$15,000 Medical-Only Program ($15K Program)
Ohio Revised Code (ORC) 4123.29(A)(6); Ohio
Administrative Code (OAC) 4123-17-59;
March 7, 2014
All EM policies and procedures regarding the $15K
Program that predate the effective date of this policy.
$15K Program Complaint Policy, effective September 21,
2011, revised July 1, 2012, superseded by this policy.
March 7, 2019
The purpose of this policy is
to ensure that BWC administers the $15K Program in accordance with the
applicable laws and rules.
This policy applies to BWC
Employer Services, employers, and employer agents/authorized representatives.
claim: A claim of eight (8) or more days of lost time due to a work related
injury. Even though compensation or wages in lieu of compensation has not been
paid, the claim is still categorized as lost time.
The maximum medical cost that an employer can pay on an individual medical-only
claim has changed over the history of the program. The date of injury of the
claim defines the maximum, as follows:
claims with a date of injury between July 1, 1995, and June 29, 2006, the maximum
claims with a date of injury between June 30, 2006, and September 9, 2007, the maximum
claims with a date of injury on or after September 10, 2007, the maximum is
the policy references the program as the $15K Program, the date of injury in a claim
establishes the maximum amount in the claim, as set forth in III(B)(1), (2),
and (3) above.
C. Medical-only claim:
A claim of seven (7) or less days of lost time due to a work related injury,
with no compensation paid to the IW.
Criteria: To begin participation in the $15K Program, an employer must:
paying premiums to the state insurance fund.
coverage that is in force.
B. Election to
formal application is required.
employer must elect to participate by calling or emailing BWC.
C. Operation of program.
employer is responsible for all medical and pharmacy bills in all medical-only
claims with a date of injury on or after the date the employer elects to
participate in the program, until the maximum is reached. The employer, or its
agent, should pay the provider on behalf of the injured worker.
employer must notify the injured worker and medical provider in writing to:
Acknowledge the medical-only claim and that the employer elects to pay
bills as provided under ORC 4123.29,
that all bills be submitted to the employer and not the injured worker or BWC.
employer must pay bills within thirty (30) days of receipt.
For claims with a date of injury prior to June 30, 2009, the employer
must pay all bills as billed or reach an appropriate reimbursement amount with
claims with a date of injury after June 30, 2009, the employer must pay medical
bills in accordance with BWC’s fee schedule. (BWC fee schedule information is
located on www.bwc.ohio.gov, under
Medical Provider, Look-Ups)
both BWC and the employer pay the same medical bill, it is the employer’s
responsibility to seek reimbursement from the provider for the duplicate
employer may remove a medical-only claim from the $15K Program by notifying BWC
in writing, or by phone:
Within fourteen (14) days of the filing of the claim, if the employer
does not wish to pay any bills in that particular claim.
last date of service on which it will be responsible for the bills in a
particular claim. The employer’s managed care organization (MCO) will begin
processing bills, regardless of date of service, after the notification.
the maximum has been paid, the employer must:
Notify BWC and the MCO that the maximum has been paid.
the MCO proof of payment and copies of bills paid in the proper format.
the payment of a particular bill will exceed the maximum, the employer should
pay the portion of the bill that will bring payment to the maximum and notify
the provider to bill the MCO for the remainder of the bill.
employer must provide copies of the bills in a claim, in the proper billing
format, to BWC, the injured worker, or the injured worker’s representative upon
The employer must, upon written request from BWC, provide BWC
documentation of all medical-only bills that the employer is paying directly.
BWC may make such request no more than semiannually.
may remove the employer from the program if the employer fails to provide the
documentation to BWC within thirty (30) days of the receipt of the request.
The employer must keep a record of the injury on file for five (5) years
from the last date the employer paid a bill, or until the information has been
received by BWC. The employer must provide the information to BWC, the injured
worker, or the injured worker’s representative upon request. The employer must
keep record of:
Injured worker name, address and social security number.
and time of injury.
of body injured.
description of accident.
of bills and proof of payment, including the payment date(s).
employer must meet federal Medicare requirements beginning July 2010. An
employer can learn more through the Centers for Medicare and Medicaid Services web
Pay bills on claims in which it has paid wages in lieu of compensation.
or deny treatment.
to additional conditions and cannot process a Physician’s Request for Medical
Service or Recommendation for Additional Conditions for Industrial Injury or
Occupation Disease (C-9).
its MCO to authorize treatment or pay medical bills.
paid wages while the employee was off work as part of the maximum.
the $15K Program for a medical-only claim that occurs during a period of lapsed
employer may participate in other compatible BWC employer programs during its
participation in the $15K Program. Employer compatibility is outlined in OAC
C. Programs that may be compatible with the $15K Program are:
Safety Program (DFSP).
Claim Program (OCP).
viii.Group Experience Rating Program.
responsibilities. BWC will:
providers that send bills to BWC that the employer is responsible for the bills
in the claim.
charge the employer’s experience for payments made under this program. If the
employer complied with the program rule, and BWC made payments in contravention
of the rule, BWC will adjust the employer’s experience.
allegations that the employer has not paid medical bills in accordance with the
program requirements. Actions that BWC may take if it is determined the
employer failed to pay medical bills according to program requirements include,
but are not limited to:
Remove the specific claim from the $15K Program.
the employer from the $15K Program. In this case, all of the employer’s
medical-only claims are removed from the program.
bills on a medical-only claim if an employer removes the claim from the
automatically remove an employer from the $15K Program if the employer’s
coverage lapses. However, a medical-only claim that occurs during a period of lapsed
coverage will not be part of the $15K Program.
of a bill by the employer does not waive BWC’s right to adjudicate the claim or
the employer’s right to contest the claim should a claim be filed.
program does not supersede the injured worker’s right to file a claim with BWC.
will not pay interest on bills that were not paid within thirty (30) days if
the bills are the responsibility of the employer.
will not mediate fee disputes between the employer and provider.
injured worker is not liable for a bill that an employer participating in the
$15K Program fails to pay.
an employer pays a bill under the program, BWC will not reimburse the employer.
claim is removed from the program immediately if the claim changes to a
lost-time claim. See Claim
employer’s failure to pay bills timely will not affect the employer’s coverage
bills must be submitted to the employer in the proper billing format and
received by the employer within one (1) year of the date of service of the bill.
E. Exit from
program. An employer may cancel its participation in the $15K Program at any time
by calling or emailing BWC. The employer’s MCO will process all bills in all
medical-only claims for the employer after the date of removal.
F. Resolution of
employer may appeal BWC’s decision to remove the employer, or a specific claim,
from the program to the BWC Adjudicating Committee, per OAC 4123-14-06.
complaints should be processed under the General
Employer Complaint Policy. BWC has not identified any program-specific
extenuating circumstances that apply to the $15K Program.
G. Combinations and
Enrolled in $15K Program.
Not enrolled in $15K Program.
Predecessor’s enrollment in the $15K Program terminates as of the effective
date of combination.
Enrolled in $15K Program.
Enrolled in $15K Program.
remains enrolled in the $15K Program. Successor must comply with all program
requirements for predecessor’s medical-only claims.