OhioBWC - Basics: (Policy library)

OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:	Self-Insured Claim Management
Policy #:	CP-19-06
Code/Rule Reference:	R.C. 4123.56, 4123.53; O.A.C. 4123-19-01, 4123-3-03, 4123-3-09, 4121-3-13, 4123-19-09
Effective Date:	05/06/2019
Approved:	Kevin R. Abrams, Chief Operating Officer
Origin:	Claims Policy
Supersedes:	Policy #CP-19-06, effective 04/05/2018; 12/06/2013 and Procedure #CP-19-06.PR1 effective 04/05/2018; 11/14/2016
History:	New: 12/06/2013; CP-19-06.PR1 Rev. 11/14/2016; 04/05/2018; 05/06/2019

I. POLICY PURPOSE

The purpose of this policy is to ensure BWC’s role and responsibilities as liaison between the injured worker (IW), self-insuring (SI) employer and the Industrial Commission (IC) are identified and detailed.

II. APPLICABILITY

This policy applies to claims services staff.

III. DEFINITIONS

Disputed Issue: An unresolved objection or non-response to a request.

Self-Insuring 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.

Subsequent Application: Applications for compensation and/or benefits filed after the initial determination request.

IV. POLICY

A. It is the policy of BWC to properly fulfill and perform its responsibilities and role as liaison between the IW, SI employer and the IC in a claim filed with a SI employer.

B. It is the policy of BWC to carry out the following responsibilities in the processing of SI claims:

1. Enter the information submitted from an initial determination request, such as a First Report of an Injury, Occupational Disease or Death (FROI) into the claim management system and assign a claim number;

2. When the information on the FROI is unclear, take reasonable steps to investigate and determine the correct information;

3. Provide the claim number and other information to the IW regarding the management of a claim filed with an SI employer;

4. Ensure subsequent applications and other correspondence sent to BWC are directed to the SI employer, as appropriate;

5. Ensure all documentation and other information received by BWC is maintained in the claim management system;

6. Refer disputed issues to the IC;

7. Process a filed Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability (C-92) pursuant to the Percentage Permanent Partial Awards policy;

8. Process requests for artificial appliances/prosthetics pursuant to the Artificial Appliance Requests policy;

9. Ensure proper handling of vocational rehabilitation claims;

10. Schedule independent medical exams:

a. Upon the request of the employer for:

i. Ninety-day exams; and

ii. Two-hundred week exams - to ensure the exam is completed prior to the end of the two hundred weeks of temporary total disability compensation, the SI employer must request at least sixty days prior to that date;

b. As instructed by the IC; or

c. For determination of percentage of permanent partial disability.

V. Procedure

A. BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim-note requirements and shall follow any other specific instructions included in this procedure.

B. BWC staff shall refer to the specific subject-matter policies and procedures for additional information on particular requirements for claims involving self-insuring employers. See the “SI Policy and/or Topic Reference Guide” on COR for a list of policies that contain references specifically related to self-insured (SI) claim management (e.g., Death Claims, Lump Sum Settlement).

C. New Claim and Initial Determination

1. When entering a new claim, if it is unclear if the employer is self-insuring and/or what policy to assign the claim to:

a. Claims services staff shall staff the claim with the supervisor.

b. The supervisor may contact the Self-Insured Department for further assistance, as needed.

2. When a claim is initiated and the employer is identified as self-insuring:

a. If the employer has certified the claim, the claims management system will automatically:

i. Update the claim status to “Accepted”;

ii. Update the claim status reason to “Accepted”; and

iii. Update the status of all ICD codes to “Accepted.”

3. If the employer certifies an application and the application does not contain the allowed ICD codes and/or conditions, claims services staff shall contact the employer to clarify and add the ICD codes and/or conditions as allowed by the employer into the claims management system.

4. If the employer certifies an initial determination request but marks the “clarification” box on the First Report of an Injury, Occupational Disease or Death (FROI):

a. The claims management system will generate a work item to the claims services staff indicating investigation is needed.

b. Claims services staff shall contact the employer to determine if a dispute exists; and

c. Process the claim consistent with the employer’s subsequent certification or rejection.

5. If the employer has rejected the claim:

a. The claims management system will:

i. Refer it to the Industrial Commission (IC) through the Interface Request, which generates a referral letter to all parties;

ii. Maintain the claim status as “Pending”;

iii. Update the claim status reason to “Hearing”; and

iv. Update all ICD codes to “Hearing”.

b. Claims services staff shall create the legal case in the claims management system.

6. When the employer does not indicate that they have accepted or rejected the claim:

a. The claims management system will generate the SI Insured Certification Letter (CORR607).

i. If the originally identified employer is changed, the letter will not be automatically generated by the claims management system to the subsequent employer.

ii. In those situations, claims services staff shall manually create the letter and send it to the subsequent employer.

b. If the employer responds, the claims management system will generate a work item to claims services.

c. If the employer does not respond to the letter within thirty (30) days, the claims management system will generate a work item to claims services staff. Claims services staff shall attempt to obtain the employer’s certification or rejection by:

i. Reviewing the claim documents to determine if the employer’s certification or rejection has been overlooked; and/or

ii. Attempting to contact the employer via telephone or email.

7. Claims services staff shall process the claim consistent with the employer’s certification or rejection, or if unable to obtain a rejection or certification from the employer, refer the matter to the IC through the Interface Request and create a legal case.

