ADR is a process facilitating resolution of disputed medical issues — medical treatment issues only, not reimbursement grievances. Ohio workers' compensation laws and rules require BWC and managed care organizations (MCO's) to have an ADR process. MCO's must have a medical dispute resolution process that includes one level of review. BWC provides a second level of review for disputes not resolved at the MCO level.
Appeals and hearings provide due process to the parties of a claim by offering them the opportunity to object to a determination on the claim. According to ORC 4123.511(B)(1) the appeal period for a BWC Order is 14 days after the date of receipt of the Order. There are four additional days attached to the 14 day appeal period to allow time for mailing purposes. The injured worker/injured worker's authorized representative, employer/employer's authorized representative or BWC, may file an appeal. It is important to note that the appeal must be filed in writing, as BWC will not accept a verbal appeal.
Authorized representatives are individuals who are selected by or hired by the injured worker or employer to represent their interests during the life of the claim. Generally an attorney is selected, but the representative can be anyone.
A BWC Order is the written notification to all parties of the claim of the decision the Customer Service Specialist (CSS) has made from the evidence that has been gathered during the investigation of a claim.
A causal relationship is a medical determination based on review of the accident description and mechanism of injury. In the medical opinion of the reviewing physician, the evidence is sufficient to conclude that the injury sustained and the mechanism of injury are compatible.
The injured worker is required to send BWC written notice when they dismiss their representative, the injured worker will also need to file a new authorization of representation when changing their representative. The injured worker should notify their former representative of their action.
If you want to change your physician of record (POR) you must notify your managed care organization (MCO) in writing with your request. You can complete a C-23 Notice to Change Physician of Record and send it to your MCO for processing. The notification must include the name and address of your new physician, reason for the requested change and you must sign the document. An injured worker may only have one POR at any given time. In claims where more than one physician treats the injured worker, there still can only be one recognized POR.
Employers, representatives and their designees can certify or reject a claim that's in a new, pending or allowed appeal status online. When you certify a claim, it means you agree the facts reported in the claim are correct and valid to the best of your knowledge. Certification does not mean BWC will automatically allow the claim, just as rejection does not mean BWC will deny the claim. BWC will conduct an investigation to determine whether to allow or deny the claim, regardless of the employer certification. However, if you certify the claim, the injured worker can receive benefits immediately after we issue the allowance order. If the injured worker is due compensation payments, BWC will not wait on the appeal period. If you reject the claim, BWC will still issue an order; however, they will not pay medical or compensation benefits until the appeal period has expired.
Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease. Physicians use the C-9 to request medical treatments and additional conditions. Office notes supporting these requests are attached to the form and sent to the injured worker's managed care organization (MCO). You can complete the C-9 manually or online and mail or fax it to the MCO. You cannot submit the C-9 electronically to the MCO.
Fraud is defined as an intentional act or series of acts resulting in payments or benefits to a person or entity that is not entitled to receive those payments or benefits. Fraud is committed when a person knowingly receives benefits which he or she is not entitled to receive by law, makes false or misleading statements for the purpose of receiving money or services, enters into a conspiracy to defraud the Ohio State Insurance Fund or self-insuring employer under the Workers' Compensation Act. Injured workers, employers and health-care providers can commit fraud. If you suspect fraud, submit a Fraud Allegation Form or call 1-800-OHIOBWC and follow the options.
Hearings are part of the claims due process that is available to the parties of the claim. Workers' Compensation hearings are conducted by the Industrial Commission of Ohio (IC). The IC is responsible for decision making when any claim issue is disputed. The parties of the claim (injured worker, employer and representatives) are entitled to receive written notice of any determination, award or hearing according to ORC 4123.511. Generally, claim determinations and award notices are provided on a BWC or IC Order.
You will receive an identification card from BWC. You will be assigned a specific claim number pertaining to your accident date. The claim number will be used as a means to track the movement of your claim during the life of your claim. Your employer and your treating physician will receive a letter notifying them of your claim number. Always carry your identification card with you as you will be asked for your claim number any time you contact BWC, your managed care organization (MCO) or your doctor. The identification card contains your claim number, the name of your claims service specialist, his/her phone number and your MCO's name and phone number.
BWC places claims in an inactive status when they no longer require any investigation, decision making or management of either extent of injury or extent of disability issues. Claims are considered inactive when at least one of the following criteria have been met within 13 months of the date of injury or the date of the last payment, whichever is later. A claim is inactive when BWC has not made any medical or compensation payments, there are no open applications, no applications have been resolved within the last 60 days and there is no active treatment plan. Although a claim may be inactive, BWC can reactivate a claim when its parties or a medical provider requests that an action be taken.
