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Policy and Procedure Name:
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Initial Claim Determination
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Policy #:
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CP-9-01
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Code/Rule Reference:
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R.C. 4123.511, 4123.84; O.A.C. 4123-3-08, 4123-3-36
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Industrial Commission (IC) Resolution/Memo
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None
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Effective Date:
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10/4/2024
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Approved:
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Shawn Crosby, Chief Operating Officer
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Origin:
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Operational Policy and Support
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Supersedes:
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Policy # CP-9-01, effective 09/28/21
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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
Auto Claims Processing (ACP)
Fast Response
Lost Time (LT) Claim
LT Indicators
Medical (MO) Claim
National Council on Compensation
Insurance (NCCI)
Placeholder Policy
Quote number
Salary Continuation (SC)
Terminating Rules
Triage
IV. POLICY
A. Claim
Filing
B. Claim
Assignment and Reassignment
C. Initial
Claim Review and Research
D. Date
of Injury
E. Employer
Certification and Retention of Appeal Rights
F. Claim
Determination and Issuing an Order
G. Dismissal
of a FROI
H. Reconsideration
of a Previously Denied Claim- Greene Case
V. PROCEDURE
A. General
Claim Note and Documentation Requirements
B. Systematic
Claim Review and Evaluation
C. Initial
Claim Review and Investigation of Claims Not Eligible for ACP
D. Claim
Determination
E. Reconsidering
a Previously Denied Claim (Greene Case)
The purpose of this policy is to ensure the Ohio Bureau of
Workers’ Compensation (BWC) processes initial claim applications in compliance
with R.C. 4123.511.
This policy applies to BWC claims services staff.
Auto Claims Processing (ACP):
The systematic evaluation and determination of low risk claims with little or
no human intervention. Claims systematically pass through established business
rules that either allow the claim to be accepted with no human intervention or
may prevent claims from completing the process and require claims services
staff to conduct further investigation. Terminating rules will prevent claims
from being allowed via ACP.
Fast Response:
A program established to immediately allow specific medical conditions with low
treatment costs that have a record of being allowed when included in a claim.
Claims in the program are filed for medical treatment only, include only one
diagnosis code/condition, and are from state-fund, private employers and taxing
district public employers who have access to the Surplus Fund.
Lost Time (LT) Claim:
A claim is considered lost time when:
·
There are eight or more days of lost time from work directly
caused by a work-related injury; or
·
BWC awards compensation, even if the IW did not miss eight or
more days of work.
LT Indicators:
One type of terminating rule that presupposes an IW will, or could, miss eight
or more days of work.
Medical (MO) Claim:
A claim is considered medical only when:
·
There are seven or fewer days of lost time from work directly caused
by a work-related injury; or
·
BWC does not award compensation.
National Council on Compensation
Insurance (NCCI): An organization that gathers data,
analyzes trends, and provides objective insurance rate and loss cost
recommendations for the workers’ compensation industry. BWC uses NCCI’s
classification system, however, BWC develops its own rates.
Placeholder Policy:
An employer policy number that is created when an alleged employer has never
established a policy with BWC, BWC no longer has a record of the policy number,
or the policy is in a cancelled status and the date of injury occurred after
the policy was cancelled.
Quote number:
A temporary number used for tracking purposes in the claims management system
when an employer files an Application for Ohio Workers’ Compensation Coverage
(U-3).
Salary Continuation (SC):
Regular full wages paid to the IW by the EOR. This includes any kind of paid
leave (e.g., sick leave, paid time off, occupational injury leave (OIL), etc.).
Terminating Rules:
Any systematic red flag that assumes a claim will, or could, be a LT claim.
Triage:
Systematic Triage: The systematic review of all claims that evaluates
the severity of a claim as identified by International Classification of
Diseases (ICD) codes. The review includes indications of lost time, benefit
applications and/or claim accident/illness type, and assigns those claims not
allowed by ACP to the appropriate claims team for determination.
