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Policy and Procedure Name:
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Motions
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Policy #:
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CP-19-02
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Code/Rule Reference:
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R.C.
4123.511(A); O.A.C.
4123-3-16; 4123-3-09(C)
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Effective Date:
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12/17/20
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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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Claims Policy
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Supersedes:
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Policy # CP-19-02, effective 09/06/18 and Procedure # CP-19-02.PR.1,
effective 05/06/19
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History:
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Previous versions of this policy are available upon
request
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Motions Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Application
Motion
Parties to a claim
Physician file review (PFR)
Preponderance of the evidence
IV. POLICY
A. Requirements
B. Applicant Responsibilities
V. PROCEDURE
A. General Requirements
B. Review and
Investigation
C. Processing the Motion
The purpose of this policy is to ensure that the Ohio Bureau
of Workers’ Compensation (BWC) consistently and appropriately processes motions
received.
This policy applies to BWC claims services staff.
Application: A form or other means of communicating to BWC a
request, authorization, or agreement.
Motion: For purposes of this policy, a written request,
typically submitted on BWC form Motion (C-86), requesting an action from
BWC or the Ohio Industrial Commission (IC).
Parties to a claim: The injured worker (IW), IW
representative, employer, employer representative and BWC.
Physician
file review (PFR): A review and evaluation of the medical
documentation in a claim by a qualified medical specialist who has met BWC
credential ing requirements to conduct independent medical exams.
Preponderance
of the evidence: A standard of proof which is met when a party’s
evidence on a fact indicates that it is “more likely than not” that the fact is
as the party alleges it to be.
1. A motion
shall be submitted in writing;
2. By a party
to the claim;
3. To request
an action on a claim; and
4. On any
matter that is not otherwise addressed by statute or rule with its own
procedure and/or form requirements (e.g., an application for approval of a lump
sum settlement; motions for drug related issues).
1. The applicant
shall not use a motion as a substitute for a timely filed appeal;
2. The motion
shall clearly and fully state the issue and the requested action;
3. The
applicant shall include with the motion substantial competent proof to support
the request;
4. The motion
shall include citations to any legal authority relied upon;
5. The motion
shall be signed by the applicant or the applicant’s authorized representative;
6. The motion
shall establish entitlement to the request by a preponderance of the evidence;
and
7. Unless the
issue addressed in the motion does not affect the rights of the non-filing
party, the applicant shall mail a copy of the motion to the non-filing party
and provide acknowledgement to BWC or the IC that a copy has been so mailed.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements;
2. Follow any
other specific instructions for claim notes and documentation included in this
procedure;
3. Refer to
the:
a. Jurisdiction
(Statute of Limitations, Statutory life of a claim) policy and
procedure to determine if a claim is statutorily open; and
b. Specific
subject-matter policy for additional information, including due process
requirements, for motions and other applications filed requesting a particular
action in a claim (e.g., Additional
Allowance; Scheduled
Loss Compensation; Psychiatric
Conditions).
1. When a
motion is submitted, claims services staff shall review it to ensure all necessary
information has been provided and:
a. It has
been signed by a party to the claim or the party’s authorized representative;
b. The filing
party has certified by signature and date that a copy of the motion has been
provided to all parties and representatives in the claim;
c. It
clearly and fully states the issue and what action is being requested;
d. Legal
citations have been provided for any authority the request relies on;
e. It is not
being used to substitute for a timely filed appeal;
f. It
is not a request that is required by law to be submitted on a different form or
in some other manner (e.g., an application for a lump sum settlement);
g. Supporting
evidence has been submitted with the motion or is specifically referenced and
contained in the claim; and
h. All legal
requirements and procedures have been complied with if it is requesting
allowance of a psychiatric condition. See the Psychiatric
Conditions policy and procedure for more information.
2. As
necessary, claims services staff shall:
a. Contact
the filing party to advise the filing party of the specific evidence needed to
support the motion (if known) (e.g., earnings statements to support a request
to adjust the average weekly wage) and request that it be submitted; and
b. Contact
the managed care organization (MCO) for assistance in obtaining any needed
medical evidence.
3. After
receipt of any additional medical evidence, claims services staff shall
consider whether a physician file review (PFR) or independent medical exam
(IME) is needed to further clarify the medical issues or develop the evidence
necessary in considering the request. Claims services staff shall refer to the
Independent
Medical Exams and Physician File Reviews and/or Additional
Allowance policy and procedure as necessary for additional
information.
1. When a
motion is received, claims services staff shall create the appropriate case in
the claims management system.
