OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Notice of Referral to the Industrial Commission

Policy #:

CP-14-01

Code/Rule Reference:

R.C. 4121.34; R.C. 4121.35; R.C. 4123.52; OAC 4121-3-13(B)

Effective Date:

04/17/20

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

Policy # CP-14-01, effective 05/16/14 and Procedure # CP-14-01.PR1, effective 11/14/16

History: 

Previous versions of this policy are available upon request.


 

Notice of Referral to the Industrial Commission Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

None

IV. POLICY

A.          Initiating a Notice of Referral (NOR)

B.          Examples of Issues To Be Referred

V. PROCEDURE

A.          General Claim Note Requirements

B.          General Procedure

C.         Special Circumstances

 

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that Ohio Bureau of Workers’ Compensation (BWC) staff refer appropriate matters to the Ohio Industrial Commission (IC) in an efficient and effective manner. 

 

II. APPLICABILITY

 

This policy applies to all BWC claims services staff.   

 

III. DEFINITIONS

 

None

 

IV. POLICY

 

A.     Initiating a Notice of Referral (NOR)

1.     It is the policy of BWC to initiate a NOR to the IC for:

a.     All issues disputed by a party to the claim; and

b.     Issues not within the jurisdiction of BWC. 

2.     A NOR may be initiated:

a.     By an application filed by the IW, employer, claimant, or authorized representative; or

b.     Upon BWC’s request.

 

 

B.     Examples of Issues To Be Referred

1.     Non-certified or rejected self-insured employer disputed matters;

2.     Disputed requests from:

a.     Injured worker (IW);

b.     Employer;

c.      Claimant; or

d.     Respective authorized representative;

3.     Requests for Permanent Total Disability (PTD);

4.     BWC Administrator requests;

5.     Modifying a previous NOR;

6.     Conflicting evidence related to ongoing compensation entitlement;

7.     An issue returned to the IC for reset after BWC has completed a requested action;

8.     Wage adjustments when the IC initially set the wages; and

9.     Any other issues where the IC has original jurisdiction (e.g., Violations of Specific Safety Regulation (VSSR).

 

 

V. PROCEDURE

 

A.     General Claim Note Requirements

1.     Claims services 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.     General Procedure

1.     Claims services staff: 

a.     Shall create a NOR in the claims management system when referral is appropriate as noted in IV.A. above. 

i.       Example of a NOR initiated by the IW/employer/claimant:  BWC receives a Request for Temporary Total Compensation (C-84) from the IW and there is a conflict, which requires the issue to be sent to the IC for determination.

ii.      Example of NOR initiated by BWC because the issue is not within BWC’s jurisdiction:  Claims services staff has obtained evidence that the IW has reached maximum medical improvement, and an administrative referral is made requesting that temporary total compensation (TT) be terminated. 

b.     May include up to three issues in one NOR if the NOR is initiated by either the IW/employer/claimant or by BWC;

c.      Shall not combine issues from IW/employer/claimant and BWC in the same NOR; and

d.     May generate more than one NOR per day. 

2.     Claims services staff shall include the following information in the NOR:

a.     A description of the issue - A clear and detailed explanation of the purpose for the referral that includes a description of the form, correspondence, or issue that initiated the referral;

b.     BWC’s recommendation or position on the request;

c.      BWC’s rationale and supporting evidence - All evidence that supports the recommendation shall be specifically identified;

d.     The opposing party’s position on the request, if known;

e.     A request for interpreter services, if needed. The referral should include the specific language or type of interpreter needed (i.e., American Sign Language or a foreign language);

f.       Identification of reference claims that are relevant to the referred issue (if applicable); and

g.     A request for additional time for the hearing (e.g., BWC requests 30 minutes for the hearing) (if applicable).

h.     When a NOR is initiated by the IW, employer, or claimant, claims services staff shall also include:

i.       The date the application was received (not the date the application was signed); and

ii.      The party that made the application (IW, employer, or claimant).

i.       When a NOR is initiated by BWC, claims services staff shall:

i.       Reflect that it is an administrative referral; and

ii.      Include the appropriate insert that describes the issue being referred.

a)     If no insert adequately describes the issue, claims services staff shall explain the issue.

b)     If additional information needs to be provided, claims services staff shall enter the additional information that is needed.  

 

C.    Special Circumstances

1.     In addition to the general procedure immediately above, the following special circumstances require additional action:

a.     Additional Allowance;

b.     Continuing Jurisdiction;

c.      Change of Election or an Award for Impairment of Earning Capacity;

d.     Modifying a Previous NOR;

e.     Referral for Reset;

f.       Resetting Full Weekly Wage (FWW) or Average Weekly Wage (AWW) When the IC Has Initially Set Wages;

g.     Scheduled Loss;

h.     Self Insured (SI) Disputed Matters;

i.       TT;

j.       Wage Loss Compensation (WL); and

k.      Withdrawal of a NOR.

