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OhioBWC - Basics: (Policy library) - File

 

Policy Name:

Self-Insuring Employer Complaint (SI-28)

 

Policy #:

SI-03-03

Code/Rule Reference:

Ohio Revised Code (ORC) 4123.35 (G) and Ohio Administrative Code (OAC) 4123-19-09

Effective Date:

December 1, 2015

Origin:

Self-Insured Department/Employer Services

History:

New

Review Date:

December 1, 2020

 

 

I.                Policy Purpose

 

This policy defines how injured worker and medical provider complaints are submitted and addressed by the Self-Insured Department.

II.              Applicability

 

This policy applies to self-insuring employers, injured workers, medical providers and the Self-Insured Department.

III.             Definitions

 

A.    SI employer: Self-insuring employer.

B.    SI Complaint: An allegation that a SI employer is not complying with the statutory requirements.

C.    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.

D.    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 employer.

 

IV.            Policy

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.

Ohio Bureau of Workers' Compensation

Attn. Self-Insured Department

30 W. Spring St., 22nd Floor

Columbus, OH 43215-2256

Phone: 614-466-8222

Fax: 614-621-1081

                                          Email: SIINQ@bwc.state.oh.us.

 

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.

1.     The 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.

2.     The 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 requested.

3.     The 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.

4.     The SI employer will be expected to make any corrections required by a valid finding within 7 days of receipt of the finding.

5.     The SI department will maintain a copy of the complete record of the complaint.

6.     Three 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.

7.     The 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.

Phone:1-800-335-0996
Fax:877-321-9481
E-mail: ombudsperson@bwc.state.oh.us

 

V.             Resolution of Complaints

A.    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.

B.    Any unresolved issues and appeals to the administrator’s designee’s finding will be referred to Self-Insured Employer Evaluation Board (SIEEB).

 

 

 

 


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