Policy and Procedure Name:
R.C. 4123.351; R.C. 4123.75
Ann M. Shannon, Chief of Claims Operations & Support
Policy # CP-19-07, effective 06/27/14
Previous versions of this policy
are available upon request.
Self-Insured Bankrupt Claims Policy and Procedure Table
employers guaranty fund
is the policy of BWC to transfer management of workers’ compensation claims in
a timely and efficient manner to BWC from a self-insuring employer in default.
is the policy of BWC to pay compensation and benefits from the guaranty fund
for claims transferred to BWC when a self-insuring employer defaults.
Claim File Documentation
(SI) Employer Default
of the Claim File
and/or Subsequent Compensation/Indemnity Benefits
and/or Subsequent Compensation/Percentage of Permanent Partial Disability (%PP)
The purpose of this policy is to ensure that the management
of workers’ compensation claims is properly transferred from a self-insuring
employer that defaults to the BWC Self-Insured Bankrupt team.
This policy applies to BWC claims service staff,
specifically members of the Self-Insured Bankrupt team.
employer: An employer granted the privilege by BWC of administering
its own workers’ compensation program and who pays compensation and benefits
directly to the injured worker (IW).
For purposes of this policy, when a self-insuring employer notifies BWC that it
is no longer willing to administer a self-insured program or when it fails to
pay compensation and/or benefits on an allowed workers’ compensation claim.
employers guaranty fund: The fund established pursuant to R.C.
4123.351 through contributions from self-insuring employers, used to guarantee
the payment of claims of a self-insuring employer in default.
Bankrupt Team: The BWC Field Operations team responsible for
management of claims transferred to BWC from a self-insuring employer in
Department: The BWC section that provides oversight and services to
self-insuring employers, including underwriting of applications for
self-insurance, self-insured claims audit, and consulting services.
administrator: An organization that processes workers’ compensation
claim on an employer’s behalf.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and
procedure for claim note requirements; and
follow any other specific instructions for claim notes included in this
a. Update the
employer’s policy status to “Cancelled” and the status reason to “SI Default’
or “SI-Bankrupt” for all policies associated with the defaulted policy, which
will cause the claim management system to:
the employers claims; and
the claims to the SI Bankrupt team.
notice to the:
vii. Ombuds Office; and
viii. MCO Business & Reporting Unit;
a) The MCO Business
& Reporting Unit will recommend an MCO assignment to the Employer
Management Services Section and the SI Department;
Employer Management Services Section will assign a managed care organization
c) The MCO is
notified of the policy assignment via an 816 electronic interface and of the
associated claims via a 148 electronic data interface (EDI).
the SI employer and third-party administrator (TPA) to:
arrangements for pick-up or delivery of hard-copy and/or electronic claim
a list of active and inactive claims and request a “loss run” report, which
worker demographic information (name, claim number, social security number,
address, phone number);
calculations for the full weekly wage (FWW) and average weekly age (AWW), if
payment history, if any;
compensation and/or medical paid dates;
3. Notify the
SI Bankrupt supervisor and team of the incoming claims, the status and specific
compensation issues of the claims, and any other special instructions.
receipt of the claim file, the CSS shall review and update the claim to ensure
inclusion of all pertinent information and documents;
2. Set up
active compensation plan history, as needed; and
ongoing claim management consistent with BWC policies and procedures, with the
exception that “SI-BWC Pay” claims do not have an employer-party
1. Except for
percentage of permanent partial compensation (see section II.E), when an SI-BWC
Pay claim has ongoing compensation or a subsequent request for compensation is
made, the CSS shall:
indemnity benefit periods paid by the SI employer as the Benefit Type
“SI-Historical Pymts”; and
the Reporting Benefit Type as the specific type of compensation, e.g.,
“Temporary Total Disability – AWW”.
2. The CSS
shall build subsequent indemnity benefit periods payable by BWC, in the manner
appropriate for the benefit type.
a. Example 1:
The SI employer paid the first six (6) weeks of temporary total at the full
weekly wage (TT – FWW).
CSS shall build the first 6 week period as the Benefit Type “SI-Historical
Pymts” and the Reporting Type as “Temporary Total Disability – FWW”.
the IW continues eligibility for TT, the CSS shall build the next 6 weeks, payable
by BWC, as Benefit Type “Temporary Total Disability – FWW”.
iii. After a
total of twelve (12) weeks of benefits at FWW (6 weeks paid by the SI employer
and 6 weeks paid by BWC), the CSS shall build any ongoing TT paid at the
average weekly wage (AWW) as the benefit type “Temporary Total Disability –
b. Example 2:
The SI employer paid the first 12 weeks of TT – FWW.
CSS shall build the first twelve (12) weeks as the Benefit Type “SI –
Historical Pymts” and Benefit Type as “Temporary Total Disability – FWW”.
3: The SI employer paid the first 12 weeks of TT – FWW and ten (10) weeks of TT
CSS shall build the first 12 weeks as the Benefit Type “SI Historical Pymts”
and the Reporting Benefit Type as “Temporary Total Disability – FWW”.
ii. The CSS
shall build the next 10 weeks as the Benefit Type “SI – Historical Pymts” and
the Reporting Benefit Type as “Temporary Total Disability – AWW”.
iii. If the IW
continues eligibility for TT, the CSS shall build the ongoing weeks payable by
BWC, as Benefit Type “Temporary Total Disability – AWW”.
d. Example 4:
The SI employer paid the first 12 weeks of TT – FWW. The claim then transferred
to BWC, at which point the IW had returned to work and was not receiving
indemnity benefits. Five weeks after the claim transferred to BWC the IW
receipt of the claim the CSS does not build any indemnity benefit periods
because there is no compensation to be paid.
receipt of the compensation request, the CSS shall build the SI employer paid
indemnity benefit periods as the Benefit Type “SI – Historical Pymts” and the
Reporting Benefit Type as “Temporary Total Disability – FWW”.
iii. If the
compensation request is allowed the CSS shall build the indemnity benefit type
using the appropriate benefit type.
1. When an
SI-BWC Pay claim has ongoing %PP or a subsequent request for %PP or an increase
%PP is made, field staff shall reflect the SI employer paid benefit periods by
building the %PP plan.
service staff shall identify the indemnity benefit periods paid by the SI
employer as the Benefit Type “% Permanent Partial” or as applicable, “%
Permanent Partial – Pain” and identify the Reporting Benefit Type as “% Permanent
service staff shall not schedule payment for these SI employer paid benefit
a. Obtain the
First Report of an Injury, Occupational Disease or Death (FROI) or
obtain the necessary information from the employer’s accident report records,
including certified conditions or conditions recognized by the employer as
b. Create the
claim in the claims management system.