Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Appeal
Hearing
Order
Parties to a Claim
Waiver
IV. POLICY
A. Requirements
B. Types
of BWC Orders
C. Waivers
D. Appeals
to BWC Orders
V. PROCEDURE
A. General
Claim Note and Documentation Requirements
B. BWC
Orders
C. Waivers
D. Appeals
to BWC Orders
E. IC
Hearings and Claims with the Attorney General’s Office
F. Issuing
Payment of Compensation/Medical Benefits After Issuance of an IC or BWC Order
The purpose of this policy is to ensure that BWC publishes
and/or executes orders, waivers, and appeals in compliance with law and
administrative rules.
This policy applies to all BWC staff.
Appeal:
A formal request for a change in, or reconsideration of, a decision.
Hearing:
A meeting wherein the parties to a claim are afforded an opportunity to present
evidence and be heard before the Ohio Industrial Commission (IC), the
statutorily mandated adjudicatory body for workers’ compensation issues.
Order: The
written notification of a decision made by BWC or the IC from the evidence
gathered in a claim.
Parties to a Claim:
Claimant, claimant representative, employer, employer representative, and
BWC.
Waiver:
A document or formal statement signed by parties to a claim agreeing to
immediate implementation of orders issued by BWC and the IC. The waiver does
not affect any past or future orders pertaining to the claim file; only the
order currently being waived.
1. It
is the policy of BWC to process and publish BWC orders and waivers, process
appeals, and perfect IC orders in accordance with legally mandated timeframes.
2. A
BWC order is required for all initial and subsequent determinations in claims
in which BWC has jurisdiction.
3. BWC
will only perfect signed court orders or IC Court Unit memos.
: Refer to Section V.B.3.a-j for specific information about
individual order types and their uses.
1. When
all parties agree in writing to waive their right to appeal an order, BWC will
consider the order as immediately effective.
2. If
the employer of record is out of business or in a final cancelled status, BWC
does not require a waiver from the employer of record.
1. A
party to the claim who disagrees with the BWC order may appeal the decision to
the IC, thereby asking that a hearing be held to further evaluate the merits of
the claim.
2. How
to Appeal:
a. Notice
of Appeal (IC-12) form;
b. On a
letter that contains all elements of the IC-12;
c. Online
at www.ic.ohio.gov through the Industrial
Commission Online Network (I.C.O.N.);
d. All
appeals must be in writing.
3. The
appeal periods for BWC orders are:
a. Tentative
Orders (TO) - The objection (appeal) period expires 20 days from the printing
of the TO;
b. All
other orders - 14 days after the date of receipt of the order.
4. Faxes
not received by the IC or BWC during core business hours (8 am to 5 pm) will be
considered received and filed on the next business day;
5. If
evidence is submitted after an appeal is filed and the appeal is not withdrawn,
BWC no longer has jurisdiction to reconsider that decision. However, BWC can
obtain additional evidence during the hearing process to support its position.
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. Creating
a BWC Order
a. Claims
services staff will generate BWC orders through the claims management system.
b. Claims
services staff will display and review the order prior to publishing.
2. Claims
services staff must include the following in all orders:
a. The
request/issue the order is addressing;
b. BWC’s
decision;
c. Evidence
relied upon to make the decision, including a detailed description of specific
factual and/or medical evidence used as the basis for the decision;
i.
Claims services staff must not paraphrase from a medical report; only
exact quotes will be used.
ii. Claims
services staff will avoid providing an opinion or comment on the weight,
credibility or significance of a medical report unless advised to do so by BWC Legal.
d. The
declared amount of the full weekly wage (FWW)/average weekly wage (AWW)
following the Wages
policy and procedure when:
i.
Wage information is available;
ii. Compensation
has been or will be requested;
iii. A request to set
wages has been submitted; and
iv. Wages
haven’t already been set.
e. The
type of compensation to be paid and the period of the award; and
f.
Any information included in the sections below on specific orders.
