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Policy and Procedure Name:
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Changing the Employer and/or Policy Number After
Initial Determination
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Policy #:
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CP-03-01
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Code/Rule Reference:
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R.C. 4123.01;
O.A.C.
4123-3-08 and 4123-17-15
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Industrial Commission (IC) Resolution/Memo
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None
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Effective Date:
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12/17/21
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Approved:
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Ann M. Shannon, Chief of Claims Policy and Support
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Origin:
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Operational Policy and Support
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Supersedes:
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Policy # CP-03-01, effective 07/13/15
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History:
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Previous versions of this policy are available upon
request
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Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Alternate Employer Organization (AEO)
AEO Agreement
Assigned Employer
Client Employer
Employer
Professional Employer Organization
(PEO)
PEO Agreement
Policy Number
Potential Employer
Shared Employee
Self-Insuring (SI) Employer
State Fund Employer
IV. POLICY
A. Reasons
for Changing the Employer and/or Policy Number
B. Systematic
Reassignment of a Policy Number
C. Investigation
D. Employer
Reassignment
E. Employer
Reassignment Order
F. IC
Referral
G. Changing
from SI Employer to Another SI Employer
V. PROCEDURE
A. General
Claim Note and Documentation Requirements
B. System
Reassignment of Employer Policies
C. Investigating
Requests to Change EOR
D. Confirming
EOR Change Requests with Supporting Documentation
E. Issuing
the Decision
F. IC
Referral
G. Changing
the Employer from an SF Employer to an SI Employer or SI Employer to SF
Employer
H. Changing
the Employer from an SI Employer to Another SI Employer
I. Changing
the Employer from a Non-Complying Employer
The purpose of this policy is to ensure that BWC determines
the correct employer of record (EOR) and/or policy number for each claim via a
comprehensive investigation when BWC receives information after the initial
determination of the claim suggesting that the EOR and/or policy number
assigned during the initial determination of a claim is incorrect.
This policy applies to BWC claims services staff and employer
services staff.
Alternate Employer Organization
(AEO): A sole proprietor, partnership, association,
limited liability company, or corporation that enters into an agreement with
one or more client employers for purposes of providing human resource
management services and sharing employer responsibility and liability. An AEO
does not include a temporary service agency.
AEO Agreement:
A written contract between a client employer and an AEO to provide human
resource management services and to share employer responsibilities and
liabilities. Upon entering into an AEO agreement, a client employer’s worksite
employees are covered under the AEO’s workers’ compensation policy.
Assigned Employer:
The entity that is designated as the EOR during the initial determination.
Client Employer:
A sole proprietor, partnership, association, limited liability company, or
corporation that enters into a PEO agreement and is assigned shared employees
by the PEO.
Employer:
Includes, but is not limited to, the following, as defined in R.C. 4123.01:
·
The state, including state hospitals, each county, municipal
corporation, township, school district, and hospital owned by a political
subdivision or subdivisions other than the state;
·
Every person, firm, professional employer organization, alternate
employer organization, and private corporation, including any public service
corporation, that: (i) has in service one or more employees or shared employees
regularly in the same business or in or about the same establishment under any
contract of hire, express or implied, oral or written; or (ii) is bound by any
such contract of hire or by any other written contract, to pay into the
insurance fund the premiums as provided by law.
Professional Employer
Organization (PEO): A sole proprietor, partnership,
association, limited liability company, or corporation that enters into an
agreement with one or more client employers for the purpose of co-employing all
or part of the client employer’s workforce at the client employer’s work site.
PEO does not include a temporary service agency.
PEO Agreement:
A written contract to co-employ employees between a PEO and a client employer
with a duration not less than 12 months in accordance with the requirements in
Chapter 4125 of the Ohio Revised Code.
Policy Number:
A term synonymous with "risk number," it is the identification number
that the BWC assigns to an employer.
