Policy Name:
|
Self-Insuring Employer Claim File Requirements
|
Policy #:
|
SI-03-02
|
Code/Rule Reference
|
Ohio Administrative Code (OAC) 4123-19-03(L)(11)
and (L)(12)
|
Effective Date:
|
February 20, 2024
|
Approved:
|
Rex Blateri, Chief of Employer Services
|
Origin:
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Self-Insured Department/Employer Services
|
Supersedes:
|
Self-Insuring Employer Claim Record Requirements policy
effective February 24, 2014.
|
History:
|
Revised February 20, 2024. New policy effective
February 24, 2014.
|
Review Date:
|
February 20, 2029
|
I.
Policy Purpose
Defines injury record
requirements for self-insuring employers (SI employers).
II.
Applicability
The policy
applies to SI employers, third party administrators (TPAs), injured workers,
medical providers, and the BWC Self-Insured Department (SI Department).
III. Definitions
There are no
policy-specific definitions.
IV. Policy
A. SI
employers shall keep a record of all injuries and occupational diseases. A
claim file is the official collection of records maintained by an SI employer
relating to a specific injury.
1.
All claim files must be available for random audits.
2.
SI employers are required to house the claim files at an Ohio location.
3.
SI employers must maintain a claim file while the claim is within the statute
of limitations. If a claim has passed the statute of limitations, SI employers
must be able to provide payment history to support that the claim is beyond the
statute of limitations.
4.
The claim file may be a hard copy file or an electronic file.
B. SI employers
may submit a written request to the SI Department for a waiver to house the
claim files with the SI employer’s TPA. The SI employer must meet the following
requirements:
1.
Provide a toll-free number for injured workers to use to address claim
file requests;
2.
Submit a plan to notify injured workers of the change in claim file
maintenance; and
3.
Provide an address and provision for copying the claim file for the
injured worker within three business days of a written request.
C. If the
request for waiver is approved, the SI employer will receive a written
confirmation of approval. If additional information is needed or the request
cannot be approved, the SI employer will be provided a written explanation. A
waiver may be revoked if the SI employer does not maintain a compliant rating
on audits or has three or more valid self-insured complaints within any twelve (12)
month period.
D. An approval
to house claim files with a TPA may be transferred with a change in TPA;
however, the SI employer must provide BWC with written notice when the TPA is
changed.
E. SI employers
housing claim files with their TPA must ensure the TPA is complying with all
claim file requirements. SI employers must ensure the claim file is made
available within three business days to injured workers upon receipt of a
written request. SI employers must also ensure requested information is
provided within three business days of a written request, which includes, but
is not limited to, wages, allowed conditions, and medical reports.
F. The
claim file shall include the following applicable records at a minimum:
1.
Incident Report or First Report of an Injury, Occupational Disease or
Death (FROI);
2.
Medical reports, narrative reports, and independent medical exam reports;
3.
Service provider medical fee bills with date received clearly
documented;
4.
Notification to injured worker and provider if payment of fee bill is
delayed, denied, or not paid in full;
5.
Payment verification that must include check number, date of payment,
payee, pay period, type of payment, and either an electronic printout or check
copy;
6.
Requests for authorization with date received clearly documented;
7.
Dated responses to requests for authorization;
8.
Return-to-work documentation;
9.
Requests for Temporary Total Compensation (C-84s);
10. Physician’s
Reports of Work Ability (MEDCO-14s);
11. BWC and Industrial
Commission (IC) communications, including orders, hearing notices, and
transcripts;
12. Motions (C-86s);
13. Payroll
information, either printout or Employer Report of Employee Earnings (Wages-EMP);
14. Full weekly
wage (FWW) and average weekly wage (AWW) information, including calculations;
15. Wage loss
documentation and worksheets used to calculate wage loss benefits;
16. Written job
offer if injured worker is working in a modified duty position;
17. Authorizations
for release of medical information;
18. Any child
support orders; and
19. Any change
of physician communication.