3. Specific
Types of BWC Orders
a. Initial
Allowance Order
i.
Published when granting the initial allowance of a claim for payment of
medical benefits and/or compensation.
a) For
a medical only claim, this order will address claim allowance and the payment
of medical benefits.
b) For a lost
time claim, this order will address claim allowance, the payment of medical
benefits and payment of compensation.
ii. The
following issues may also be addressed:
a) Setting
of the FWW and AWW;
b) Temporary total
compensation (TT);
c) First
seven days of lost time;
d) Non-complying
employers (no coverage);
e) Scheduled
loss compensation awards (loss of use, amputation, loss of vision, and loss of
hearing); and
f) Salary
continuation.
iii.
Claims services staff must address all valid conditions alleged on the First
Report of Injury, Occupational Disease, or Death (FROI).
a) Claims
services staff must only allow conditions that are causally related to the
injury and have supporting medical documentation. However, medical
documentation may not be required for minor injuries as noted in the Medical
Evidence for Diagnosis Determinations (MEDD) policy and procedure.
b) Claims
services staff will deny conditions that are not supported by medical
documentation or are not causally related.
c)
Claims services staff must not deny a condition when some evidence is
submitted but it is not conclusive enough to support the condition unless it is
the only condition requested.
i)
When the evidence is inconclusive, the order must include a statement
that this condition is neither allowed nor disallowed but will be considered
upon submission of additional proof and a formal request if required.
ii) When
additional supporting documentation is filed within the appeal period, claims
services staff will reconsider conditions that were requested on the FROI but
were not previously allowed or denied. If the documentation is submitted after
the appeal period has expired, claims services staff must follow the Additional
Allowance policy.
iv. If
compensation is requested after the initial allowance order has been issued but
no appeal has been filed and the appeal period has not expired, claims services
staff may vacate the initial allowance order and issue a new order addressing
compensation.
v.
Claims services staff must ensure:
a) A
description of the injury is in in the order;
b) The
description includes information received on the FROI and/or during the
investigation; and
c) The
description is spelled correctly and is grammatically correct.
vi. Claims
services staff will use the “based on” texts in the initial allowance order.
a) The
first “based on” text is for specific information relied upon to make the
decision. An example of language to be used in the “based on” text for the
decision: "This decision is based on the medical report from Dr. W.
Zimmerman, D.O., dated 05/13/19, and the MRI report dated 05/13/19, which
states the diagnosis of herniated lumbar disc L4-5 is directly and causally
related to the industrial injury of 05/10/19.”
b) The second
“based on” text is the “compensation based on” section and must be used if
wages are being set or if compensation is being ordered. An example of language
to be used in the “compensation based on” text: “The information regarding
salary continuation was based on the signed C-55 dated 9/10/2019”; or, “wages
were set based on the 52 weeks of earnings received from the employer of record
and the IW’s part time job at City Window Cleaning”; or, “TT compensation was
based on the C-84 dated 09/03/2019 from Dr. Jones.”
b. BWC
Initial Auto Adjudication Allowance Order
i.
Published systematically by the claims management system when an initial
claim meets a set of criteria that causes the claims management system to
automatically generate this allowance order;
ii. The
claim status is systematically updated to “Allow;”
iii. All parties
retain their appeal rights.
c. BWC
Initial Denial Order
i.
Published when denying an initial allowance of a claim.
ii. Claims
services staff must include a description of the injury in the BWC initial denial
order. The description must include information received on the FROI and/or
during the investigation.
iii. The most common
reasons BWC will deny a claim include:
a) The
employee did not sustain an injury in the course of and arising out of
employment;
b) There is
no evidence to support the injury or occupational disease (e.g., claim is
alleged for exposure only);
c) There
is no medical relationship between the diagnosed condition and the described
injury/occupational disease;
d) There is
no Ohio jurisdiction; or
e) There
is not an employee/employer relationship.
iv. Claims
services staff may also deny a claim for any reason found in the initial denial
order inserts on COR.
d. BWC
Abate Order: Claims services staff will use this order to notify the dependent
that the claim application has been abated by the death of the claimant.
e. BWC
Subsequent Decision Order
i.
