Self-Insuring Employer Claim Record Requirements
Ohio Administrative Code (OAC) 4123-19-03(K)(3)
February 24, 2014
Self-Insured Department/Employer Services
February 1, 2019
defines injury record requirements for SI Employers.
applies to self-insuring employers, injured workers, medical providers and the
BWC Self-Insured Department.
A. Third Party
Administrator (TPA): An organization that assists employers in managing
their claims and programs.
Claim File: A record of a specific injury maintained by the employer.
SI Employer: Self-insuring employer.
to OAC 4123-19-03(K)(3), SI employers shall keep
a record of all injuries and occupational diseases resulting in more than seven
days of total disability, or death, and all contested or denied claims.
SI department requires that all other claim records be available for random
SI employer is required to house the files at an Ohio location and their files
are considered to be the official record for each claim.
SI employer may submit a written request to the SI Department for a waiver to
house the files with the employer’s TPA. The employer must meet the following
a toll free number for injured workers to use to address file requests;
a plan to notify injured workers of the change in file maintenance;
an address and provision for copying the file for the injured worker within three
(3) business days of a written request.
the request for waiver is approved, the employer will receive a written
confirmation of approval. If additional information is needed or the request
cannot be approved, the employer will be provided a written explanation. A
waiver may be revoked if the SI employer does not maintain a compliant rating
on audits, or has 3 or more valid self-insured complaints in a rolling 12 month
An approval to house files with a third party administrator may be
transferred with a change in TPA; however, the employer must provide BWC with a
written notice when the TPA is changed.
The employer is solely responsible for maintaining the record of the
claim for the entire period that the claim is active regardless of holding a
waiver to house the files with its TPA.
1. Pursuant to OAC 4123-19-03 (K)(6), the employer must make records available to BWC
The file record shall include the following items at a minimum:
1. Incident Report and/or First Report of an Injury,
Occupational Disease or Death (FROI);
2. Medical reports, narrative reports, independent medical
3. Service provider medical fee bills with date received
4. Notification to injured worker/provider if payment of fee
bill is delayed, denied or not paid in full;
5. Payment verification must include check number, date of
payment, payee, pay period and type of payment, and can be an electronic
printout or check copy;
6. Requests for authorization with date received clearly
7. Dated responses to requests for authorization;
8. Return-to-work documentation;
9. Requests for Temporary Total Compensation (C-84);
10. Physician’s Reports of Work Ability (MEDCO-14);
BWC and IC communications, hearings
12. Motions (C-86);
13. Payroll information, either printout or Wage Statement (C-94-A);
FWW and AWW information;
15. Working wage loss documentation and worksheets used to
calculate wage loss benefits;
16. Written job offer if claimant is working in a modified-duty
17. Authorization for release of medical information
18. Child support orders, if applicable;
19. Change of physician communication, if applicable.