2. Due
Process
a. Claims
services staff shall provide notification of receipt of a request for action by
motion and provide an opportunity to respond as may be required by any
applicable subject-matter specific policy and procedure.
b. If the
subject matter of the motion and/or the required due process is not addressed
in a subject-matter specific policy or procedure:
i. Claims
services staff shall attempt to contact the non-filing party as notification that
a motion has been filed and offer an opportunity to submit additional
information.
a) The first
attempt shall be made by phone.
b) When the
party cannot be contacted by phone, but claims services staff leaves a message
for the party:
i) They
have three full business days to return the call.
ii) Claims
services staff shall set a work item for four business days.
c) When the
party cannot be contacted by phone and leaving a message is not an option,
claims services staff shall send the applicable letter by mail, fax, or
e-mail.
i) When
the letter is sent by fax or e-mail, the non-filing party has three full business
days to respond. Claims services staff shall set a work item for four business
days.
ii) When
the letter is sent by mail, the non-filing party has seven calendar days (plus
four additional days per the Mailbox
Rule policy) to respond. Claims services staff shall set a work item
for 12 calendar days.
iii) The response
time frames may be extended, not to exceed 18 calendar days.
iv) The non-filing
party’s authorized representative shall be copied on the letter.
v) The filing
party shall not be copied on the letter sent to the non-filing party.
d)
Do not continue considering the request until the waiting period has
expired or evidence has been received.
ii. Claims
services staff may direct the non-filing party to www.bwc.ohio.gov to view the motion and
accompanying evidence. However, if requested, claims services staff shall
provide the non-filing party a copy of the motion and any accompanying
evidence.
iii. Claims
services staff must make a decision on a motion:
a) Within 28
days of receipt of the motion; or
b) If a
physician file review or independent medical examination has been requested,
within 14 days of receipt of the report.
3. Motion
Filed Prior to the Final Initial Determination of the Claim
a. When a
motion is filed after an initial determination order is issued but prior to it
becoming final (i.e. during the appeal period with no appeal filed), claims
services staff shall:
i. Review
the request included in the motion; and
ii. Consider
the most expedient and efficient course of action, taking into account any
impact on timely payment of compensation and benefits to the IW.
b. After
careful review of the motion, claims services staff shall take one of the
following actions:
i. Vacate
the initial order and issue a new order to issue a decision on the motion; or
ii. Suspend
acting on the motion until final determination of the claim.
c. If
the motion is suspended, claims services staff shall send the “Suspension Letter”
to all parties in the claim.
i. If
the claim is subsequently allowed, once it is in final allowed status and all
appeal periods have expired, claims services staff shall proceed with
processing the motion.
ii. If
the claim is subsequently disallowed, claims services staff shall send the “Moot
Issue Letter” to the filing party and copy the non-filing party.
4. Suspending
a Motion Pending Resolution of a Related Issue
a. Upon
reviewing a motion, if claims services staff determines the request cannot be
addressed until a related issue is resolved, claims services staff shall:
i. Send
the filing party the “Application/Request Pending Letter” to advise that the
motion will not be acted on until there is a final decision on the related
matter;
ii. Update
the case to “suspend”; and
iii. Set a work
item to address the motion.
b. Claims
services staff shall begin to consider the request when the related issue is
resolved.
5. Referral
to the MCO
a. Upon
reviewing the motion, if claims services staff determines the request is for
medical treatment or vocational services, claims services staff shall refer the
motion to the MCO.
i. Claims
services staff shall ensure the description of the request is clearly stated on
the referral letter.
ii. Claims
services staff shall mail a copy of the letter to the IW and copy the MCO.
b. If claims
services staff determines the request is for medical treatment or vocational
services as well as other issues, claims services staff shall refer the medical
or vocational issues to the MCO and address the remaining issues.
6. Dismissing
and Reinstating a Motion
a. Claims
services staff shall dismiss a motion when:
i. There
is no evidence to support the request, even after reasonable attempts to obtain
evidence;
ii. The
requested action is not clear, despite reasonable attempts to clarify the
request;
iii. The filing
party requests to withdraw the motion; or
a) The filing
party may request withdrawal in writing or verbally (a verbal request must be
documented in claim notes).
b) The
dismissal shall be issued via Miscellaneous Order.
c) If the
filing party requests to withdraw the motion after a decision has been issued
and during the appeal period with no appeal filed, claims services staff shall
vacate the order and issue a new Miscellaneous Order to dismiss the motion.
d) If the
filing party requests to withdraw the motion after an order has become final,
claims services staff shall send the filing party the “No Dismissal Letter”
indicating the motion cannot be withdrawn or dismissed.
e) If the
filing party requests to withdraw the motion after it has been referred to the
IC, see the Notice
of Referral to the Industrial Commission (IC) policy and
procedure for instructions related to withdrawing a notice of referral.
iv. The requested
action must be pursued on a mandated form and/or by some other mandated means
(e.g., request for settlement must be filed on a C-240 form, Settlement
Agreement and Application for Approval of Settlement Agreement.
b. Claims
services staff shall reinstate a dismissed motion when the filing party submits
a new motion.
7. Issuing an
Order
a. If the
request contained in the motion is within BWC’s jurisdiction and there is no
conflict of evidence, claims services staff shall issue an order to address the
request.
b. Claims
services staff shall refer to the Orders,
Waivers, Appeals and Hearings policy and procedure for more
information.
8. Referring
to the IC
a. Claims
services staff shall refer the motion to the IC when:
i. The
requested action is not within the jurisdiction of BWC;
ii. There
is a conflict of evidence; or
iii. Multiple
issues have been presented in one motion and one or more of the issues are not
within the jurisdiction of BWC.
b. Claims
services staff shall refer to the Notice
of Referral to the IC policy and procedure for more information.