BWC subsequent decisions are published when granting a request for
action after the initial claim determination or when issues are identified
after the initial allowance of the claim;
ii. Is
only available for accident and occupational disease claims;
iii. The following
are types of issues that staff may address in a BWC subsequent decision order:
a) Additional
allowance;
b) Payment of
new periods of temporary total disability compensation for lost time claims or
for medical only changeovers when the appeal period for the initial allowance order
has expired;
c) Wage
information, including setting AWW for payment of a percentage of permanent partial
disability (%PP) award;
d) Wage loss;
e) Facial
disfigurement;
f) Change
of occupation;
g) Proactive
allowance of an additional condition;
h) Permanent partial
(including loss of use, amputation, loss of vision, loss of hearing);
i)
Permanent total disability (PTD) rate adjustment;
j)
The amount and reason for the injured worker’s (IW) overpayment;
k) Physician
of Record (POR) or treating physician has submitted a statement that the IW has
reached maximum medical improvement (MMI) for all allowed conditions;
l)
POR or treating physician has submitted a statement that the IW is
released to the former position of employment without restrictions.
iv. BWC does
not have authority to deny a subsequent request except for requests for medical
treatment (via Alternative Dispute Resolution (ADR) order), lump sum
advancement, medication reimbursement, and travel reimbursement (via miscellaneous
order.)
v. Claims
services staff will issue a BWC subsequent decision order to address
compensation allowances if compensation is requested after an initial order has
been issued and the appeal period has expired.
vi. A BWC subsequent
decision order should not be issued while the allowance of the claim is under
appeal. However, one possible exception is to issue an order for wages if there
is a hearing order that grants compensation and wages have not been set.
vii. The print location for
this order defaults to central printing, but “Print to S.O.” can be selected.
Claims services staff will only print to the service office if it is necessary
to attach additional documentation to the order.
viii. When setting wages and paying a %PP
award at the same time, claims services staff will issue two separate orders.
a) A
BWC subsequent decision order is issued to set the wages and a BWC TO is issued
to pay the %PP award.
b) Two
separate orders are issued because of the difference in the appeal periods. The
TO has a 20-day objection (appeal) period and the subsequent decision order has
a 14-day appeal period.
f.
BWC Miscellaneous Order
i.
The following are types of issues that staff will address in a BWC miscellaneous
order:
a) Initial
claim dismissal;
b) Participation
in vocational rehabilitation (including living maintenance);
c) Living
maintenance wage loss; and
d) Any other
issue not covered specifically by any other order.
ii. Staff
will refer to the individual policy and procedures for specific instructions.
g.
BWC Death Allow Order
i.
Claims services staff must publish the BWC death allow order to:
a) Grant
death benefits and apportion benefits between dependents, either as the initial
decision in the claim or as a subsequent decision on an existing claim; and
b) Reapportion
death benefits between dependents and to award accrued compensation in claims
where death benefits have been allowed.
c)
Staff may refer to the Death
Claims policy and procedures for specific instructions.
h. BWC
Death Deny Order
i.
Claims services staff must publish the BWC death deny order to
communicate BWC’s decision to deny death benefits, either as the initial
decision in the claim or as a subsequent decision in an existing claim
ii. Claims
services staff may refer to the Death
Claims policy and procedures for specific instructions.
i.
BWC ADR Order
i.
ADR orders are published to communicate the determination of medical
disputes.
ii. Information
needed to generate an ADR order is entered by the MCO on behalf of BWC and the
order is printed and mailed by central printing.
j.
BWC Disabled Workers’ Relief Fund Order
i.