Potential Employer:
The entity that is likely to be designated as the EOR following an
investigation of the employer and/or policy number after the initial
determination; typically, not the employer assigned to a claim at initial
determination.
Shared Employee:
An individual intended to be assigned to a client employer on a permanent
basis, not as a temporary supplement to the client employer’s workforce, who is
co-employed by a PEO and a client employer pursuant to a PEO agreement.
Self-Insuring (SI) Employer:
Employers who have been granted the privilege by BWC of administering their own
workers’ compensation programs and who pay compensation and benefits directly
to the IW.
State Fund Employer:
Public and private employers who pay premiums for workers’ compensation
coverage.
1. BWC
will change the employer and/or policy number after the initial determination
of a claim when there was an error in employer/policy assignment at initial
determination and there is agreement by the parties.
2. BWC
will also change the employer and/or policy number after the initial
determination of a claim if the Adjudicating Committee or Ohio Industrial
Commission (IC) orders the change.
1. It
is the policy of BWC to systematically reassign the policy number of a claim when
the employer assumes the policy number of another employer (also known as a
“policy combine”).
2. BWC
will also systematically reassign the policy number when a PEO/AEO agreement is
entered into or changed.
1.:
BWC will investigate the assignment of the EOR, including policy number, to
determine if the employer assignment and/or policy number is correct upon
receipt of a written request with supporting documentation to change the
employer.
1. BWC
will issue an order for employer reassignment when:
a. A
written request to change employer assignment is submitted with supporting
evidence;
b. The
IC has not ruled on the issue of who is the correct EOR (i.e., the issue of
correct employer is included in the initial claim determination); and
c. The
assigned employer, potential employer, and BWC agree to the reassignment of a
claim.
: It is the policy of BWC to send a copy of the claim reassignment
order to the parties to the claim and to the MCO to serve as notice that the
assigned employer is being corrected and the claim in question will not be
designated to the employer assigned to the claim during initial determination.
1.:
It is BWC’s policy to refer an employer assignment issue to the IC by Notice of
Referral (NOR) when:
1. The
assigned employer contests assignment of the claim in writing and with
supporting evidence, but the potential employer objects to assignment of the
claim;
2. The
assigned employer disputes assignment of a claim in writing and with supporting
evidence after the claim has gone to a hearing;
3. The
IC has already ruled on the issue of who is the correct EOR; or
4. BWC
does not agree with the request for change.
1.:
It is BWC’s policy to change an employer from an SI employer to another SI
employer when:
1. A
request is submitted in writing with supporting documentation;
2. BWC
agrees to the change; and
3. The
employers agree to the change.
1. BWC
staff will refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Must
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. PEO
Agreements
a. When
an employer hires a SF PEO:
i.
The lease agreement is established, all applicable claims are
systematically reassigned either on January 1st or July 1st to the SF PEO in
Rates & Payment and then interfaced to the claims management system.
ii. A
note is placed in each claim when this change occurs. The note looks similar to
this, “##/##/#### 00:00AM/PM, BATCH, PEO agreement effective ####-##-## moved
claim 00-000000 from client ######## to PEO ########, Username A#.
b. Employer
Ends Contract with SF PEO
i.
When the lease is terminated, all applicable claims are systematically
reassigned to the client employer in BWC Rates and Payments and then interfaced
to the claims management system.
ii. A
note is placed in each claim when this change occurs.
c. When
an employer hires a SI PEO:
i.
Existing claims assigned to the client employer remain assigned to the
client employer and are not reassigned to the SI PEO when a lease agreement is
established.
ii. Any
claims filed with the date of injury (DOI) on or after the date of the lease
agreement are assigned to the SI PEO.
d. Employer
Ends Contract with SI PEO: When the lease is terminated, all claims that were
assigned to the SI PEO during the lease agreement remain permanently assigned
to the SI PEO.
