staffing, BWC has determined that the event does not meet the definition of a multiple claims occurrence as defined by the Multiple Claims Occurrence policy, a member of the responsible regional multiple claims occurrence team shall:

1.    Enter a staffing note and update the  multiple claim occurrence screen;

2.    Reassign the claim to the appropriate regional service office and CSS who shall then process the claim(s) in accordance with the Initial Determination policy and procedure in the appropriate service office.

 

B.  If, after the initial staffing, it is determined that the event does meet the definition of a multiple claims occurrence, then all claims related to this event, even if previously filed, shall be reassigned to the regional multiple claims occurrence CSS.

 

C. Upon determining the event is a multiple claims occurrence event a member of the responsible regional multiple claims occurrence team shall:

1.    Update the multiple claim occurrence screen accordingly and create a multiple claims occurrence action plan: and,

2.    Process each claim associated with the event in accordance with the Initial Determination policy and procedure. 

 

V.    Multiple claims occurrence  action plan

 

A.  A designee of the responsible regional multiple claims occurrence team shall create an action plan by using the template located on the Multiple Claim Occurrence policy page on COR.

 

B.  Multiple claims occurrence staff shall document each action step in the plan. Staff shall utilize the action plan to capture tasks and outcomes associated with claims occurring from a multiple claims occurrence.

 

C. Staff shall close a CAT event action plan after an initial determination has been made on all claims in the event and reassign claims other than death claims to the appropriate regional service office for further management.

 

D. The closure of a CAT event action plan results in closure of the multiple claims occurrence event.

 

E.  Upon closure of the CAT event action plan, involved claims shall be processed in accordance with all applicable policies and procedures.

 

 

 


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