OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Standard Claim File Documentation and Altered Documents

Policy #:


Code/Rule Reference:


Effective Date:



Ann M. Shannon, Chief of Claims Policy & Support


Claims Policy


Policy # CP-19-03, effective 03/06/13 and Procedure # CP-19-03.PR1, effective 07/11/16


Previous versions of this policy are available upon request









A.       Claim File General Provisions. 4

B.       Notes. 4

C.       Documents. 5

D.       Altered Documents. 5

E.       Hard Copy Evidence (HCE) 6

F.       Text Messages, Faxed Cover Sheets, and Blank Forms. 7

G.       BWC Attorney-Client Privilege, Attorney Work Product, and Fraud Information and Documentation. 8

H.       Retrieving Hard Copy or Physical Files or HCE From MAFIL, and Claim Reconstruction. 8






The purpose of this policy is to ensure that the Bureau of Workers’ Compensation (BWC) provides direction to BWC and managed care organization (MCO) staff for entering appropriate, accurate, and complete information into a claim.




This policy applies to BWC claims staff and MCO staff.




Altering documents: Making a mark or markings that change the meaning, intent or facts presented in a document.


Attorney work product: Documents, electronically stored information, and tangible items prepared by an attorney in anticipation of litigation or for trial.


Claim files: Individual claim information maintained in BWC’s claims management system or in remaining paper claim files.


Electronic storage media: Any electronic device that can be used to store data. This includes, but is not limited to, internal and external hard drives, CDs, DVDs, Floppy Disks, USB drives, ZIP disks, magnetic tapes, and SD cards.


Evidence: Any document or claim note used to support or disprove allegations or facts of a claim.


Hard copy evidence: Evidence that cannot be imaged into a claim or can be imaged but significant detail is lost in the imaging process (e.g., CDs, DVDs, memory cards, photographs, X-rays).


MAFIL: The main file room for BWC to house hard copy claim files and hard copy evidence.


Tampering with evidence: Altering, destroying, concealing, or removing evidence that is relevant to an investigation or decision in a claim.




A.     It is the policy of BWC to ensure that claim files contain a complete and accurate record of all claim activity.

B.     Claim files shall not include BWC attorney-client privileged information, fraud investigation information or other confidential information unless specifically authorized.

C.    BWC claims staff shall document specific information in claim level notes the same day the action occurs.

D.    Claim files shall be maintained in compliance with the BWC Record Retention schedule.



A.    General Claims Provision

The contents of a claim file shall include general information pertaining to the injured worker (IW), MCO, employer and provider demographics, claim level information, documents and reports related to the claim, and compensability information. See Standard Claims File and Altered Documents General Information Checklist for data elements that should be included in a claim file.


B.    Notes

1.     General Procedures Applicable to All Notes

a.     BWC claims staff and MCO staff shall ensure that claim notes are carefully reviewed for proper content, spelling, and grammar and that notes are located in the proper claim before saving notes to a claim.

b.     Based on the type of note, BWC claims staff and MCO staff shall add the proper information for “Category,” “Subject,” “Call Type,” and text that contains the specific information being documented.

c.      BWC and MCO staff shall identify a note as “Phone Note” if the information being documented is related to a telephone contact or “Note” for all other information.

d.     BWC claims staff shall only copy notes between multiple claims, for the same IW, when one of the following occurs:

i.       Compensation is split between claims;

ii.      Processing the following claim requests:

a)      Occupational Disease;

b)     Lump Sum Settlements;

c)      Additional Conditions;

d)     Claim Determination; and

e)     C-92 Applications.

iii.     An overpayment is recovered from multiple claims; or

iv.    Other appropriate circumstances, as approved by the supervisor.

2.     Claim Level Notes

a.     Claim level notes, which include general notes, linked notes, and case notes, shall reflect a complete history of a claim throughout its life cycle. BWC and MCO staff shall enter claim notes that:

i.       Contain only relevant information stated clearly and succinctly;

ii.      Are professional in tone and do not contain any rude or derogatory language;

iii.     Relate events in a logical, sequential order; and

iv.    Include authors’ and contacts’ names:

a)      BWC and MCO authors and contacts shall be cited by first name and last initial.

b)     External contacts shall be cited by first and last name, phone number, and relationship to the claim.

b.     Claim level notes shall document the following:

i.       Facts gathered during the investigation of the claim;

ii.      Issues identified throughout the life of the claim;

iii.     Action steps to resolve claim issues (e.g., attempt at phone contacts, phone conversations or voicemail messages, etc.);

iv.    Outcomes of claim issue resolution;

v.      Compensation payments and adjustments;

vi.    Claim decisions and the reason(s) for decisions.

c.      In accordance with Chapter 2 of the MCO’s Policy Reference Guide, MCO staff shall ensure the following when documenting claim notes:  

i.       In new claims, notes shall be submitted within one business day of claim number receipt.

ii.      Notes are submitted within one business day of creation.

iii.     MCOs shall continue to enter notes in compliance with the MCOs’ medical management policies and procedures as required by URAC accreditation, with the following exceptions:

a)      MCOs shall not include BWC servicing provider numbers.

b)     MCOs cannot append an existing note. The MCO shall create a new note.

iv.    Notes submitted with a creation date more than ten (10) calendar days prior to the submission date will be rejected.

