|
Policy and Procedure Name:
|
Changing the Employer and/or Policy Number after Initial
Determination
|
|
Policy #:
|
CP-03-01
|
|
Code/Rule Reference:
|
R.C. 4123.01
O.A.C. 4123-3-08 and 4123-17-15
|
|
Effective Date:
|
12/17/21
|
|
Approved:
|
Ann M. Shannon, Chief of Claims Policy and Support
|
|
Origin:
|
Claims Policy
|
|
Supersedes:
|
Policy # CP-03-01, effective 07/13/15
|
|
History:
|
Previous versions of this policy are available upon
request
|
Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Alternate Employer Organization (AEO)
AEO Agreement
Assigned Employer
Client Employer
Employer
Professional Employer Organization
(PEO)
PEO Agreement
Policy Number
Potential Employer
Shared Employee
Self-Insuring (SI) Employer
State Fund (SF) Employer
IV. POLICY
A. Reasons for Changing
Employer and/or Policy Number
B. Systematic Reassignment
C. Investigation
D. Employer reassignment
E. Employer reassignment
Order
F. IC Referral
G. Change from SI Employer
to Another SI Employer
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. System Reassignment of
Employer Policies
C. Investigating Requests
to Change EOR
D. Confirming EOR Change
Requests with Supporting Documentation
E. Issuing the Decision
F. IC Referral
G. Changing the Employer
from an SF Employer to an SI Employer or SI Employer to SF Employer
H. Changing the Employer
from an SI Employer to Another SI Employer
I. Changing the Employer
from a Non-Complying Employer
The purpose of this policy is to ensure that the BWC
determines the correct employer of record (EOR) and/or policy number for each
claim via a comprehensive investigation when BWC receives information after the
initial determination of the claim suggesting that the EOR and/or policy number
assigned during the initial determination of a claim is incorrect.
This policy applies to BWC Claim Services staff and Employer
Services staff.
Alternate Employer Organization (AEO): A
sole proprietor, partnership, association, limited liability company, or
corporation that enters into an agreement with one or more client employers for
purposes of providing human resource management services and sharing employer
responsibility and liability. An AEO does not include a temporary service
agency.
AEO
Agreement: The A written contract between a client employer
and an AEO to provide human resource management services and to share employer
responsibilities and liabilities. Upon entering into an AEO agreement, a client
employer’r worksite employees are covered under the AEO’s workers’ compensation
policy.
Assigned Employer: The entity that is
designated as the EOR during the initial determination.
Client Employer: A sole proprietor, partnership,
association, limited liability company, or corporation that enters into a PEO
agreement and is assigned shared employees by the PEO.
Employer:
Includes, but is not limited to, the following, as defined in R.C. 4123.01:
·
The state, including state hospitals, each county, municipal
corporation, township, school district, and hospital owned by a political
subdivision or subdivisions other than the state;
·
Every person, firm, professional employer organization, alternate
employer organization, and private corporation, including any public service
corporation, that: (i) has in service one or more employees or shared employees
regularly in the same business or in or about the same establishment under any
contract of hire, express or implied, oral or written; or (ii) is bound by any
such contract of hire or by any other written contract, to pay into the
insurance fund the premiums as provided by law.
Professional
Employer Organization (PEO): A sole proprietor, partnership,
association, limited liability company, or corporation that enters into an
agreement with one or more client employers for the purpose of co-employing all
or part of the client employer’s workforce at the client employer’s work site.
PEO does not include a temporary service agency.
PEO
Agreement: A written contract to co-employ employees between
a PEO and a client employer with a duration not less than twelve (12) months in
accordance with the requirements of ORC Chapter 4125.
Policy
Number: A term synonymous with "risk number," it is
the identification number that the BWC assigns to an employer.
Potential
Employer: The entity that is likely to be designated as the EOR
following an investigation of the employer and/or policy number after the
initial determination; typically not the employer assigned to a claim at
initial determination.