Published to communicate a decision on the IW’s entitlement to Disabled
Workers’ Relief Fund benefits per the Permanent
Total Disability (PTD) and Disabled Workers’ Relief Fund policy and
procedure.
ii. Types
of issues that may be addressed in the BWC Disabled Workers’ Relief Fund order
are:
a) Entitlement
to Disabled Workers’ Relief Fund benefits;
b) Non-entitlement
to Disabled Workers’ Relief Fund benefits;
c) Social
security disability rate;
d) Permanent total
disability (PTD) declared rate;
e) Adjustment
for increase or decrease in the Disabled Workers’ Relief Fund rate;
f) Overpayment
of Disabled Workers’ Relief Fund benefits;
g) Stopping
Disabled Workers’ Relief Fund benefits.
k. BWC
Tentative Order (TO)
i.
Published to either grant or deny an initial determination or subsequent
increase of percentage of permanent partial disability.
ii. Has
a 20-day objection period;
iii. Claims services
staff may refer to the Percentage
of Permanent Partial Disability or Increase of Permanent Partial Disability
Compensation policy and procedures for specific instructions.
4. Vacating
an Order and Issuing a New Order
a. Claims
services staff may vacate the order and issue a new order when:
i.
New and changed circumstances, corrections to specific conditions and/or
body parts, and/or clear clerical errors have occurred after issuance of the
order. Common reasons to vacate a BWC order and issue a new order include:
a) Changes
to compensation payments (type, period or rate);
b) Changes to
the original decision (allow/deny);
c) Changes
to specific conditions;
d) Changing
the part of body from right to left or left to right;
e) Correcting
an employer of record;
f) Correcting
a date of injury;
g) Modifying
the diagnosis/condition, following the ICD
Modification policy and procedures.
ii. Requested
evidence is received after the determination has been issued via a BWC order
but no appeal has been filed, and that evidence changes the decision; or
iii. All parties
agree.
b. Claims
services staff may vacate an order and issue a new one within the following
time periods:
i.
Within Appeal Period and No Appeal Filed
a) Claims
services staff must review the evidence received and determine if the evidence
supports a change to the BWC order.
b) If
evidence is submitted within the appeal period, no appeal has been filed, and
all parties to the claim agree, claims services staff can vacate the BWC order
and issue a new, corrected BWC order.
c) In
all situations except those involving initial determination, when all parties
do not agree to the modification, claims services staff will refer the claim to
the IC.
ii. Within
Appeal Period and Appeal Has Been Filed
a) Claims
services staff must review the new evidence to determine if the evidence
changes the published decision. At that time, although the IC has jurisdiction,
BWC may approach the parties and discuss the parties’ option to withdraw the
appeal so that BWC can issue a new order. If the parties agrees, staff may
vacate the original order and issue a new order.
i)
The appeal must be withdrawn in writing during the appeal period.
ii) If
the appeal is withdrawn and all parties to the claim agree, claims services
staff will vacate the BWC order and immediately issue the new, corrected BWC
order.
iii) If the
withdrawal is received by BWC and the claim is currently at the IC, BWC will notify
the IC. If the withdrawal is received at the IC, the IC will notify BWC.
iv) If the appealing
party does not wish to withdraw the appeal, the IC will process the appeal.
Claims services staff must ensure the new evidence is made available for the
IC’s consideration of the appeal.
b) Claims
services staff will follow the Notice
of Referral to the Industrial Commission policy if evidence is
submitted after an appeal is filed and the appeal is not withdrawn.
iii. After Expiration
of the Appeal Period and No Appeal Was Filed
a) A
new original order may be issued after the expiration of the appeal period with
agreement from all parties of the claim.
b) Example:
Claim was originally allowed for shoulder sprain based on the medical
documentation submitted by the emergency department. One week after the
expiration of the appeal period the orthopedic surgeon submits office notes and
an MRI report indicating the IW did not suffer a strain but instead diagnoses
the IW with a rotator cuff tear. Claims services staff will follow the ICD
Modification policy and if the parties agree, vacate the original order
and issue a new original order.
c) If
claims services staff believes that the original order contains an error, but
all parties do not agree to a change, claims services staff will consult with
the local BWC attorney as to whether a motion for continuing jurisdiction is
warranted (i.e., a mistake of fact, mistake of law, clerical error or new and
changed circumstances).
i)
If a motion for continuing jurisdiction is completed by the BWC
attorney, claims services staff will complete the Notice of Referral (NOR) to
the IC referencing the BWC attorney’s motion.
ii) The
documentation must be imaged, and the IC will obtain all claim information
though a systematic transfer of information prior to the IC hearing.
c. Creating
the New Order After the Order Has Been Vacated
i.
