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OhioBWC - Basics:  Initial Decision Phase

Compensability

The initial decision phase applies to the allowance of the claim and outlines the activity necessary to make fair and equitable decisions. Jurisdiction, Coverage and Compensability are the three basic requirements to be considered when determining if an injury is compensable. With the implementation of the Health Partnership Program (HPP), the Customer Service Team (CST) will partner with managed care organizations (MCOs) to resolve these issues.

Jurisdiction addresses time, place and whether an employment relationship has sufficient Ohio contacts to enact the workers’ compensation application in Ohio.

Coverage addresses the employee/employer relationship as opposed to an independent contractor or volunteer.

Compensability addresses the following four components:

  • Accidental in nature;
  • Physical injury;
  • In the course of employment;
  • Arising out of the employment.

During the initial investigation of an injury, the CST now partners with the MCO to ensure that appropriate medical evidence is obtained to determine if a claim is compensable. Coordinating information with the MCO will help to establish the causal relationship between the employee’s work-related injury and his/her employment. Based on the information received from your first report of injury, BWC or your self-insuring employer will make a decision to allow or deny the claim. BWC will make the decision within 28 days or your self-insuring employer will make it within 30 days. If you or your employer disagree with the decision, you may file an appeal with the Ohio Industrial Commission (IC) within 14 days of that decision.

Once the decision is made, ORC 4123.511 requires the CST to issue a written legal notice, called a BWC Order, to the injured worker and employer and their authorized representatives. The claim or medical condition allowance or denial will be sent via EDI to the MCO, who in turn, should update the provider. BWC’s goal is to make claim determinations within an average of 18 days of the initial notification of injury.

Effective Aug. 6, 1999, House Bill 180 eliminated the provision in ORC 4123.511(B)(1) that prohibited BWC from issuing an order before 21 days. The order may be issued once the investigation of the claim is completed and BWC has reached a decision. Prior to H.B.180, if the employer had certified the claim, the CSS could issue the initial BWC Order awarding benefits and/or compensation immediately upon completion of his/her investigation that included gathering all necessary information from all parties. If the employer had not certified the claim, the CSS could not publish the order before 21 days from the receipt date of the initial application.



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