Claims Triage: The transfer of a claim to either a specialty team
or a particular discipline within claims services (e.g., Intake, Return to
Work, Remain at Work) based upon the severity of the condition or where the
claim falls in the life cycle.
1. It
is the policy of BWC to process claims that are filed:
a. Via
BWC online;
b. By
BWC phone call to the contact center;
c. Electronically
by the MCO; or
d. Via
the application processing unit at BWC upon receipt of a First Report of Injury,
Occupational Disease, or Death (FROI).
2. BWC
employees are prohibited from filing any claim on behalf of the IW or IW’s
family unless the IW or IW’s family expressly requests BWC file on their
behalf.
1. Upon
receipt, BWC will assign a claim number to each initial application for
benefits and will provide the claim number to the claimant and employer.
2. BWC
will use ACP until claim determination is complete, unless one of the
terminating rules removes it and redirects the claim to the appropriate claims
team for processing.
3. BWC
will assign the claim to the appropriate claims team or specialized unit.
Claims will be assigned to a specific team based on:
a. Benefit
type (medical only or lost time);
b. Accident
type (e.g., injury, death);
c. Severity
of injury (catastrophic);
d. Multiple
claim event; or
e. Requested
condition.
1. BWC
will complete a systematic evaluation of every claim entered into the claims
management system to determine if the claim is eligible to be considered for
immediate determination.
2. Claims
that meet all of the required eligibility rules will be immediately determined.
3. Claims
that may meet the eligibility requirements will continue to be systematically
reviewed for three days before being assigned to claims services staff.
4. Claims
that fail to meet the eligibility requirements are assigned to claims services
staff for review and processing.
5. Claims
services staff will review all documentation, claim notes, and demographic
information in the claims management system.
6. It
is the policy of BWC to pursue missing evidence to support decisions made in
the claim.
1. The
date of injury assigned to a claim is the date the injury occurred, regardless
of when the IW’s shift began or ended.
2. Occupational
Disease (OD) claims are assigned a date of disease, not a date of injury (DOI).
See Occupational
Disease policy and procedure for additional information.
1. It
is the policy of BWC to attempt to obtain certification or rejection of the
claim from the employer.
a. When
the claim is certified, the employer has only acknowledged that the IW’s
work-related injury occurred.
b. An
employer’s certification of a claim does not automatically mean that BWC will
allow the claim.
2. Certification
may be written or verbal.
a. State
fund and public employers can only certify or reject the claim.
b. Self-insured
employers can certify, reject, or clarify their certification.
3. Only
a sole proprietor who has elected coverage for themselves can certify their own
claim.
4. Employers
who have certified the claim retain the right to appeal a decision.
1. BWC
must issue the most complete order:
a. No
later than 28 calendar days after BWC received notice of the claim and provides
notification to the injured worker and employer; or
b. No
more than 28 calendar days after the receipt of the report for a medical
examination in OD claims in which examination is required by statute.
2. At a
minimum, the order must contain the:
a. Description
of the condition or conditions for which the claim is being allowed and parts
of body affected; and
b. Basis
of the decision.
1. BWC
will dismiss a claim prior to issuance of a BWC Initial Allowance Order or
during the appeal period when an IW/IW representative requests dismissal of a
claim either verbally or in writing.
2. BWC
may dismiss a claim at any time during the 28-day determination period when:
a. The
investigation of the claim is complete, the claim allowance is not supported,
and there is no signed FROI on file;
b. No
medical documentation was available;
c. An
employer is an elective coverage person that did not elect coverage for
themselves;
d. An
employer cannot be identified after a thorough investigation; or
e. It
is requested by the IW/IW representative.
3. BWC
will not dismiss an initial claim application if the appeal period has expired.
Requests to dismiss after the appeal period has expired must be referred to the
IC for hearing.
4. Once
a claim is dismissed, BWC can take no further action in the claim, except
updating claim notes, unless a party re-files the claim application.