Claims services staff must always vacate an order when it is being
replaced with a new order. All issues that were addressed in the original order
must be repeated in the new order.
ii. When
vacating an order and issuing a new order, claims services staff will use the
“Vacated” button, which will automatically insert a paragraph stating the
original order is being vacated and allows claims services staff to choose the
reason the order is being vacated.
iii. For orders that
do not have the “Vacated” button option available, claims services staff must enter
the following statement in the free form text area of the order: “This order
replaces the BWC order dated <enter date> which is now vacated because
<<reason order is being vacated>>.”
iv. The new
order must cite specific changes to the previous order and include in the
“based on” text area the new information or evidence that was received which
changed the previous decision.
v. A
new appeal period begins when the new BWC order is issued.
5. Time
Frames for Publishing a BWC Order
a. Claims
services staff will publish the BWC initial allowance or BWC initial denial order
no later than 28 days after claim notification (the date the Initial
Notification Letter is sent in the claims management system).
b. If a
medical examination is statutorily required for an initial determination, the
time limit for the BWC order will be extended. The examination should be
promptly scheduled and the BWC order published no later than 28 days from
receipt of the examination report.
c. An
order may be issued once the investigation of the claim is complete and BWC has
reached a decision, regardless of employer certification. However, BWC must continue
to actively pursue employer certification during the initial investigation of
the claim.
d. ADR
orders are systematically generated within seven days after the MCO’s receipt
of the ADR IME report.
e. Claims
services staff will follow any additional operational directives regarding time
frames for orders.
f.
Prior to completing a task on the claims management system, staff must
review all open orders with overlapping or concurrent appeal periods and ensure
they are completing the correct task.
1. Who
can waive:
a. IW/Claimant
and IW/Claimant representative;
b. Employer
and Employer representative;
c. BWC
attorney can waive an IC notice of hearing or IC order.
2. The
third-party administrator (TPA) or other non-lawyer legally cannot
independently waive proper notice of hearing or waive the right to appeal on
behalf of any party. They may submit a waiver, but the waiver must indicate
they are doing so at the direction of the employer and not at the independent
discretion of the TPA.
3. How
to waive:
a. Waiver
of Appeal Period (C-108);
b. Letter
that contains all elements of the C-108;
c. Online
at www.bwc.ohio.gov or www.ic.ohio.gov.
4. How
to submit waiver:
a. Fax;
b. Scanned
and emailed;
c. Physical
delivery of the waiver to BWC or the IC.
5. To
release payment prior to the expiration of an appeal period, parties to the
claim must waive in writing. If the award relates to compensation only, no
waiver is required from the IW.
6. The
waiver does not affect any past or future orders pertaining to the claim.
7. Claims
services staff must enter notes summarizing the waivers and update the order
status in the claims management system.
8. Claims
services staff will process an appeal and stop any payments during an appeal
period, even if a waiver was previously received by the appealing party.
1. Claims
services staff will review the appeal for timeliness, per the Mailbox
Rule policy, so that BWC can assign the appropriate claim status prior
to the appeal being heard by the IC.