3.     Customer Level Notes

a.     BWC claims staff shall ensure that notes entered at the customer level contain only general information about the customer and do not contain claim-specific information.

b.     If customer information is not already in the claims management system, BWC claims staff shall enter the information, if appropriate to do so, or notify the appropriate department responsible for entering the information about the customer.


C. Documents

1.     BWC shall immediately scan all claim-related mail and documents received through email or fax into the claim upon receipt.

2.     BWC claims staff shall rename and delete an imaged document when it is an exact duplicate of a previously imaged document. The deleted document will be stored in a holding file for future reference, as needed.

3.     BWC claims staff shall comply with indexing and renaming guidelines available on the Claims On-Line Resources (COR) site.


D. Altered Documents

1.     BWC and MCO staff shall not withhold, destroy, or alter any document in a manner that may cause harm or damage to an IW, provider, representative, employer, or the originator of the document.

2.     BWC claims staff and MCO staff may correct information on a hard copy document if the change is a non-substantive error (e.g., an employer’s policy number, manual classification, telephone number, or contact name).

a.     Corrections shall be made by striking through the error, so it is still readable, making the proper correction above the error, and initialing and dating the correction.

b.     Correction products (e.g., fluid, tape, erasers) or any other means that obscure the text to correct information on a document shall not be used.

c.      BWC claims staff or MCO staff shall document the description of the alteration in claim notes, which includes:

i.       The date;

ii.      The name and title of the person contacted for clarification, if applicable;

iii.      Whether the alteration was made by BWC or the MCO;

iv.    The name of the BWC or MCO staff member who made the alteration; and

v.      An explanation for the alteration.

3.     BWC claims staff and MCO staff shall assess all alterations made to documents to determine if an alteration is appropriate or inappropriate.

a.     Examples of appropriate alterations may include, but are not limited to, the following:

i.       An incorrect date was entered on a document and the originator of the document corrects the error by drawing a line through the incorrect date ensuring legibility of the original entry and dating and initialing the correction.

ii.      A provider, who is the originator of a document, submits an addendum that is used to provide additional information about an injured worker’s condition.

iii.     BWC claims staff receives a document from the Industrial Commission (IC) that is mislabeled and has a misspelling. BWC claims staff appropriately labels the document (rename) and corrects the spelling error.

b.     Examples of inappropriate alterations may include, but are not limited to, the following:

i.       An IW collecting non-working wage loss (NWWL) submits a previously submitted job search form with a current date that appears to be modified.

ii.      An IW submits proof of earnings with dates and wages that appear to be modified.

4.     If BWC receives an altered document where the alteration has changed the meaning, intent, or facts presented in the document, BWC claims staff shall determine, based on the extent of the alteration and the information altered, what action to take.

a.     If BWC claims staff determines that the alteration is significant, and clarity is needed (e.g., cross-outs and write-ins on the document without initials indicating who altered the document), BWC claims staff shall request that the originator of the document:

i.       Submit a written statement indicating the nature of the alteration, the reason for the alteration, and that the alteration accurate; or

ii.      Verbally verify the nature of the alteration, the reason for the alteration, and that the alteration is accurate. BWC claims staff shall document this verbal verification in a claim note and send an email or letter to the originator, requiring that the originator respond in writing and indicate agreement; or

iii.     Provide a copy of the original unaltered document or a copy of the initially sent document with the originator’s initials by each alteration and the date initialed.

b.     If the originator submits a new document, BWC claims staff shall identify both the originally received document and the new document in the claim file. BWC claims staff shall entitle the new document “Revised” followed by the description of the new document type. For example, if BWC claims staff receives a new medical report, BWC claims staff shall entitle the document, “Revised Medical Report.” 

c.      If BWC claims staff is unable to obtain a copy of the unaltered document or obtain appropriate verification of the alteration, the issue shall be staffed with the supervisor to determine next steps. If fraud is suspected, the CSS and supervisor shall refer to the Special Investigations Unit (SIU). Refer to the Fraud policy and procedure for directions on addressing potential fraud situations.