2. Combine
Policy
a. When
a combine occurs the predecessor policy number systematically changes to the
successor policy number in existing determined claim(s).
b. A
systematic note is dropped into the claim when the reassignment occurs. The
note will look similar to this: “Claim ##-###### was transferred when Policy
######## was combined into Policy ######## effective 2021-02-01. Please do not
change the policy number as it may affect policy rates. If more information is
needed, please call ###-###-####. Username A#.”
1. If
the employer assignment of the claim is contested, claims services staff must
ensure the party filing the dispute has submitted the issue in writing with
supporting documentation. Requests to reassign the employer in a claim from
internal BWC staff must also include a:
a. Thorough
explanation to support the change; and
b. Explanation
as to where documentation to support the change can be found.
2. If a
party verbally notifies BWC that the party is disputing employer assignment,
claims services staff will inform the party that they must submit the dispute
in writing, and may submit a Motion (C-86) or
Request to Correct Employer and/or Policy Number Assignment (C-264).
Upon request, claims services staff will send a C-264 to the party filing the
dispute.
3. When
a dispute of employer assignment is submitted in writing with supporting
documentation, claims services staff may use one or more of the following
methods to investigate and determine correct employer information, including
policy number:
a. Call
the injured worker (IW) or assigned employer and request evidence (e.g., W-2,
temporary employer information (if applicable), paystub for the date of injury
(DOI) that includes the employer’s federal identification number automated on
it) to help identify the correct employer;
b. Contact
the provider’s office who initially filed the claim for the name of the
employer;
c. Perform
a look up by name and Social Security Number for the IW on the claims
management system to determine if there is a duplicate claim or previous claim
that may list the correct employer information.
i.
If an existing duplicate claim is found, claims services staff will
combine the claims.
ii. Refer
to the Duplicate
Claims policy and procedure for more information.
d. Investigate
the employer in BWC’s employer management system. Use the employer management
system for the following:
i.
To search for an employer’s policy number;
ii. To
perform a “doing business as” search;
iii. To determine if
a policy number has been combined into another policy number; and
iv. To
determine if an employer has entered into a PEO agreement.
e. Investigate
online;
f.
Investigate the claims documents, including hospital information, to
determine if employer information has been included in any of them;
g. Staff
the issue with applicable Employer Services staff;
h. Run
the Employer-Locator query from data warehouse to assist in locating the
correct employer policy number; and/or
i.
Utilize the “Employer of Record Investigation Checklist” to
summarize information gathered.
j.
Claims services staff may also refer to the Employer
of Record Change policy.
4. Claims
services staff will refer to the steps outlined in the Coverage
and Employer/Employee Status policy and procedures, and email BWC Policy Processing when claims
services staff:
a. Can
determine the correct employer, but the employer has no policy number or
coverage; or
b. Determines
that the place holder policy was not needed because the correct policy number
has been identified.
5. When
the assigned employer contests assignment of the claim in writing, but does not
submit supporting documentation, claims services staff must:
a. Contact
the assigned employer by phone and notify them that supporting documentation is
required to consider the issue of correct employer. The assigned employer has
three calendar days from the date of the call to submit evidence.
b. If
the assigned employer cannot be contacted by phone:
i.
Send a “Changing the Employer and/or Policy Number – Supporting
Documentation Needed Letter” located on COR to the assigned employer as
notification that supporting documentation is required for BWC to consider the
issue of correct employer.
ii. The
assigned employer has seven calendar days (plus four, per mailbox rule) to
respond from the mailing date of the letter to submit evidence.
c. If
no supporting documentation is submitted timely, send the “Dismissal Letter” to
the assigned employer as notification that BWC is terminating investigation of
the issue due to a lack of evidence.
1. For
a written change of employer request from a party to a claim, claims services
staff will review the matter with an Employer Services staff member and an
Injury Management Supervisor (IMS) or Medical Claims Specialist Supervisor
(MCSS) to verify that the information obtained is accurate and the requested
change is appropriate.
