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OhioBWC - Basics:  Claims Process Responsibilities

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Claims Process Responsibilities

BWC is responsible for:

  • Claim determinations and allowances;
  • Paying lost time compensation;
  • Second level of dispute resolution;
  • Educating injured workers, employers and providers about HPP.

MCOs are responsible for:

  • Provider management;
  • Utilization review;
  • First level of dispute resolution;
  • Determining reimbursement eligibility and paying providers for services;
  • Educating injured workers, employers and providers about HPP.

NOTE:HPP will not affect fee bills for marine fund or black lung claims, family caregivers, and BWC/Industrial Commission (IC) examinations. BWC retains responsibility for payment of these services.

Self-insuring employers are responsible for:

  • Authorizing and determining medical necessity;
  • Paying or reviewing fee bills and medical documentation;
  • Authorizing guidelines.

Self-insuring employers may choose to form their own Qualified Health Plans (QHP) to deliver medical services to their employees, however, they are not required to do so.