Policy Name:	Self-Insuring Employer Claim File Requirements
Policy #:	SI-03-02
Code/Rule Reference	Ohio Administrative Code (OAC) 4123-19-03(L)(11) and (L)(12)
Effective Date:	February 20, 2024
Approved:	Rex Blateri, Chief of Employer Services
Origin:	Self-Insured Department/Employer Services
Supersedes:	Self-Insuring Employer Claim Record Requirements policy effective February 24, 2014.
History:	Revised February 20, 2024. New policy effective February 24, 2014.
Review Date:	February 20, 2029

 

I.       Policy Purpose

 

Defines injury record requirements for self-insuring employers (SI employers).

II.     Applicability

The policy applies to SI employers, third party administrators (TPAs), injured workers, medical providers, and the BWC Self-Insured Department (SI Department).

III.   Definitions

There are no policy-specific definitions.

IV.   Policy

A.      SI employers shall keep a record of all injuries and occupational diseases. A claim file is the official collection of records maintained by an SI employer relating to a specific injury.

1.      All claim files must be available for random audits.

2.      SI employers are required to house the claim files at an Ohio location.

3.      SI employers must maintain a claim file while the claim is within the statute of limitations.  If a claim has passed the statute of limitations, SI employers must be able to provide payment history to support that the claim is beyond the statute of limitations.

4.      The claim file may be a hard copy file or an electronic file.

B.      SI employers may submit a written request to the SI Department for a waiver to house the claim files with the SI employer’s TPA. The SI employer must meet the following requirements:

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

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

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

C.      If the request for waiver is approved, the SI employer will receive a written confirmation of approval. If additional information is needed or the request cannot be approved, the SI 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 three or more valid self-insured complaints within any twelve (12) month period.

D.     An approval to house claim files with a TPA may be transferred with a change in TPA; however, the SI employer must provide BWC with written notice when the TPA is changed.

E.       SI employers housing claim files with their TPA must ensure the TPA is complying with all claim file requirements. SI employers must ensure the claim file is made available within three business days to injured workers upon receipt of a written request. SI employers must also ensure requested information is provided within three business days of a written request, which includes, but is not limited to, wages, allowed conditions, and medical reports.

F.      The claim file shall include the following applicable records at a minimum:

1.      Incident Report or First Report of an Injury, Occupational Disease or Death (FROI);

2.      Medical reports, narrative reports, and independent medical exam reports;

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

4.      Notification to injured worker and provider if payment of fee bill is delayed, denied, or not paid in full;

5.      Payment verification that must include check number, date of payment, payee, pay period, type of payment, and either 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-84s);

10.  Physician’s Reports of Work Ability (MEDCO-14s);

11.  BWC and Industrial Commission (IC) communications, including orders, hearing notices, and transcripts;

12.  Motions (C-86s);

13.  Payroll information, either printout or Employer Report of Employee Earnings (Wages-EMP);

14.  Full weekly wage (FWW) and average weekly wage (AWW) information, including calculations;

15.  Wage loss documentation and worksheets used to calculate wage loss benefits;

16.  Written job offer if injured worker is working in a modified duty position;

17.   Authorizations for release of medical information;

18.  Any child support orders; and

19.  Any change of physician communication.