2. For
requests to reassign the employer in a claim from internal BWC staff, claims
services staff must review the matter with an IMS to verify that thorough
explanation for the change has been provided and documentation, if necessary,
is available for the claim file.
3. If,
after review, all necessary BWC staff agree with the request for change of
employer, claims services staff will contact the local claims director or
designee for review and approval.
4. When
the change of employer is approved by the claims
director or designee, claims services staff will contact the potential
employer and send a State Fund Employer’s Agreement to Accept Claim
Assignment (C-263) to obtain written agreement to accept the claim.
a. If
the potential employer agrees, claims services staff will issue a BWC Order, in
accordance with Section V.E. of this procedure.
b. If
the potential employer cannot be located or does not agree to accept the claim,
claims services staff will send the issue to the IC, in accordance with Section
V.F. of this procedure.
5. If
BWC staff do not agree with the request for change of employer, claims services
staff will send the issue to the IC, in accordance with Section V.F. of this
procedure.
1. Claims
services staff will issue an employer reassignment order to change the employer
and/or policy number when:
a. The
request to change the assigned employer of the claim is in writing with
supporting documentation;
b. The
change has been approved by the claims director and/or designee;
c. Both
employers have agreed to change the employer and policy number;
d. The
IC has not ruled on the issue of who is correct EOR (i.e., the issue of correct
employer is included in the initial claim determination).
2. When
claims services staff issues an employer reassignment order to correct the
assigned employer and/or policy number, they will note the agreement from both
employers in the order.
3. The
original allowance order is not vacated when the employer reassignment order is
issued. They employer reassignment order only addresses the correction and
agreement of the employer assignment of the claim.
4. Claims
services staff will send a copy of the employer reassignment order to serve as
notice that the employer assigned to the claim during initial determination is
being corrected and the claim in question will not be assigned to that employer
to the following entities:
a. The
IW;
b. The
correct employer;
c. The
employer assigned to the claim during initial determination;
d. The
managed care organization (MCO) for the employer assigned to the claim during
initial determination; and
e. Any
authorized representative(s) for the above-named parties, including any
authorized representative(s) for the employer assigned to the claim during
initial determination, as listed in BWC’s initial determination order.
5. To
serve proper notice of the employer reassignment, claims services staff must
add the correct employer as a customer recipient to the subsequent order.
6. Claims
services staff will not send notice to the MCO when the employer is changing
from an SI employer to an SF employer. Changing a claim from SI to SF in the
claims management system will automatically result in MCO assignment and
generate notice to the MCO.
7. Claims
services staff will update the claims management system with the change of employer
information after the decision is final.
1. Claims
services staff will refer the issue to the IC when:
a. A
request to change the employer and policy number is submitted in writing with
supporting documentation, but both employers do not agree to the change;
b. The
IC has already ruled on the initial claim determination/correct employer (i.e.,
the issue of correct employer is included in the initial claim determination);
or
c. BWC
does not support the request for change.
2. When
completing the NOR, claims services staff must indicate that the requested
action is to change the employer, not to change the policy number. The IC will
not hear issues regarding change of policy number.
1. When
claims services staff receives a written request with supporting documentation
to change the employer in a claim assigned to an SF employer to an SI employer
or a claim assigned to an SI employer to an SF employer, claims services staff will
investigate the change of employer to determine if the change is appropriate
pursuant to Section V.C. above.
2. After
investigation, claims services staff will email
the SI Department to request a recommendation on the appropriateness of the
request to change the employer.
3. To
determine whether the change of employer is appropriate, the SI Department will:
a. Contact
the potential employer in writing to notify them that the claim may be assigned
to the potential employer and request a written response for the claim;
b. Provide
the potential employer an opportunity to address whether reassignment of the
claim is appropriate;
c. Send
the written response to the imaging queue to serve as supporting documentation
to change the employer; and
d. Notify
claims services staff by email regarding whether the employers agree with the
change of employer and if the change of employer is the recommended course of
action.