5. The
dismissal and subsequent re-filing of a claim application will not change the
statute of limitations for filing the claim.
1. It
is the policy of BWC to reconsider a previously denied claim if the original
claim was denied due to a lack of specific information that was requested, but
never received.
2. BWC
will only reconsider the claim if the missing information has been submitted
with the IW’s intent, in writing, for BWC to reconsider the claim within the
statute of limitations.
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. Upon
receipt, all claims filed are systematically evaluated to determine if they can
potentially be allowed by automated processing. If the claim does not meet the
ACP eligibility rules:
a. The claims
management system will generate a “new claim-ineligible for ACP” work item;
b. The claim
will be assigned to the appropriate team (e.g. medical only, lost time, special
claims); and
c. Claims
services staff from the appropriate team will process the claim per sections
V.C. and V.D. below.
2. All
claims that potentially meet ACP eligibility rules will be systematically
evaluated for determination.
a. If,
upon initial evaluation, the claim meets all required ACP eligibility rules,
the claims management system generates an Initial Allowance Order.
i.
If the claim meets the fast response requirements, both the claim and
ICD statuses will be updated to accepted.
ii. If
the claim is certified by the employer, both the claim and ICD statuses are
updated to accepted.
iii. If the claim is
not certified by the employer, the claim status is updated to accepted, but the
ICD status is placed in accepted/appeal. The ICD status will remain in
accepted/appeal and will be updated to:
a) Accepted
status at the end of the appeal period; or
b) Hearing
status if an appeal is filed.
b. Claims
that do not initially meet all of the required ACP eligibility rules will
continue to be systematically evaluated for three days. During the three days:
i.
If information is received that causes the claim to be ineligible for
the ACP process, the claim is automatically reassigned to the appropriate area
for manual processing (e.g., information is received that indicates the claim
is lost time).
ii. If
information is received that causes the claim to meet all of the required ACP
eligibility rules, the claims management system will generate an allowance
order and assign the claim to the ACP group. See V.B.3.a.i-iii above for
further status update information.
c. If
additional information is still needed to determine if the claim meets the ACP
eligibility rules, the claim will be assigned to claims services staff for
processing. Claims services staff will receive a “new claim pending ACP” work
item.
i.
Within two business days of receipt of the work item, claims services
staff must review and verify all available information has been entered into
the claims management system correctly.
a) Claims
services staff must ensure the claim is assigned an appropriate ICD code(s), in
accordance with the narrative description of the injury or disease.
b) If the
information is available in claim documents or notes, claims services staff
will enter or correct it in the claims management system and:
i)
Allow the claim to go through ACP; or
ii) Pull
the claim from the ACP process if the claim does not meet the ACP criteria.
c) If
the information is not available, claims services staff will contact the
managed care organization (MCO) for medical documentation (e.g., supporting
documentation, statement of causality) or the appropriate party to obtain the
missing evidence.
d) If, after
three calendar days, the information is still not available, claims services
staff will make one more attempt to obtain it.
e) After
14 calendar days, the system will generate a “no claim decision” work item if
the claim is still undetermined. Claims services staff will continue to
investigate the claim and the claims management system will continue to
evaluate the claim using ACP eligibility rules.
3. Fast
Response Claims
a. When
the diagnosis code is one that can be allowed through fast response, but the
claim does not meet ACP eligibility criteria, claims services staff must:
i.
Verify all other compensability tests under Section V.C.2. below;
ii. Update
all available claim information in the claims management system;
iii. Enter a claim
note to indicate a fast response claim;
iv. Issue a
BWC order;
v. Immediately
update the claim and ICD statuses to accepted in the claims management system;
and
vi. Place the
claim in hearing status if an appeal is filed to the BWC order.
b. See
Appendix A to OAC 4123-3-36 for a list of acceptable codes.
