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OhioBWC - Basics:  Claim Allowance

Claims

Accident Description
A narrative description of the accident or exposure which resulted in the injured worker’s injury, occupational disease or death. Ideally, injured workers should provide their written accident descriptions, unless, it is provided by either the injured worker or the employer when the claim is filed.

Additional Conditions/Subsequent Decision
To issue compensation to injured workers and medical payments to providers, all medical conditions must be included and allowed in the claim. After a claim is allowed, it is possible for new medical conditions (i.e., additional conditions) to arise in addition to those already included in the claim. Additional conditions can be considered at the request of the injured worker, employer, their authorized representatives, medical providers, the assigned managed care organizations or BWC. By law, before including additional conditions in a claim (i.e., making a subsequent decision), BWC researches the request, makes a determination and provides due process to all interested parties. Regardless of who initiates this process, all decisions are based on medical evidence provided in support of the request.

Alleged Condition/Alleged Injury
Under Ohio workers’ compensation law, when a claim is filed with BWC, all medical conditions requested in a claim are considered alleged until a determination is made either allowing or disallowing them.

Allowances/Allowed Conditions/Allowed Diagnosis
Allowances are medical conditions recognized as directly resulting from a compensable work-related injury or occupational disease. Allowances are supported by medical documentation submitted by providers. Allowances are also referred to as allowed conditions and allowed diagnoses.

BWC-Required Data Elements
When reporting a claim, pursuant to the Ohio Administrative Code and BWC Provider Agreement, providers are required to submit a number of key pieces of information to the injured worker’s managed care organization (MCO). This data is specific to the injured worker, injury, employer and provider. Required information that cannot be submitted when the claim is filed must be forwarded to the MCO no later than five days from the date of initial treatment.

Case Management
Case management is a cornerstone in the successful resolution of workers’ compensation claims. BWC’s and the managed care organization’s (MCO’s) case management standards and practices adhere to the definition established by the American Accreditation HealthCare Commission/URAC. In its Case Management Organization Standards, version 1.2, case management is defined as “A collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a client’s health needs through communication and available resources to promote quality, cost effective outcomes.”

The MCO case management plan is an essential tool in the management of the claim’s allowed conditions. The case manager develops the plan in collaboration with the injured worker, members of the health-care team and employer, if applicable. The plan represents a mutual commitment to the primary goal of return to work or resolution of the claim. The plan will identify: short- and long-term goals; time frames for response to referrals, follow up, and evaluation; resources to be used; collaborative approaches to be used; criteria for case closure; and anticipated case results. The plan elements identified here are identical to the case management plan elements identified in URAC’s Case Management Standard No. 23.

Causality/Causally Related
Under Ohio law, for a workers’ compensation claim to be allowed, the injured worker’s injury or occupational disease must be caused by a work-related accident or exposure. Burden of proof requirements are typically placed upon the injured worker to show that this causal relationship exists.

Causal Relationship
A causal relationship is a medical determination based on review of the accident description and mechanism of injury. In the medical opinion of the reviewing physician, the evidence is sufficient to conclude that the injury sustained and the mechanism of injury are compatible.

Claim Allowance
A claim allowance is a medical condition recognized as a direct result of a compensable work-related injury or occupational disease.

Claim History
A claim history is a record of all claims filed with BWC for an injured worker. This history contains information, such as allowances, dates of injury, demographic data and the claim’s status. BWC’s Web site allows injured workers, their authorized representatives and medical providers to look up histories for individual injured workers. Additionally, employers and their authorized representatives can look up this information, as well as all of the employer’s claim history for all employees.

Claim Number
A claim number is a unique number containing the year of assignment and a sequential six- digit number used to identify and track that claim (i.e., 02-123456).

Claim Status
When BWC receives a claim, it assigns it a status describing where it is in the decision making process. For purposes of provider reimbursement, it is important to remember that neither BWC or the injured worker’s managed care organization pay bills until a claim is in an allowed status.

Date(s) of Injury
The date of injury is the date on which a work-related injury occurred.

Date of Death
The date of death is the date that an injured worker died as the result of either a work-related injury or occupational disease. Date of death is confirmed by providing BWC with a copy of the injured worker’s death certificate or a Physician’s Certificate in Proof of Death (C-44).

Date of Diagnosis
The date of diagnosis is a term that should be applied exclusively to occupational disease (OD) claims. The date of diagnosis is the date that an injured worker is first diagnosed with an OD. It is important to report the correct date of diagnosis to BWC and the injured worker’s managed care organization because it is used to establish the time limit for filing the claim, setting wages and other vital claim elements.

Date of Disability
The date of disability is the first day that an injured worker is unable to work due to either an injury or occupational disease (OD). When used in reference specifically to OD claims, date of disability is a legal term used in conjunction with date of diagnosis. Date of disability and date of diagnosis must be established for BWC to establish the injured worker’s compensation (i.e., wages).

Diagnosis
A diagnosis is the description of the injury or illness that an injured worker sustained during the course of employment.

Diagnosis Code
The diagnosis code is the standard medical code and description associated with the injury or illness sustained by an injured worker during the course of employment.

Inactive
BWC places claims in an inactive status when they no longer require any investigation, decision making or management of either extent of injury or extent of disability issues. Claims are considered inactive when there has been no payment of compensation, no paid date of service and no manual reactivation in excess of 24 months.

Injury Description
An injury description is a written narrative of an injury or occupational disease sustained by the injured worker. Injury descriptions, accident descriptions and thorough medical documentation are all valuable aids in determining claims and authorizing the appropriate medical services needed by an injured worker.

Lost-Time Claim
A workers’ compensation claim becomes lost time when eight or more calendar days are lost from work due to an industrial injury or occupational disease. The eight days do not need to be consecutive.

Medical-Only Claim
A workers’ compensation claim becomes medical only when seven or fewer calendar days are lost from work due to an industrial injury or occupational disease.

Motion
A motion is used by injured workers or employers and/or their authorized representatives to request a decision by either BWC or the Industrial Commission of Ohio.

Party
Under Ohio law, parties to a workers’ compensation claim are the injured worker, the employer, the injured worker’s authorized representative, the employer’s authorized representative, and BWC’s Administrator. Medical providers are not parties to workers’ compensation claims.

Primary Diagnosis/Principal Diagnosis
The primary diagnosis is the most significant injury or condition in a workers’ compensation claim. Primary ICD-9 codes must be specified for all claims and only one primary diagnosis can be identified per claim. This may also be referred to as a claim’s principal diagnosis.

Self-Insured Claims
Self-insured claims are covered by employers who have been authorized by BWC to administer their employees’ workers’ compensation claims.

Type of Accident
Type of accident describes if the claim resulted from a work-related injury, occupational disease or death. Type of accident is more commonly referred to as accident type.

Work-Related
For a claim to be a workers’ compensation claim, either a physical injury or occupational disease must be related to an injured worker’s employment. As specified by Ohio law, the claim must arise from and be in the course of employment (i.e., work-related). While all claims received by BWC are considered, those not clearly related to the injured worker’s employment will be denied. When a claim is filed, the injured worker bears the burden of proof for demonstrating that the claim directly or proximately resulted from his or her employment. Burden of proof standards are met by providing BWC with thorough documentation, particularly all medical evidence developed by providers who have provided services to the injured worker.



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