E. Hard Copy Evidence (HCE)

1.     When claims service staff receives hard copy evidence (HCE), such as a CD, DVD, flash drive, or photograph, claims service staff shall ensure the evidence is retained and identified with the claim.

a.     If the HCE is a form of electronic storage media and claims service staff have the equipment necessary, claims service staff shall

i. Print any printable images or documents stored on the electronic storage media.

ii.  Insert (scan)/image the printed images or documents into the claim file. If the HCE is a photograph, claims service staff shall image the photograph into the claim file.

b.     Claims service staff shall then:

i.       Securely label each piece of HCE with the IW’s name and claim number;

ii.      Package the HCE appropriately to ensure it is not damaged; and

iii.     Send the HCE to MAFIL.

2.     MAFIL staff will create an HCE folder and enter a claim note, if one does not already exist, describing the HCE in MAFIL storage.

3.     If claims service staff receive documents on a CD or flash drive and do not have the equipment to image the documents into the claim file, claims service staff may contact MAFIL directly to make arrangements to have MAFIL image the documents and store the CD or flash drive as HCE.


F. Text Messages, Faxed Cover Sheets and Blank Forms

1.     Text Messages: Claims Service staff may, when approved by Claims Service management and with the written agreement of the claimant, text a short message to a claimant via the claims service staff’s BWC email (or other approved BWC system).

a.     A text message shall be used primarily to convey a reminder to the claimant to take action important to the claim, or to alert the claimant of important communications sent by email or letter to the claimant (e.g., “This is a message to remind you to submit your class registration for fall semester”).

b.     A text message shall not contain any unnecessary confidential personal information (e.g., claim numbers, medical information).

c.      Claims service staff shall retain a text message and the response in the claim file in the same manner as any other communication to the claimant.

2.     Outgoing Fax Cover Sheets:

a.     In addition to entering an appropriate claim note and documenting the action and relevant information or request in the claim, claims service staff shall image into the claim the outgoing fax cover sheet and any information sent that is not already in the claim file.

b.     Claims service staff shall ensure that the following data elements are on the fax cover sheet:

i.       First name;

ii.      Last initial (do not include the entire last name); and

iii.     Direct telephone number; and

iv.    Description of content within the fax.

3.     Blank Forms: Claims service staff shall enter a claim note reflecting that blank forms were sent but are not required to image the blank forms or accompanying cover sheets into the claim file.


G.    BWC Attorney-Client Privilege, Attorney Work Product and Fraud Information and Documentation

1.     Claims service staff shall ensure that attorney-client privileged communications or attorney work products between BWC claims staff and BWC attorneys are not contained in a claim file.

a.     Claim files and claim notes shall not include copies, descriptions or summaries of legal opinions provided by BWC attorneys.

b.     BWC claims staff shall not image, copy, or paste an email from BWC attorneys into claim files and claim notes.

c.      BWC claims staff shall document in a claim note only the outcome of a staffing with a BWC attorney (e.g., “Staffed with BWC attorney who recommended paying the compensation and allowing the claim.”)

d.     BWC claims staff shall direct questions regarding attorney-client privilege and attorney work product as it relates to claim file documentation and notes to a BWC attorney.

2.     Fraud Information and Documentation

a.     Claim files shall not include any documents or references to fraud referrals, meetings, correspondence, or other communications, or any information pertaining to fraud allegations or pending investigations.

b.     Upon completion of a fraud investigation, the SIU shall determine and be responsible for updating the claim file with necessary and appropriate investigation documents.


H.    Retrieving Hard Copy, Physical Files, or HCE from MAFIL, and Claim Reconstruction

1.     When claims service staff are trying to determine if a hard copy or physical file exists or a claim has hard copy evidence stored at MAFIL, claims staff shall review the Folder Details and Folder Location information in the claims management system, which will indicate if there is a physical file at MAFIL (if there is HCE it will also be reflected as a physical file).

2.     If a physical file is identified as being at MAFIL, claims service staff shall utilize the MAFIL Tracker application (typically available via an icon on the desktop) to retrieve the physical file. Claims service staff shall:

a.     Select “ODI SO” (On Demand Imaging) in “Request Type” if claims service staff are requesting that hard copy documents be imaged into the claim for viewing; and

b.     Select “Service Office” in “Request Type” if claims service staff is requesting that the hard copy file or HCE be sent to the office location field.

3.     Claims service staff shall ensure that any original hard copy documentation or HCE retrieved from MAFIL is:

a.     Returned to MAFIL in its folder or otherwise intact; and

b.     That the claim folder location is updated to reflect “In Transit”.

4.     If MAFIL does not have the claim or there is an existing electronic file, but documentation is missing, claims service staff shall contact any of the participants (e.g., IW, dependents, employer, MCO) in a claim to obtain the needed documentation, as appropriate.

5.      Upon receipt of the needed documentation, claims service staff shall:

a.     Ensure all retrieved documentation is imaged into the claim;

b.     Enter a claim note indicating the claim has been electronically reconstructed and the date.