1. Claims
services staff will review the claim in totality to determine what information
has already been received and what additional information is necessary for
claim processing. The medical claims specialist (MCS)/claims services
specialist (CSS) must:
a. Review
and confirm demographics submitted with the claim, FROI, job description, MCO and
other notes, mechanism of injury, date of injury and compare the medical
documentation on file to what the Medical Evidence for Diagnosis Determination
(MEDD) guidelines or other medical evidence resources (e.g., WebMD) state
should be present to make an appropriate determination.
i.
If medical documentation (e.g., supporting documentation, statement of
causality) or clarification of medical information is required, claims services
staff must contact the MCO to request the specific information needed.
ii. If
the MCO does not respond to the request after three business days, claims
services staff must make a second request for the information.
iii. If the MCO fails
to respond to the second request, claims services staff must report the issue
to their supervisor. The BWC supervisor must call the MCO supervisor to discuss
the issue.
iv. Claims
services staff must contact the MCO after three days if additional information
is needed to make the claim determination but will not contact the MCO solely
to validate the information in claim notes. Claims services staff may only
contact the MCO to confirm validation of an MCO note when conflicting
information is on file or received.
v. Claims
services staff will e-mail the BWC MCO Business Unit
Referral box for assistance when:
a) The
BWC supervisor and MCO supervisor have discussed the issue and the MCO fails to
provide the required data elements and/or necessary medical documentation to
make a determination on the claim and fails to establish good cause for
failure; or
b) The MCO
has shown a pattern of not providing the required data elements or obtaining
the required documentation.
b. Confirm
the IW’s social security (SSN) is entered into the claims management system
correctly and there are no duplicate claims or customer records by searching
the customer’s name and address.
i.
When a new application has been entered, the claims management system
will identify if there are any possible duplicate claims.
ii. If
an IW does not have an SSN or visa number, claims services staff will check the
“Tax ID unavailable” box in the claims management system so that compensation
may be released to the IW when appropriate.
c. Verify
that the employer policy number listed in the claims management system matches
the employer information documented in the file and that the evidence supports
there is an employee/employer relationship.
i.
If the employer identity and an employer/employee relationship has not
been verified, claims services staff will:
a) Gather
additional information from the IW; and
b) Staff with
a supervisor and legal, if necessary.
ii. If
the employer identity and an employer/employee relationship has been verified,
claims services staff will:
a) Confirm
that the employer has active coverage;
b) Check that
the NCCI code in the claims management system matches the job description; and
c) Identify
the correct employer policy number by completing a thorough investigation and
documenting in claim notes all attempts to locate the correct identifier.
i)
If, after investigation the policy number cannot be identified, the CSS
will initiate an EM Referral using the EM Referral Tracker and copy their team
leader.
ii) The
referral will be assigned to the Employer Compliance Department (ECD) for
further review by inserting ECD Rush in the EM Referral Office field of the
referral.
iii) If the correct
policy number is identified, ECD will notify the CSS by e-mail and the referral
will be complete.
iv) If the correct
policy number is not identified, ECD will create a quote number in the claims
management system.
v) ECD
will e-mail the quote number to the BWC RTS Manual Classification Unit and
request the quote number be transitioned to a placeholder policy number. ECD
will copy the CSS on the e-mail.
vi) The BWC RTS
Manual Classification Unit will transition the quote to a placeholder policy
number and notify the CSS and ECD via e-mail upon completion of the process.
vii) If the correct policy number
is not identified and a placeholder policy is not appropriate, the claim should
be staffed with a supervisor and dismissed against a no insured found risk.
d. If
the employer recently applied for coverage, the claims management system may
show a quote number for the employer. A search can be conducted in the claims
management system similar to a search for a claim.
e. Verify
each element of jurisdiction, coverage, and compensability by investigating all
facts of the accident. Staff must ensure that:
i.
