Policy and Procedure Name:
Ohio Department of Job and Family Services (ODJFS)
Reimbursement and Claim Adjustment
R.C. 4123.56(A), 4121.63, 4141.21, 4141.22, and 4141.43
Kevin R. Abrams, Chief Operating Officer
Policy # CP-05-02, effective 03/07/2013 and Procedure # PR-15-02.PR1,
Rev. 05/23/2019; 05/06/2019; 11/16/2018; New 03/07/2013
ODJFS Reimbursement Table of Contents
I. POLICY PURPOSE
Ohio Job Insurance (OJI)
A. ODJFS Reimbursement
B. Claim Adjustment
A. Standard Claim File
C. Designee Procedures for
E. Adjustment Orders
F. Adjusting and Reimbursing
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
This policy applies to claims services staff.
BWC claims services staff member in each service office authorized to access
the ODJFS Ohio Job Insurance system.
Claims: A claim in which BWC and the IW have not reached a
full and final settlement.
Insurance (OJI): ODJFS system detailing ODJFS’s payment of
unemployment compensation benefits.
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.
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.
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:
awarded TT or LM prior to ODJFS’s payment of unemployment compensation during
the concurrent period;
unemployment compensation benefits are funded by an entity other than ODJFS
(e.g., another state, the federal government);
pays compensation other than TT or LM during a concurrent period of
unemployment compensation benefits.
reimbursement to ODJFS is required, BWC shall adjust the TT or LM benefit plan
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.
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.
and documentation received from parties to the claim will be noted and imaged
into the claim file and may be disclosed at hearing.
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.
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
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:
social security number;
claim number; and
time period in question.
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.
If the Designee determines that ODJFS paid unemployment
compensation benefits during the period that BWC awarded TT or LM, the Designee
a note in the claims management system that staff reviewed OJI, identified a
possible cross match and referred for further investigation;
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:
period(s) of TT or LM and unemployment compensation payments;
rate of the unemployment benefits; and
an entity other than ODJFS issued the unemployment compensation payment (e.g.,
other state, or federal funds).
If the Designee determines no unemployment compensation benefits
were paid during the period that BWC awarded TT or LM, the Designee:
note in the work item comment that OJI was reviewed and there was no cross
send a work item to the claims services staff member that no match was found.
services staff Investigation if OJI Evidences Unemployment Compensation Has
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.
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:
the IW and the IW’s employer if the IW received or requested unemployment
compensation benefits from ODJFS during the period being investigated; and
the response to the inquiry is yes, claims services staff shall request that
the IW or employer send confirmation from ODJFS to the BWC.
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.
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.
services staff and the supervisor shall:
the claim to determine if TT or LM is appropriate if the IW is receiving
unemployment benefits; and
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.
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.
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.
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
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
a subsequent order to declare the overpayment if the appeal period has expired
and the claim is not settled.
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 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.
the parties later agree to a new settlement, BWC shall deduct any existing
overpayment from the final award.
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
services staff shall refer to the ODJFS Reimbursements job aid on COR.
services staff shall also add ODJFS as an alternate payee in the claims
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
Support Enforcement Award (if applicable, refer to the Family Support policy);
is an existing overpayment in the claim.