OhioBWC - Basics: Life cycle of a claim

OhioBWC - Basics: Life cycle of a claim

Life cycle of a claim

�The Four Phases of the Life Cycle of a Claim are Continuous and Reflect the Path of a Claim at BWC.�

Every claim goes through a process cycle, from the date it is reported to the date the claim is closed. This is called the life cycle of a claim.

What to expect during the life cycle of your claim

The life cycle chart will give you a better understanding of what happens during each phase of the claim�s life cycle. If you do not understand a specific phase or a term that is used, or you have additional information, please contact your claims service specialist (CSS) via the Internet or telephone.

In the following life cycle chart, your managed care organization's (MCO's) role will be identified by the bold italic print. Your MCO will serve as the primary resource for medical management of the claim. The MCO will provide your CSS with the medical evidence and documentation that will be used if there are questions about coverage throughout the life of the claim.

Notification

Initial Decision

Outcome Management

Claim Outcomes

New Injury

Received By BWC
-Claim Reported
-Acknowledged
-Assigned

Investigation

Issue Recognition
-Jurisdiction
-Coverage
-Compensability
-Extent of Injury
-Extent of Disability
-Subrogation
-Fraud/SIU

Gather Information
-Identify Barriers
-Gather Outstanding Information
-Verify and Compare

Evaluate and Decide
-Weigh Evidence
-Evaluate Evidence
-Make Initial Determination
-Decision is based on spirit and intent of the law

Resolution

Investigation
-Issue Recognition
-Gather Information
-Evaluate
-Decide

Extent of Injury
-Medically Supported
-Causally Related
-Concurrent Factors
-Other Factors

Extent of Disability
-Medically Supported
-Causally Related
-Concurrent Factors
-Other Factors

Dispute Resolution
-Gather Information
-Evaluate and Decide

Finalize

Whole Claim
-Expiration of the Statute of Limitations
-Denial of Claim
-Full/Final Settlement

Issues in a Claim
-Successful Return to Work
-Subrogation Resolved
-Partial Settlement
-Supportive Medical Care
-Resolution of Appeals
-Maximum Medical Improvement