2.     In such cases, claims services staff shall follow the issue-specific directions detailed below. 

a.     Additional Allowance - Prior to referral for an additional allowance issue(s), claims services staff shall obtain evidence (e.g. file review or exam) to support BWC’s position on the issue.

b.     Continuing Jurisdiction

i.       A BWC attorney may file a Motion (C-86) for continuing jurisdiction based on one or more of the following:

i)       Mistake of fact;

ii)      Mistake of law;

iii)    Clerical error;

iv)    New and changed circumstances; and

v)     Fraud.

ii.      The BWC attorney may file the C-86 directly with the IC, or claims services staff may complete the NOR referring to the BWC attorney’s C-86 once it has been submitted.

iii.     If the BWC attorney files the C-86 directly with the IC, they shall notify claims services staff that a C-86 has been filed and ensure that the C-86 is imaged into the claim.  In these circumstances, a NOR is not required.

c.      Change of Election or an Award for Impairment of Earning Capacity

i.       Clearly indicate the specific name of the physician(s), dates of medical reports, diagnostic tests, and the specific statements or evidence from the reports relied on to make the referral, including the medical documentation from the treating physician that outlines the IW’s inability to return to his or her former position of employment, if applicable;

ii.      Include the job description of IW’s regular job at the time of injury and the description of the new occupation, which includes physical requirements;

iii.     If the IW is employed, reference the documentation for wages earned during the period; and

iv.    If the IW is unemployed, reference the documentation that indicates the specific period of time they were unemployed.

d.     Modifying a Previous NOR - If a previously sent NOR needs to be modified rather than withdrawn, claims services staff shall send a new NOR that includes:

i.       The date of the original NOR;

ii.      The issue(s) previously identified; and

iii.     An explanation for the new NOR;

e.     Referral for Reset

i.       Claims services staff shall use a NOR to return a claim to the IC for reset after claims services staff has completed a requested action.

Example:  The IC remanded a claim back to BWC for an exam to be completed.  Once the exam is completed, the issue is referred back to the IC as a reset.

ii.      When returning a claim to the IC for reset, claims services staff shall indicate the NOR was initiated by the IW/employer/claimant and provide the information needed to identify the reason for the reset.

iii.     If BWC has identified a new issue(s), the NOR shall clearly identify that a new issue(s) is being added to the issue(s) that was originally referred to the IC.

f.       Resetting Full Weekly Wage (FWW) or Average Weekly Wage (AWW) When the IC Has Initially Set Wages

i.       Identify who is initiating the request;

ii.      State the number of weeks claims services staff recommends should be included or excluded from the calculation and specific time periods covered;

iii.     Include the basis for calculation by stating the amount earned divided by the number of weeks included in the calculation; and

iv.    Provide a recommendation on the adjustment of any past compensation paid, when requested by the filing party in writing.

g.     Scheduled Loss

i.       Clearly indicate the name of the physician(s), date(s) of medical report(s), diagnostic test(s), and the specific statement(s) or evidence from the report(s) relied on to make the referral.  Claims services staff shall indicate the exact place or percentage of loss, when applicable;

ii.      Identify recommended start date for payment; and

iii.     If applicable, identify if there is information on a previous or similar award.

h.     Self Insured (SI) Disputed Matters - Claims services staff shall use a NOR to refer self-insured claims to the IC for hearing within seven days of notice of a dispute. 

i.       TT - When preparing a NOR for TT issues, claims services staff shall identify the specific period and dates requested and, as applicable:

i.       State if TT is due to a non-allowed condition(s);

ii.      Identify any defects or missing information on the C-84 or MEDCO-14 in addition to attempts to obtain missing information or resolve the defects;

iii.     Cite any medical file review or independent medical exam that does not support temporary total benefits and the basis for the medical opinion;

iv.    Cite information regarding return to work (RTW), light duty job offer by employer (in writing), or previous/current findings of maximum medical improvement and receipt of any unemployment compensation; and

v.      Document any recent rehabilitation activity.

j.       Wage Loss Compensation (WL) – As applicable, claims services staff shall:

i.       Document any reason for objection;

ii.      Clearly describe job search information and results;

iii.     Identify any contact with potential employers and any responses, as described in the Wage Loss policy and procedure;

iv.    Describe information regarding the IW’s former job or any job offer from the former employer; and

v.      Report information or involvement in rehabilitation.

k.      Withdrawal of a NOR

i.       Claims services staff may withdraw a NOR in the following circumstances:

a)     The party that filed the original request which prompted the NOR has indicated in writing the desire to withdraw the request.

Example:  The NOR was prompted by a C-86 filed by the IW asking for an additional condition(s), but subsequently, the IW asked to withdraw the C-86.

b)     BWC can now take action on the request that prompted the NOR.

Example:  BWC made a referral to the IC regarding payment of temporary total compensation because there was insufficient information to support approval, but subsequently, BWC received the necessary documentation.

c)     BWC referral was made in error.

Example:  A referral was made to the IC requesting an adjustment to the IW’s wages, but claims services staff later recognized that BWC initially set the wages and can address resetting the wages. 

ii.      To withdraw a NOR, claims services staff shall send a Request for Cancellation (C-50) to the IC Hearing Administrator and follow any other  instructions given by his or her office supervisor (e.g., staffing with the local BWC attorney, staffing with team leader).

iii.     The IC will do one of the following in response to the C-50: 

a)     If the Hearing Administrator agrees to allow claims services staff to withdraw the NOR and the hearing has not been scheduled, the IC will send an Ex Parte Order to all parties dismissing the issue.

b)     If the Hearing Administrator agrees to allow claims services staff to withdraw the NOR and the hearing has already been scheduled, the IC will send a cancellation notice to all parties explaining the reason for the cancellation of the hearing.

c)     If the Hearing Administrator does not agree to allow claims services staff to withraw the NOR, the hearing will go forward. 

iv.    Claims services staff shall contact the IW and the employer, as applicable, to advise of the status of the issue.

v.      Claims services staff shall not issue a BWC order, if one is needed, until claims services staff receives a cancellation notice from the IC.  Claims services staff shall discuss with a BWC attorney any questions regarding whether an order is appropriate.