2. If
BWC estimates an appeal has been filed within the appeal period:
a. Claims
services staff must image and index any appeal stamped “Tracked on IR” in
application tracking. When the appeal is stamped “Tracked on IR” it has already
been processed with the IC and does not need to be forwarded to them. When the
appeal appears on the claims services staff’s work list, a note/task will be
entered indicating the issue, party filing, and date.
b. The
IC will obtain all claim documents through a systematic transfer of information
prior to the IC hearing.
c. If
claims services staff receives evidence which might cause the appealing party
to reconsider (especially issues involving clear clerical error), they must contact
the party that filed the appeal to discuss the evidence received and provide an
opportunity for the party to withdraw the appeal.
i.
The party can withdraw the appeal, in writing, during the appeal
period.
ii. If
the withdrawal is received by BWC, the withdrawal must be imaged into the claim
file and a NOR must be completed.
iii. If the
withdrawal is received at the IC, the IC will notify BWC. The IC should send
BWC a copy of the ex parte order officially recognizing the withdrawal of the
appeal or a notice that the hearing on the issue has been cancelled.
d. If
the claim was certified and compensation was being paid at the time of the
appeal, claims services staff will place the claim in Hearing status and stop
compensation until a District Hearing Officer (DHO) decision is issued.
3. If
BWC believes an appeal has been filed after expiration of the appeal period,
claims services staff will:
a. Ensure
the appeal is imaged into the claim;
b. Complete
a NOR if the appeal has not been stamped as “Tracked on IR”;
c. Keep
the claim in the status as determined by the initial determination order; and
d. Rename
all documents imaged in the claims management system.
1. If
claims services staff believes there is an error in an IC order that needs to
be corrected:
a. Claims
services staff will staff clerical errors on IC orders with their supervisor.
b. If
the supervisor determines the error may need to be corrected, the supervisor
may discuss the issue with the local BWC attorney.
c. If
further discussion or clarification is needed, the local BWC attorney or the
supervisor may contact the IC Regional Manager.
d. BWC will
file the Request for Corrected Order (IC-13) if the BWC attorney
determines a corrected order is necessary.
2. If a
subsequent request is filed with BWC when a claim is at the Attorney General’s
office on appeal, claims services staff will refer to the Processing
Subsequent Requests for Attorney General Appeals chart on COR to determine
when a subsequent request for action can be processed.
3. Claims
services staff will implement a court order only upon the receipt of the signed
IC Court Unit memo.
4. Emergency
Hearings
a. For
information about emergency hearings or to request an emergency hearing, claims
services staff will notify the IW to contact the IC.
b. Claims
services staff may notify IWs experiencing financial emergencies that the IW
may be eligible for certain federal and state benefits in addition to workers’
compensation.
c. Claims
services staff may suggest that the IW contact their attorney or their county
Ohio Department of Jobs and Family Services (ODJFS) for information regarding
financial assistance that may also be available.
d. Claims
services staff will notify BWC Legal of any emergency hearing so that BWC Legal
may determine if BWC representation at the hearing is necessary.
1. Claims
services staff must pay all compensation, except %PP, beginning the earlier of the
following:
a. The
expiration of the appeal period if no appeal to an order has been filed,
following the Mailbox
Rule policy;
b. The
date when the employer has waived the right to appeal a decision;
c. Upon
issuance of the initial allowance order if the claim is certified by the
employer or an employer waiver is received; or
d. The
date the DHO, Staff Hearing Officer (SHO), or IC order is received by the
employer.
2. Claims
services staff must pay %PP when the order granting the award becomes final or
upon receipt of the SHO order.
3. Payment
of medical benefits begins the earlier of the following:
a. The
date the order is issued by the SHO; or
b. The
date of the final administrative or judicial determination. This includes the
date the appeal rights are waived by the employer.
4. If
the claim meets the Fast Response criteria, as defined in the Initial
Claim Determination policy, immediate payment can be made upon issuance
of the BWC order regardless of employer certification.
5. Claims
services staff will issue an order and hold payment of compensation and
benefits until the expiration of the appeal period or a written waiver from the
employer is received if the undetermined claim is not certified by the
employer. A waiver from the IW is not required to pay compensation.
6. Additional
information can be found on the Orders Quick Reference Guide on COR.