Shared Employee:
An individual intended to be assigned to a client employer on a permanent
basis, not as a temporary supplement to the client employer’s workforce, who is
co-employed by a PEO and a client employer pursuant to a PEO agreement.
Self-Insuring
(SI) Employer: Employers who have
been granted the privilege by BWC of administering their own workers’
compensation programs and who pay compensation and benefits directly to the IW.
State Fund (SF)
Employer: Public and private
employers who pay premiums for workers’ compensation coverage.
- It is the policy of BWC to change the employer and/or
policy number after initial determination when:
1. There was
an error in employer/policy assignment at initial determination and there is
agreement by the parties; or
2. The
Adjudicating Committee or Ohio Industrial Commission (IC) orders the change.
- It is the policy of BWC to systematically reassign the
policy number of a claim when the employer assumes the policy number of another
employer (also known as a “policy combine”) or a PEO/AEO agreement is entered
into or changed.
- Upon receipt of a written request with supporting
documentation to change the employer, it is BWC’s policy to investigate the
assignment of the employer of record (EOR), including policy number, to
determine if the employer assignment and/or policy number is correct.
- It is BWC’s policy to issue an order for employer
reassignment when:
1. A written request
to change employer assignment is submitted with supporting evidence;
2. The IC has
not ruled on the issue of who is the correct EOR (i.e., the issue of correct
employer is included in the initial claim determination); and
3. The
assigned employer, potential employer, and BWC agree to the reassignment of a
claim.
- It is BWC’s policy to send a copy of the
claim-reassignment order to the parties to the claim and to the MCO to serve as
notice that the assigned employer is being corrected and the claim in question
will not be designated to the employer assigned to the claim during initial
determination.
- It is BWC’s policy to refer an employer-assignment issue
to the IC by Notice of Referral (NOR) when:
1. The
assigned employer contests assignment of the claim in writing and with
supporting evidence, but the potential employer objects to assignment of the
claim;
2. The
assigned employer disputes assignment of a claim in writing and with supporting
evidence after the claim has gone to a hearing;
3. The IC has
already ruled on the issue of who is the correct EOR; or
4. BWC does
not agree with the request for change.
- It is BWC’s policy to change an employer from an SI employer
to another SI employer when:
1. A request
is submitted in writing with supporting documentation;
2. BWC agrees
to the change; and
3. The
employers agree to the change.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Shall
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. PEO
Agreements
a. When an
employer hires a SF PEO:
i. The
lease agreement is established, all applicable claims are systematically
reassigned either on January 1st or July 1st to the SF
PEO in Rates & Payment and then interfaced to the claims management system.
ii. A
note is placed in each claim when this change occurs. The note looks similar to
this, “##/##/#### 00:00AM/PM, BATCH, PEO agreement effective ####-##-## moved
claim 00-000000 from client ######## to PEO ########, User name A#.
b. Employer Ends
Contract with SF PEO
i. When
the lease is terminated, all applicable claims are systematically reassigned to
the client employer in BWC Rates and Payments and then interfaced to the claims
management system.
ii. A
note is placed in each claim when this change occurs.
c. When
an employer hires a SI PEO:
i. Existing
claims assigned to the client employer remain assigned to the client employer
and are not reassigned to the SI PEO when a lease agreement is established.
ii. Any
claims filed with the Date of Injury (DOI) on or after the date of the lease
agreement are assigned to the SI PEO.
d. Employer Ends
Contract with SI PEO - When the lease is terminated, all claims that were
assigned to the SI PEO during the lease agreement remain permanently assigned
to the SI PEO.
2. Combine Policy
a. When a
combine occurs the predecessor policy number systematically changes to the
successor policy number in existing determined claim(s).
b. A
systematic note is dropped into the claim when the reassignment occurs. The
note will look similar to this, “Claim ##-###### was transferred when Policy
######## was combined into Policy ######## effective 2021-02-01. Please do not
change the policy number as it may affect policy rates. If more information is
needed, please call ###-###-####. User name A#.”
