Self-Insuring Employer Complaint (SI-28)
Ohio Revised Code (ORC) 4123.35 (G) and Ohio
Administrative Code (OAC) 4123-19-09
December 1, 2015
Self-Insured Department/Employer Services
December 1, 2020
This policy defines how injured worker and medical provider complaints are
submitted and addressed by the Self-Insured Department.
This policy applies to self-insuring employers, injured workers, medical
providers and the Self-Insured Department.
SI employer: Self-insuring employer.
SI Complaint: An allegation that a SI employer is not complying
with the statutory requirements.
Formal Complaint: An allegation submitted on a SI-28 form, or
similar format via fax, mail or email. Phone calls may be treated as formal
complaints if followed by a written submission, or upon request of the caller.
Informal Complaint: An allegation brought to the attention of the
SI department by phone or other informal format that can be addressed in an
expeditious manner without formal allegations being presented.
E. SI-28 Filing
of an Allegation Against a Self-insuring Employer: BWC formal complaint form
used by injured workers to notify the Bureau of an allegation against a SI
A. Pursuant to OAC 4123-19-09, an
injured worker may file a complaint against a SI employer, which will be
investigated by the BWC SI department complaint resolution team. A complaint
may be submitted via the SI-28, telephone,
fax, email or mail.
Bureau of Workers' Compensation
W. Spring St., 22nd Floor
B. Many complaints
are a result of misunderstandings between the injured worker, medical provider
and SI employer. Therefore, the SI department will attempt to resolve any complaint
in an informal manner whenever possible. Informal complaints will be resolved
expeditiously or be addressed as formal complaints.
C. If a formal
complaint is made the following policy applies.
SI employer will be provided with a copy of the allegation and must provide a
written response to BWC and the injured worker within
fourteen (14) days of receipt of a formal complaint. If a response is not
received within this timeframe, BWC will proceed with a determination.
investigation will be completed based on information provided with the
complaint and the response from the employer.
The investigator may also consider information already available in the BWC’s
claims system. At the investigator’s discretion, additional information may be
allegation may be found invalid, valid & resolved, and valid & unresolved.
A copy of the finding will be provided to all parties. The injured worker may
withdraw the complaint at any point until a finding is published.
SI employer will be expected to make any corrections required by a valid
finding within 7 days of receipt of the finding.
SI department will maintain a copy of the complete record of the complaint.
valid complaints in a rolling twelve (12) month period will result in an audit
by the SI department auditing team, and will be considered when renewal of the SI
employer’s self- insured program is being addressed.
SI department will attempt to resolve any allegations presented by providers. However,
a provider must first submit a formal complaint
through the office of the Ombudsperson.
Resolution of Complaints
The SI department will issue a formal written response to formal complaints.
If the complaint is not resolved as a result of the formal response issued by
the SI department, the SI department will pursue the resolution with the
employer, or pursue administrative action that may include termination of the
employer’s SI status. Upon receipt of the finding, either party may file a
request for reconsideration, if there are new or changed circumstances or
information not previously provided. The reconsideration will be addressed by
the administrator’s designee and a finding sent to all interested parties.
Any unresolved issues and appeals to the administrator’s designee’s
finding will be referred to Self-Insured Employer Evaluation Board (SIEEB).