OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Ohio Department of Job and Family Services (ODJFS) Reimbursement and Claim Adjustment

Policy #:

CP-15-02

Code/Rule Reference:

R.C. 4123.56(A), 4121.63, 4141.21, 4141.22, and 4141.43

Effective Date:

05/23/2019

Approved:

Kevin R. Abrams, Chief Operating Officer

Origin:

Claims Policy

Supersedes:

Policy # CP-05-02, effective 03/07/2013 and Procedure # PR-15-02.PR1, effective 11/16/2018

History:

Rev. 05/23/2019; 05/06/2019; 11/16/2018; New 03/07/2013


 

ODJFS Reimbursement Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

Designee

Non-Settled Claims

Ohio Job Insurance (OJI)

Settled Claims

IV. POLICY

A.         ODJFS Reimbursement

B.         Claim Adjustment

C.         Investigation

V. PROCEDURE

A.         Standard Claim File Documentation

B.         Unemployment Compensation Queries

C.         Designee Procedures for ODJFS Query

D.         Investigation

E.         Adjustment Orders

F.     Adjusting and Reimbursing ODJFS

 

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure BWC accurately adjusts awards of Temporary Total Compensation (TT) and Living Maintenance (LM) to injured workers (IW) and properly reimburses ODJFS when ODJFS pays unemployment compensation to an IW prior to BWC awarding TT or LM for the same period.

 

II. APPLICABILITY

 

This policy applies to claims services staff.

 

III. DEFINITIONS

 

Designee:  BWC claims services staff member in each service office authorized to access the ODJFS Ohio Job Insurance system.

 

Non-Settled Claims:  A claim in which BWC and the IW have not reached a full and final settlement.

 

Ohio Job Insurance (OJI):  ODJFS system detailing ODJFS’s payment of unemployment compensation benefits.

 

Settled Claims:  A claim in which BWC and the IW have reached a full and final settlement, and the claim is closed in whole or in part. 

 

IV. POLICY

A.     ODJFS Reimbursement

1.     It is the policy of BWC to reimburse ODJFS for state unemployment compensation benefits ODJFS paid to an IW prior to BWC awarding TT or LM for the same period. 

2.     Reimbursement to ODJFS shall equal the unemployment compensation benefits ODJFS paid to the IW up to, but not exceeding, the TT or LM rate for the same period.

3.     BWC shall not reimburse ODJFS for unemployment compensation paid to an injured worker in the following circumstances:

a.     BWC awarded TT or LM prior to ODJFS’s payment of unemployment compensation during the concurrent period;

b.     The unemployment compensation benefits are funded by an entity other than ODJFS (e.g., another state, the federal government);

c.      BWC pays compensation other than TT or LM during a concurrent period of unemployment compensation benefits.

 

B.     Claim Adjustment

1.     If reimbursement to ODJFS is required, BWC shall adjust the TT or LM benefit plan as follows:

a.     If BWC has not released the TT or LM payment, BWC shall adjust the TT or LM benefit plan reflecting the ODJFS reimbursement.

b.     If BWC released the TT or LM payment, BWC shall adjust the TT or LM benefit plan reflecting the ODJFS reimbursement and place the IW in overpaid status equal to the amount BWC paid to ODJFS.

2.     BWC shall pay the IW any balance of TT or LM that is over and above the amount BWC has reimbursed to ODJFS.

 

C.    Investigation

1.     Before awarding TT or LM, or when BWC receives information that indicates payment of unemployment compensation is being made, it is the policy of BWC that it shall investigate to verify whether unemployment compensation payments are being made. 

2.     Information and documentation received from parties to the claim will be noted and imaged into the claim file and may be disclosed at hearing.

 

V. PROCEDURE

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.     Unemployment Compensation Queries

1.      The claims services staff designee (Designee) completes a weekly review of the BWC Cognos report that lists all claims with new awards of temporary total (TT) or living maintenance (LM) for the previous week; or

2.      The Designee receives a work item from claims services staff requesting that a query be generated to determine if ODJFS has paid an injured worker (IW) unemployment compensation benefits over a period in which BWC awarded the IW TT or LM.  When requesting a query, claims services staff shall provide the following information to the Designee:

a.      IW’s social security number;

b.      BWC claim number; and

c.      The time period in question.

 

C.    Designee Procedures for ODJFS Query

1.      The Designee shall compare the IW’s periods of TT or LM on the Cognos report or the periods noted on the claims services staff email with unemployment compensation benefits listed on the Ohio Job Insurance (OJI) system to determine whether there is a period of concurrent payments of unemployment compensation and TT or LM. 