1. If the employer
assignment of the claim is contested, claim services staff shall ensure the
party filing the dispute has submitted the issue in writing with supporting
documentation. Requests to reassign the employer in a claim from internal BWC
staff must also include a:
a. Thorough
explanation to support the change; and
b. Explanation
as to where documentation to support the change can be found.
2. If a party
verbally notifies BWC that the party is disputing employer assignment, claims
services staff shall inform the party that he or she must submit the dispute in
writing and may submit a Motion
(C-86) or Request
to Correct Employer and/or Policy Number Assignment (C-264). Claims
services staff shall send a C-264 to the
party filing the dispute, when requested.
3. When a
dispute of employer assignment is submitted in writing with supporting
documentation, claims services staff may use one or more of the following
methods to investigate and determine correct employer information, including
policy number:
a. Call the
injured worker (IW) or assigned employer and request evidence (e.g., W-2, temporary
employer information (if applicable), paystub for the date of injury (DOI) that
includes the employer’s federal identification number automated on it) to help
identify the correct employer;
b. Contact
the provider’s office who initially filed the claim for the name of the
employer;
c. Perform
a look up by name and Social Security Number for the IW on the claims
management system to determine if there is a duplicate claim or previous claim
that may list the correct employer information;
i. If
an existing duplicate claim is found, claims services staff shall combine the
claims.
ii. Refer
to the Duplicate
Claims policy and procedure on Claims
Online Resources (COR) for more information.
d. Investigate
the employer in BWC’s employer management system. Use the employer management
system for the following:
i. To
search for an employer’s policy number;
ii. To
perform a “doing business as” search;
iii. To
determine if a policy number has been combined into another policy number; and
iv. To determine if
an employer has entered into a PEO agreement.
e. Investigate
using the Internet;
f. Investigate
the claims documents, including hospital information, to determine if employer
information has been included in any of them;
g. Staff the
issue with applicable Employer Services staff;
h. Run the
Employer-Locator query from data warehouse to assist in locating the correct
employer policy number; and/or
i. Utilize
the Employer
of Record Investigation Checklist to summarize information gathered.
j. Claims
services staff may also refer to the Employer
of Record Change policy.
4. Claims
services staff shall refer to the steps outlined in the Coverage and
Employer/Employee Status policy and procedures, and contact BWC Policy Processing via email when
the claims services staff:
a. Is able to
determine the correct employer, but the employer has no policy number or
coverage; or
b. Determines
that the place holder policy was not needed because the correct policy number
has been identified.
5. When the
assigned employer contests assignment of the claim in writing, but does not
submit supporting documentation, claims services staff shall:
a. Contact
the assigned employer by phone and notify them that supporting documentation is
required to consider the issue of correct employer. The assigned employer has three
(3) calendar days from the date of the call to submit evidence.
b. If the
assigned employer cannot be contacted by phone, send a “Changing
the Employer and/or Policy Number – Supporting Documentation Needed Letter”
(located on COR) to the assigned employer as notification that supporting
documentation is required for BWC to consider the issue of correct employer.
The assigned employer has seven (7) calendar days (+4 per mail rule) to respond
from the mailing date of the letter to submit evidence.
c. If
no supporting documentation is submitted timely, send the “Dismissal Letter” to
the assigned employer as notification that BWC is terminating investigation of
the issue due to a lack of evidence.
1. For a written
change of employer request from a party to a claim, claims services staff shall
review the matter with an Employer Services staff member and an Injury
Management Supervisor (IMS) or Medical Claims Specialist Supervisor (MCSS) to
verify that the information obtained is accurate and the requested change is
appropriate.
2. For
requests to reassign the employer in a claim from internal BWC staff, claims
services staff shall review the matter with an IMS to verify that thorough
explanation for the change has been provided and documentation, if necessary,
is available for the claim file.
3. If after
review all necessary BWC staff agree with the request for change of employer, claims
services staff will contact the local claims director or designee for review
and approval.