8. On all SI claims, claims services staff shall:

a. Enter all appropriate updates to the claims management system including ICD codes and/or condition status updates, and certification rationale or reasons for rejection when the claims management system has not automatically entered the information. ICD modification may be required.

b. Consistent with the Occupational Disease policy, refer an initial determination request involving a qualifying statutory occupational disease (OD) to the Statutory Occupational Disease Team for handling. The responsibilities of BWC and the SI employer do not change.

c. When notified of incorrect information in a claim, take reasonable steps to determine the correct information and correct it, as appropriate.

i. Depending on the nature of the correction, staffing with the supervisor may be appropriate.

ii. Claims services staff shall enter a claim note to document what steps were taken, how the correct information was obtained, who provided the correct information and the documentation of any staffing and the outcome.

D. Subsequent Claims Management

1. Claims services staff shall image all SI claim related documents received into the claims management system.

2. Cases and Applications

a. The claims services staff shall create a case in the claim management system when a motion is filed and whenever there is any other notice of an action that may be referred to the Industrial Commission. Examples include, but are not limited to:

i. Notice that the SI employer has denied or failed to respond to a Motion (C-86), Initial Application for Wage Loss Compensation (C-140) or Request for Temporary Total Compensation (C-84);

ii. Notice that a C-86 was filed seeking a prosthetic;

iii. Receipt of an Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability (C-92). A C-92 shall be processed consistent with the Percentage of Permanent Partial Awards policy.

b. If the employer accepts the application, the case issue is then updated to “Accepted at BWC” and the case closed.

c. Claims services staff shall not create a case when a Self-Insured Joint Settlement Agreement and Release (SI-42) is filed.

i. An SI-42 shall be processed in Claims Details > Details > Interface Requests in the claims management system.

ii. Claims services staff may reference the “Self-Insured Settlement Process” PowerSuite job aid for detailed claims processing information.

d. Claims services staff shall forward to the SI employer any application or other correspondence received by BWC that requires action by the SI employer, unless BWC has clearly only been copied on the document, along with the SI employer.

e. Claims services staff shall build a legal case for an application, depending upon its type.

f. When a C-84, C-86 or a C-140 is filed with BWC, and there is no indication the SI employer has taken action, claims services staff shall send the Notice on Self Insuring Insured Claim (CORR114) letter to the SI employer and set a work item for 30 days to follow up.

g. When a provider files an invoice directly with BWC, in addition to forwarding the invoice to the SI employer, claims services staff may enter the provider name into the claims management system and generate a letter to the provider advising the provider of the self-insured status of the claim.

3. Disputed Issues

a. Within seven (7) days of notice of a dispute in a claim, claims services staff shall refer the matter to the IC, pursuant to the Notice of Referral to the Industrial Commission policy.

b. Claims services staff shall determine that a dispute exists in a claim when:

i. The SI employer has not responded within thirty (30) days of the sending of a Notice on Self Insuring Insured Claim letter;

ii. The employer submits a C-86 requesting resolution of an issue (e.g., maximum medical improvement) or requesting claim suspension.

iii. The IW files a motion to BWC requesting a hearing on an issue, with documentation showing the issue has been rejected by the employer;

iv. Any other documentation is received which clearly reflects an action is being sought or a request is being made which the other party has received and rejected, and a party is now seeking resolution.

E. Medical Examinations for SI Claims

1. Claims services staff shall schedule the following medical examinations:

a. Upon Request of the SI employer:

i. 90-day exam

ii. 200-week exam

b. C-92 Exam - Claims services staff shall schedule C-92 examinations prior to a determination for percentage permanent partial pursuant to the Percentage of Permanent Partial Awards policy; and

c. IC-requested medical exams or physician reviews.

2. Claims services staff shall create a medical case for the exam.

3. Claims services staff shall ensure payment for a C-92 exam, related travel and interpreter services are paid pursuant to the Percentage of Permanent Partial Awards policy.

F. Artificial Appliances/prosthetics: Claims services staff shall process all requests for artificial appliances/prosthetics and related travel expenses pursuant to the Artificial Appliance Requests policy.

G. Vocational Rehabilitation Services: When claims services staff receive a request from a SI employer related to vocational rehabilitation services for an IW, claims services staff shall refer the matter to the disability management coordinator, who will consult with the Vocational Rehabilitation Services Unit on direction, consistent with Vocational Rehabilitation policies and procedures.

H. Self-Insured Department

1. Claims services staff shall refer SI employer requests for reimbursement from the Surplus Fund to the SI Department.

2. If an SI employer becomes bankrupt, the BWC SI Department will notify claims services staff.

a. The BWC SI Department will be responsible for changing the status of the employer and reassigning the claim(s) to the Self-Insured Bankrupt Team.

b. The Self-Insured Bankrupt Team will assume management of the reassigned claim(s).

3. If claims services staff receive a communication from an IW who wishes to file a complaint against a self-insuring employer, claims services staff shall:

a. Refer the IW to BWC.OHIO.GOV for more information; and/or

b. Provide the IW with a Filing of an Allegation Against a Self-insuring employer (SI-28) form to be submitted via:

i. Email - ( SIINQ@bwc.state.oh.us );

ii. Fax - (614-621-1081); or

iii. Mail - Bureau of Workers’ Compensation

Attn: Self-Insured Department

30 W. Spring St.

Columbus, OH 43215