4. If
the SI Department recommends the requested change of employer, claims services
staff will contact the local claims director or designee for review and
approval.
5. If
the change of employer is approved by the claims director or designee, claims
services staff will issue an employer reassignment order to change the
employer, in accordance with Section V.E. of this procedure. When changing from an SF employer to an SI employer,
claims services staff will issue the order notifying all parties of the change
of employer before assigning the claim to the SI employer in the claims
management system.
6. Claims
services staff will refer the issue to the IC in accordance with Section V.F.
of this procedure when:
a. The
employers do not agree to the change of employer following discussion of the
issue with BWC’s SI Department; or
b. BWC
staff determines that the change of employer is not appropriate.
7. When
the decision to change the employer is final, claims services staff will:
a. Coordinate
with the SI Department, Medical Billing and Adjustments (MB&A), and/or
Pharmacy staff to determine any necessary adjustments for medical and pharmacy
bill payments; and
b. Send
an email to Rate Adjustment
Department to ensure appropriate adjustments to reserves when BWC has paid
compensation and the claim is subsequently changed to an SI employer.
8. Reimbursements
a. When
an SI claim subsequently changes to SF, claims services staff will:
i.
Reimburse the SI employer using a miscellaneous payment if compensation
was paid by the SI employer;
ii. Enter
a period(s) of miscellaneous ineligibility in the claims management system for
compensation paid by the SI employer to prevent BWC from paying compensation
over the same period(s);
iii. Enter salary
continuation payment(s) into the claims management system for temporary total
compensation (TT) paid by the SI employer to ensure the SI employer’s TT
payment(s) is counted toward the first 12 weeks of TT; and
iv. Accept
copies of check stubs showing compensation paid, or other documentation
verifying compensation paid in the claim.
b. The
SI Department will obtain documentation of medical payments from the SI
employer for MB&A to reimburse the SI employer.
c. When
a SF claim subsequently changes to SI, the SI Department will notify and
coordinate reimbursements from the SI employer.
1. When
claims services staff receives a request from a
single SI employer with multiple locations to change the location only of the
claim, claims services staff may update the claims management system as
requested.
2. When
a C-262 has been submitted, the claims services staff may update the claims
management system as requested.
3. For
all other SI to SI change of employer requests:
a. Claims
services staff will:
i.
Investigate the change of employer to determine if the change is
appropriate pursuant to Section V.C. above; and
ii. Email the issue to the SI Department to
request a recommendation on the appropriateness of the request to change the
employer.
b. The
SI Department will notify claims services staff by email regarding whether the
employers agree with the change of employer and if the change of employer is
the recommended course of action.
c. If
the SI Department recommends the requested change of employer, claims services
staff will contact the local claims director or designee for review and
approval.
d. If
the change of employer is approved by the claims director or designee, claims
services staff will update the claims management system with the change of
employer information.
e. If
both employers do not agree to the written request for a change of employer,
claims services staff will refer the issue to the IC. If there is no written
request for change of employer, it is the responsibility of the SI employer who
requested the change to file a C-86.
1. Once
the decision to change the employer from a non-complying employer (i.e.
employer without coverage on the date of injury) to another employer is final,
claims services staff will email BWC
Policy Processing to address any billing issues for the employers.
2. When
changing from a non-complying employer to another employer with coverage, the
email must include the following message with the applicable information
inserted: “Claim number XX-XXXXX was previously assigned to policy number AAA,
a non-complying employer on the DOI. The claim is now assigned to policy number
BBB, a covered employer. Please review policy number AAA for non-compliance
claim billings and void the billings accordingly.”
3. When
changing from a non-complying employer to another non-complying employer, the
email must include the following message with the applicable information
inserted: “Claim number XX-XXXXX was previously assigned to policy number CCC,
a non-complying employer on the DOI. The claim is now assigned to policy number
DDD, also a non-complying employer. Please review policy number CCC for
non-compliance claim billings and void the billings accordingly.”