The claim is within Ohio’s jurisdiction;
ii. The
claim was timely filed;
iii. An
employer/employee relationship exists;
iv. The injury
must have been accidental (unexpected);
v. The
accident/injury occurred while in the course of and arising out of employment;
vi. Review the
evidence for possible coverage issues (e.g., trucking industry owner/operator
issue, subcontractors with no coverage, construction, etc.); and
vii. Staff with a supervisor
and legal, if necessary.
f.
Review the claim for subrogation and determine if a referral should be
made to the subrogation unit. See Subrogation
policy and procedure for additional information.
g. Determine
if a referral to EM is needed. If a referral is:
i.
Appropriate, send the referral through the existing tracker and enter a
corresponding note in the claims management system.
ii. Not
appropriate, the CSS should enter a note with the reason why.
h. Ensure
the claim is assigned the appropriate ICD code(s), in accordance with the
narrative description of the injury or disease.
i.
Request modification of the narrative description, if necessary, and
ii. Wait
to create the order until the narrative modification is complete.
2. Claims
services staff will make initial contacts to all parties within three business days
of the assignment of the claim, regardless of whether the claim is lost time or
medical only.
a. The
CSS must make the contact by phone unless an employer has specifically
requested contact be made via e-mail.
b. The
MCS will make contact via letter, however, the MCS is expected to make a
contact by phone when necessary.
c. During
these contacts, claims services staff will:
i.
Complete the 3-point contact questions in the claims management system;
ii. Request
new or missing information that is necessary for determination of the claim;
iii. Set expectations
for IWs and employers during the claim process; and
iv. If
necessary, leave a detailed message asking the customer to return the call and
leave a call back number.
d. Claims
services staff must enter a detailed note in the claims management system after
each contact or attempt at contact with any party to the claim.
3. When
contacting the employer, the CSS must:
a. Verify
the IW is their employee;
b. Verify
the policy number and NCCI classification code or job description;
c. Verify
the accident description and request claim certification or rejection. If the
CSS is unable to obtain this over the phone and the information has not already
been secured by the MCO, the CSS must send the Employer Certification
Request letter;
d. Request
any missing information;
e. Ask
if the employer intends to pay salary continuation or pay disability payments.
See Salary
Continuation policy and procedure for additional information.
f.
Discuss availability of modified/light duty work; and
g. Request
the IW’s wages for the 52 weeks prior to the DOI. Refer to the Wages
policy and procedure for additional information.
4. When
contacting the IW, the CSS must:
a. Clarify
all conflicting demographic information (e.g., date of birth, SSN, address,
etc.);
b. Verify
conflicting accident description and parts of body injured;
c. Verify
name and address of the employer, if information on file needs to be clarified;
d. Request
that the IW provide a verbal description of their job duties in order to aid in
selection of the correct NCCI classification code, if necessary;
e. Explain
what specific evidence the IW needs to provide in order for BWC to determine
the claim;
f.
Make the IW aware of any missing medical documentation BWC has requested
the MCO obtain from the treating physician;
g. Request
wages for all employers for the 52 weeks prior to the DOI. See Wages
policy and procedure for additional information.
h. Confirm
whether or not the IW is working anywhere (e.g., a second job);
i.
Verify if the IW is receiving any type of wage replacement from another
source (e.g., SSR, salary continuation, disability, etc.);
j.
Discuss return to work goals and expectations (e.g., participating in
light/modified duty work, if available); and
k. Review
the Better You Better Ohio program.
1. Claims
services staff must review the FROI, MCO & BWC claim notes, MEDD guidelines,
and all available documentation to make a determination on the requested
condition(s).
a. Claims
services staff must follow the
ICD Modification policy and procedure if any condition(s) cannot be
accurately coded or if clarification is necessary.
b. When
claims services staff is otherwise unable to obtain the correct International
Classification of Diseases (ICD) code, they may use the encoder, or the online ICD-10
look up and enter the ICD code in the diagnosis window in the claims management
system.
c. Claims
services staff must attempt to obtain all medical documentation including exam
results or diagnostic test(s) and a statement of causality from the MCO prior
to sending the issue for medical review.
i.