4. When the change of employer is approved by the claims director
or designee, claims services staff shall contact the potential employer and
send a State
Fund Employer’s Agreement to Accept Claim Assignment (C-263) to obtain
written agreement to accept the claim.
a. If the
potential employer agrees, claims services staff shall issue a BWC Order, in
accordance with Section V.E. of this procedure.
b. If the
potential employer cannot be located or does not agree to accept the claim, claims
services staff shall send the issue to the IC, in accordance with Section V.F.
of this procedure.
5. If BWC
staff do not agree with the request for change of employer, claims services
staff shall send the issue to the IC, in accordance with Section V.F. of this
procedure.
1. Claims
services staff shall issue a employer reassignment order to change the employer
and/or policy number when:
a. The request
to change the assigned employer of the claim is in writing with supporting
documentation;
b. The change
has been approved by the claims director and/or designee;
c. Both
employers have agreed to change the employer and policy number;
d. The IC has
not ruled on the issue of who is correct EOR (i.e., the issue of correct
employer is included in the initial claim determination).
2. When claims
services staff issues a employer reassignment order to correct the assigned
employer and/or policy number, he or she shall reflect the agreement from both
employers in the order.
3. The
original allowance order is not vacated when the employer reassignment order is
issued. They employer reassignment order only addresses the correction and
agreement of the employer assignment of the claim.
4. Claims
services staff shall send the following entities a copy of the employer
reassignment order to serve as notice that the employer assigned to the claim
during initial determination is being corrected and the claim in question will
not be assigned to that employer:
a. The IW;
b. The correct
employer;
c. The
employer assigned to the claim during initial determination;
d. The managed
care organization (MCO) for the employer assigned to the claim during initial
determination; and
e. Any
authorized representative(s) for the above-named parties, including any
authorized representative(s) for the employer assigned to the claim during
initial determination, as listed in BWC’s initial determination order.
5. In order
to serve proper notice of the employer reassignment, claims services staff must
add the correct employer as a customer recipient to the subsequent order.
6. Claims
services staff shall not send notice to the MCO when the employer is changing
from an SI employer to an SF employer. Changing a claim from SI to SF in the
claims management system will automatically result in MCO assignment and
generate notice to the MCO.
7. Claims
services staff shall update the claims management system with the change of
employer information after the decision is final.
1. Claims
services staff shall refer the issue to the IC when:
a. A request
to change the employer and policy number is submitted in writing with
supporting documentation, but both employers do not agree to the change;
b. The IC has
already ruled on the initial claim determination/correct employer (i.e., the
issue of correct employer is included in the initial claim determination); or
c. BWC
does not support the request for change.
2. When
completing the NOR, claims services staff shall indicate that the requested
action is to change the employer, not to change the policy number. The IC will
not hear issues regarding change of policy number.
1. When claims
services staff receives a written request with supporting documentation to
change the employer in a claim assigned to an SF employer to an SI employer or
a claim assigned to an SI employer to an SF employer, claims services staff
shall investigate the change of employer to determine if the change is
appropriate pursuant to Section V.C. above.
2. After
investigation, claims services staff shall refer the issue to the SI Department
by email to “BWC Self-Insured Inquiries”
to request a recommendation on the appropriateness of the request to change the
employer.
3. To
determine whether the change of employer is appropriate, the SI Department shall:
a. Contact in
writing the potential employer notifying them that the claim may be assigned to
the potential employer and request a written response for the claim;
b. Provide
the potential employer an opportunity to address whether reassignment of the
claim is appropriate;
c. Send
the written response to the imaging queue to serve as supporting documentation
to change the employer; and
d. Notify claims
services staff by email regarding whether the employers are in agreement with
the change of employer and if the change of employer is the recommended course
of action.
4. If the SI
Department recommends the requested change of employer, claims services staff
shall contact the local claims director or designee for review and approval.
