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OhioBWC - Basics: (Policy library) - File

 

Policy Name:

Self-Insuring Employer Claim Record Requirements

 

Policy #:

SI-03-02

Code/Rule Reference:

Ohio Administrative Code (OAC) 4123-19-03(K)(3)

Effective Date:

February 24, 2014

Origin:

Self-Insured Department/Employer Services

Supersedes:

 

History:

New

Review Date:

February 1, 2019

 

 

    I.         Policy Purpose

 

This policy defines injury record requirements for SI Employers.

   II.         Applicability

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

  III.         Definitions

 

A.    Third Party Administrator (TPA): An organization that assists employers in managing their claims and programs.

B.    Official Claim File: A record of a specific injury maintained by the employer.

C.    SI Employer: Self-insuring employer.

 

 IV.         Policy

 

A.    Pursuant 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. 

1.     The SI department requires that all other claim records be available for random audits.

2.     The 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.                                                                                  

 

B.    The 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 requirements:

1.     Provide a toll free number for injured workers to use to address file requests;

2.     Submit a plan to notify injured workers of the change in file maintenance;

3.     Provide an address and provision for copying the file for the injured worker within three (3) business days of a written request.

 

C.    If 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 period.

 

D.    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.

E.    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 upon request.

F.     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 exams;

3.     Service provider medical fee bills with date received clearly documented;

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 documented;

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);

11.  BWC and IC communications, hearings & orders;

12.  Motions (C-86);

13.  Payroll information, either printout or Wage Statement (C-94-A);

14.  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 position;

17.  Authorization for release of medical information (optional);

18.  Child support orders, if applicable;

19.  Change of physician communication, if applicable.

 

 

 


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