Claims services staff must send the claim to the MSS for medical review
if:
a) The
claim falls outside the MEDD guidelines; or
b) Claims
services staff is unable to interpret the medical documentation or determine
the accuracy of the requested condition(s).
ii.
A condition(s) listed on an unsigned FROI or in the claim file must have
supporting medical documentation and a statement of causality for the condition(s)
on file prior to sending the claim to the MSS for medical review. The
condition(s) will not be sent for physician file review if supporting medical
documentation and a statement of causality for the condition(s) is not on file.
d. If
all jurisdiction, coverage, and compensability elements are met and the claim
appears to be non-controversial, but the only diagnosis provided is a symptom,
claims services staff may refer the claim to the MSS for medical review once
all attempts to secure a condition has been exhausted.
e. If
necessary, the MSS will obtain a physician file review or schedule an
independent medical exam, but an exam does not extend the 28-day time frame to
issue a decision as required by law, except for OD claims that statutorily require
an exam prior to determination. Claims services staff must refer to the Occupational
Disease Claims policy and procedure for additional information.
f.
The MSS will enter notes in the claims management system detailing the
findings of the physician reviewer and listing the documentation used to form
that opinion.
g. Claims
services staff must address all conditions listed on the FROI signed by the IW.
If a condition(s) listed on the FROI signed by the IW cannot be allowed or
denied, claims services staff must:
i.
Explain in the add text section of the order if additional documentation
is needed to make a determination; or
ii. Indicate
that the requested condition(s) cannot be allowed or denied under BWC
guidelines.
h. Claims
services staff must deny the claim when only one condition that cannot be
allowed is listed on the signed FROI and there is not another condition(s)
within the supporting medical that can be allowed.
i.
Claims services staff must deny the claim for the no injury code A00.00
when there are no codes listed on a signed FROI and there is not another
condition(s) within the supporting medical that can be allowed.
j.
For the initial determination only, claims services staff may allow a
condition(s) that is identified in medical documentation but not specifically
requested by the IW. Staff will not deny a condition(s) not specifically
requested.
k. If
an additional allowance(s) has been requested on a properly signed C-86 and BWC
has not published an initial claim decision yet, claims services staff must
include the newly requested allowance(s) in the initial decision, even though
it is not listed on the FROI because the C-86 is a formal request.
l.
If an additional allowance(s) has been recommended on a C-9 and BWC has
not published an initial claim decision yet, the condition(s) is treated as a
condition(s) found in the medical evidence (e.g., the condition(s) can be
allowed, but cannot be denied because it was not requested by the IW). C-9
recommendations received prior to initial determination are not treated as an
additional allowance request.
m. If a subsequently
requested condition(s) is filed during the appeal period of the initial
decision, claims services staff will pend the request. Claims services staff must
refer to the Additional
Allowance policy and procedure.
n. Claims
services staff must issue a BWC order to accept or deny the claim based on the
claim investigation and the evidence in the file. Claims services staff will
note in the add text section of the BWC order the documentation and rationale
used to make the claim determination.
i.
If a FROI is not signed by the IW, the claim may be allowed, but staff
cannot deny a claim solely because the FROI is not signed. If the claim would
be denied and a signed FROI is not on file at the end of the 28-day
determination period and cannot be obtained, claims services staff must dismiss
the claim by miscellaneous order.
ii. Claims
services staff may allow a claim for a minor injury without supporting medical
documentation if the injury is “self-evident” or a “common knowledge” injury.
a) Self-evident
or common knowledge injury examples include, but are not limited to:
i)
First degree burns to less than 10% of the body;
ii) Superficial
lacerations (e.g., cut, open wound);
iii) Superficial
contusions (e.g., bruise, hematoma);
iv) Insect stings;
v) Minor
animal or human bites;
vi) Superficial
foreign body in the eye;
vii) Corneal abrasions;
viii)
Conjunctivitis (also known as pink eye);
ix) Dermatitis;
x) Blisters;
and
xi) Superficial
injury/abrasion.