2.      If the Designee determines that ODJFS paid unemployment compensation benefits during the period that BWC awarded TT or LM, the Designee shall:

a.      Enter a note in the claims management system that staff reviewed OJI, identified a possible cross match and referred for further investigation;

b.      Send a work itemto the appropriate claims services staff member notifying the claims services staff to further investigate and make necessary adjustments.  The work item comment shall include the following information:

i.       Concurrent period(s) of TT or LM and unemployment compensation payments;

ii.      Weekly rate of the unemployment benefits; and

iii.     Whether an entity other than ODJFS issued the unemployment compensation payment (e.g., other state, or federal funds).

3.      If the Designee determines no unemployment compensation benefits were paid during the period that BWC awarded TT or LM, the Designee:

a.      Shall note in the work item comment that OJI was reviewed and there was no cross match;

b.      Shall send a work item to the claims services staff member that no match was found.

 

D.    Investigation

1.      Claims services staff Investigation if OJI Evidences Unemployment Compensation Has Been Paid

a.      Upon receiving notice from the Designee that the IW received unemployment compensation, claims services staff shall independently investigate and obtain information prior to making any adjustments in the claim or reimbursing ODJFS. 

b.      Claims services staff shall seek confirmation from the claim parties (e.g., IW, IW’s representative, employer, employer’s representative) whether the IW received unemployment compensation during the period being investigated.  Claims services staff may:

i.       Ask the IW and the IW’s employer if the IW received or requested unemployment compensation benefits from ODJFS during the period being investigated; and

ii.      If the response to the inquiry is yes, claims services staff shall request that the IW or employer send confirmation from ODJFS to the BWC.

c.      Claims services staff shall note in the claims management system if any of the parties submit information. Staff shall image documentation received into the claim.  Although it is not permissible for BWC to redisclose information received from ODJFS, claims services staff may re-disclose information a party submits.

d.      If independent investigation does not lead to additional evidence, claims services staff shall process the adjustment and reimbursement (if applicable) based on the information the Designee obtained from the OJI system.

e.       Claims services staff and the supervisor shall:

i.       Review the claim to determine if TT or LM is appropriate if the IW is receiving unemployment benefits; and

ii.      Verify if ODJFS paid unemployment compensation with state funds. BWC shall not reimburse ODJFS for unemployment benefits that are federally-funded or funded by a state other than Ohio.

f.       Following investigation, claims services staff shall adjust the TT or LM in the claim and reimburse ODJFS if ODJFS paid unemployment compensation prior to BWC awarding TT or LM for the same period.

2.      Claims services staff may contact ODJFS if BWC will continue to pay TT or LM and inform ODJFS of the period the IW is being awarded compensation so ODJFS can determine whether it will pay unemployment benefits.

 

E.     Adjustment Orders

1.      When adjusting the TT or LM award, claims services staff shall issue one of the following orders in non-settled claims (in addition to processing an ODJFS adjustment):

a.      Issue a modified order to adjust future compensation if the appeal period is still running on the TT or LM award noting the reason for the modification in the order; or

b.      Issue a subsequent order to declare the overpayment if the appeal period has expired and the claim is not settled.

2.      If the claim is settled, BWC takes no action to collect the overpayment from the IW (although the claim file is adjusted to reimburse ODJFS).

a.      If a party withdraws from settlement prior to the settlement being fully effective, the claim status will change to non-settled and claims services staff shall follow the procedures set forth in V.E.1.b., above.

b.      If the parties later agree to a new settlement, BWC shall deduct any existing overpayment from the final award.

3.      If an appeal is subsequently filed with the Industrial Commission, claims services staff shall request that a BWC attorney attend the hearing and shall provide a copy of the OJI screen print (located in confidential documents) and any relevant claim notes and imaged documents to the field attorney.  BWC attorneys may show parties to the claim and the hearing officer the OJI screen print at the hearing but shall not distribute copies of the OJI screen print to hearing attendees.

 

F.     Adjusting and Reimbursing ODJFS

1.      Claims services staff shall refer to the ODJFS Reimbursements job aid on COR. 

2.      Claims services staff shall also add ODJFS as an alternate payee in the claims management system.

3.      Before following the claims processing steps, claims services staff shall review how the claim is currently being paid and determine whether any of the following would impact an adjustment to compensation and shall seek assistance from a supervisor:

a.     Family Support Enforcement Award (if applicable, refer to the Family Support policy);

b.     There is an existing overpayment in the claim.