5. If the
change of employer is approved by the claims director or designee, claims
services staff shall issue a employer reassignment order to change the
employer, in accordance with Section V.E. of this procedure. When changing from an SF employer to an SI employer, claims
services staff shall issue the order notifying all parties of the change of
employer before assigning the claim to the SI employer in the claims management
system.
6. Claims
services staff shall refer the issue to the IC, in accordance with Section V.F.
of this procedure, when:
a. The
employers do not agree to the change of employer following discussion of the
issue with BWC’s SI Department; or
b. BWC
staff determines that the change of employer is not appropriate.
7. When
the decision to change the employer is final, claims services staff shall:
a. Coordinate
with the SI Department, Medical Billing and Adjustments (MB&A), and/or
Pharmacy staff to determine any necessary adjustments for medical and pharmacy
bill payments; and
b. Send
an email to the Rate Adjustment Department at EmpRateAd@bwc.state.oh.us to ensure
appropriate adjustments to reserves when BWC has paid compensation and the
claim is subsequently changed to an SI employer.
8. Reimbursements
a. When
an SI claim subsequently changes to SF:
i. Claims
services staff shall reimburse the SI employer using a miscellaneous payment if
compensation was paid by the SI employer;
ii. Claims
services staff shall enter a period(s) of miscellaneous ineligibility in the
claims management system for compensation paid by the SI employer to prevent
BWC from paying compensation over the same period(s);
iii. Claims
services staff shall enter salary continuation payment(s) into the claims
management system for temporary total compensation (TT) paid by the SI employer
to ensure the SI employer’s TT payment(s) is counted toward the first 12 weeks
of TT; and
iv. Claims services
staff shall accept copies of check stubs showing compensation paid, or other
documentation verifying compensation paid in the claim.
v. The
SI Department shall obtain documentation of medical payments from the SI
employer for MB&A to reimburse the SI employer.
b. When
an SF claim subsequently changes to SI, the SI Department shall notify and
coordinate reimbursements from the SI employer.
1. When claims services staff receives a request from a single
SI employer with multiple locations to change the location only of the claim,
the claims services staff may update the claims management system as requested
2. When a C262
has been submitted, the claims services staff may update the claims management
system as requested.
3. For all
other SI to SI change of employer requests:
a. Claims
services staff shall:
i. Investigate
the change of employer to determine if the change is appropriate pursuant to
Section V.C. above; and
ii. Refer
the issue to the SI Department by email to “BWC Self-Insured Inquiries” to request
a recommendation on the appropriateness of the request to change the employer.
b. The SI
Department shall notify claims services staff by email regarding whether the employers
are in agreement with the change of employer and if the change of employer is
the recommended course of action.
c. If
the SI Department recommends the requested change of employer, claims services
staff shall contact the local claims director or designee for review and
approval.
d. If the
change of employer is approved by the claims director or designee, claims
services staff shall update the claims management system with the change of
employer information.
e. If
both employers do not agree to the written request for a change of employer,
claims service staff shall refer the issue to the IC. If there is no written
request for change of employer, it is the responsibility of the SI employer who
requested the change to file a C-86.
1. Once the
decision to change the employer from a non-complying employer (i.e. employer
without coverage on the date of injury) to another employer is final, claims
services staff shall send an email to BWC
Policy Processing to address any billing issues for the employers.
2. When changing
from a non-complying employer to another employer with coverage, the email
shall include the following message with the applicable information inserted:
“Claim number XX-XXXXX was previously assigned to policy number AAA, a
non-complying employer on the DOI. The claim is now assigned to policy number
BBB, a covered employer. Please review policy number AAA for non-compliance
claim billings and void the billings accordingly.”
3. When
changing from a non-complying employer to another non-complying employer, the
email shall include the following message with the applicable information
inserted: “Claim number XX-XXXXX was previously assigned to policy number CCC,
a non-complying employer on the DOI. The claim is now assigned to policy number
DDD, also a non-complying employer. Please review policy number CCC for
non-compliance claim billings and void the billings accordingly.”