b) The claim
is compensable even if the injured worker did not seek treatment for the
injury.
i)
When allowing a claim, claims services staff must update the claim to an
allowed status when the appeal period has expired, and no appeal has been
filed. Benefits are then payable, and the claims management system will update
the claim status. For additional information regarding the appeal period, refer
to the Mailbox
Rule policy and procedure.
ii) When
denying a claim, claims services staff must update the claim to a denied status
when the appeal period has expired, and no appeal has been filed. For
additional information regarding the appeal period, refer to the Mailbox
Rule policy and procedure.
iii) If the IW or
employer appeals the BWC order during the appeal period, claims services staff must
check that the appeal was filed with the IC and place the claim in hearing status,
so no benefits are paid.
iv) If an appeal is
filed after the appeal period expires, claims services staff must refer the
claim to the IC and keep the claim in the determined status so benefits will
continue. Once the notice of hearing is received, the claim status must be
updated to hearing.
o. A
modified BWC initial allowance order must be sent if the correct employer
information is discovered prior to expiration of the initial appeal as long as
no appeal has been filed.
2. If
claim dismissal is appropriate, claims services staff must:
a. Update
all ICD codes in the claims management system to dismissed before the miscellaneous
order is created;
b. Issue
a miscellaneous order, if BWC dismisses the claim application before an initial
determination order has been issued or within the appeal period of the initial
determination order; and
c. Include
the following language in the order: “The required
evidence to determine if this is a compensable claim was not received. Should a
signed FROI be filed, additional information may be requested, and a full
investigation will be completed to determine the claim’s compensability. Please
reach out to your assigned CSS to see what information is needed.”
d. Complete any correspondence before updating the claim
status.
e. Update the claim status to expired occurrence and choose
the claim status reason of dismissed.
f.
Once a claim is dismissed, claims services
staff can take no further action in the claim, except updating claim notes,
until the claim is re-filed.
g. When the IW requests dismissal of the claim after
expiration of the initial determination appeal period and the claim is in a
final accepted or denied status, claims services staff must:
i.
Refer the claim to the IC; and
ii. Place Stop Payment type of indemnity on the claim to
prevent any indemnity payments from being issued.
1. Upon
receipt of an IW’s written request to have their previously denied claim
reconsidered:
a. Claims
services staff will ensure that:
i.
The request is submitted via a:
a) Motion
(C-86) with or without a new claim application;
b) New claim
application; or
c) Copy
of the original claim application with written documentation of the IW’s intent
for BWC to reconsider the claim.
ii. The
evidence that was previously requested but never received has been submitted;
and
iii. The request was
submitted within the applicable statute of limitations.
b. Claims
services staff must enter a claim note to acknowledge the IW’s intent for BWC
to reconsider the claim.
c. Claims
services staff will then staff with a BWC attorney to determine whether there
is sufficient evidence to reconsider the claim.
d. Following
staffing, claims services staff will vacate the previous order and either:
i.
Allow, if sufficient evidence in support of the allowance was submitted
within the applicable statute of limitations;
ii. Deny,
if sufficient evidence is not submitted to justify allowing the reconsidered
claim; or
iii. Dismiss. If sufficient
evidence is not submitted to justify allowing the reconsidered claim, claims
services staff must deny or dismiss the claim consistent with this policy and
procedure.
2. Example:
a. A
claim was previously filed for allowance of a broken tibia and an x-ray report
to support allowance of the claim was requested but not submitted; therefore,
the claim was denied.
b. Six
months later, the IW files a letter stating their intent for BWC to reconsider
the claim. The IW includes x-ray results from the date of injury showing they
suffered a broken tibia.
c. The
claim will be reconsidered because the specific information that caused denial
of the initial claim was submitted with the IW’s intent for BWC to reconsider
the claim.