Sometimes employers mistakenly consider a worker to be an independent contractor and neglect to provide workers' compensation coverage. If an employer controls the working hours, selection of materials, traveling routes and quality of performance of a worker, an employer-employee relationship exists and the employer is required to provide workers' compensation coverage for that employee.
The Industrial Commission of Ohio (IC) is the adjudicatory branch of the workers' compensation system. In addition to establishing adjudicatory policies, the IC has original jurisdiction on claims matters, such as determining levels of disability and resolving disputed claims issues. The IC is comprised of three hearing levels. The District Hearing Officer (DHO) jurisdiction to hear and decide all appeals to determinations under Ohio Revised Code (ORC) 4123.511(B) and all other contested claim matters under ORC 4121; 4123; 4127 and 4131 except those matters under the jurisdiction of the SHO. The DHO Order may be appealed to the 2nd level. The Staff Hearing Officer (SHO) has jurisdiction to hear and decide the following issues: Appealed DHO Orders, applications for Permanent Total Disability (PTD) awards and applications for Violation of Specific Safety Regulations (VSSR) awards, applications for reconsideration of compensation awards made under ORC 4123.57 and
review of settlement agreements made according to ORC 4123.65(D). The SHO order may be appealed to the IC commissioners. The IC Commissioners' Panel is a governor-appointed, three-member board representing employers, employees and the public.
Maximum Medical Improvement (MMI) is a treatment plateau in each person's healing process. It can mean that the patient has fully recovered from the injury or that the patient's medical condition has stabilized to the point that no major medical or emotional change can be expected in the injured workers' condition. This occurs despite continuing medical treatment or rehabilitative programs the injured worker partakes in.
Medical only claims are identified as minor injuries that may or may not include lost time from the workplace up to seven days. Lost time claims occur when the injured worker is off work for eight days or longer due to the allowed injury or occupational disease. Compensation for lost wages can be paid after medical evidence is submitted which supports the period of disability and BWC issues an order approving payment.
Each managed care organization (MCO) must use nationally recognized treatment and return-to-work guidelines to evaluate the necessity and/or effectiveness of medical care and be able to use these guidelines to communicate and educate providers in all decision correspondence. MCO's use The Official Disability Guidelines (ODG). The ODG are evidence-based treatment guidelines that BWC and the MCO's use extensively.
Party/Parties to the claim are the injured worker, the employer, the injured worker authorized representative, the employer authorized representative and the Administrator of the BWC or designee. The managed care organization is not a party to the claim.
Physician of Record. Primary treating physician in the claim. POR must be a medical doctor (M.D.), a doctor of osteopathic medicine (D.O.), a doctor of mechanotherapy (D.M.T.) or a doctor of chiropractic (D.C.). In some instances, a doctor of podiatry (D.P.M.), a doctor of dental surgery (D.D.S) or licensed psychologist (Ph.D. or Psy.D.) may be a physician of record. POR must be BWC certified.
When you go to get medicine for your work-related injury, be sure to tell the pharmacist that the prescription is for a workers' compensation claim. If your claim is not yet allowed, your pharmacist may ask you to pay for the prescription or the pharmacist may choose to accept assignment. If you pay, you will be reimbursed once your claim is allowed. If the pharmacy accepts assignment, the pharmacy will be reimbursed once your claim is allowed. If your claim is allowed, you will receive your prescriptions for your work-related injury at no up-front cost to you. The MCO does not handle reimbursement for prescriptions. BWC's Pharmacy Benefits Manager is SXC Health Solutions (SXC). To contact SXC call
1-800-OHIOBWC and follow the prompts.
For a period not to exceed 60 days following the injured workers' date of injury, physicians have presumptive authorization for providing specific services when treating soft tissue and musculoskeletal injuries. Presumptive authorization of these services can only be applied to allowed conditions in allowed workers' compensation claims.
The managed care organization (MCO) or the self-insuring employer in self-insuring employers' claims is responsible for authorizing and determining medical necessity for all claims. The injured worker's treating physician is responsible for contacting the appropriate MCO or self-insuring employer with authorization requests.
BWC's proactive allowance policy allows BWC customer service specialists to initiate the allowance of additional conditions to a claim. This process can begin when a recommendation for an additional condition is submitted to BWC by the injured worker's managed care organization (MCO). The MCO's recommendation is based on evidence submitted by the injured worker's provider of record (POR).
Providers are able to request retroactive medical treatment by completing BWC's Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) and submitting it to the injured worker's managed care organization (MCO). The MCO is responsible for authorizing, denying or pending retroactive medical requests within 30 calendar days of their receipt.
When the parties to the claim, the injured worker, employer and BWC agree to a sum of money, which BWC will pay to the injured worker, they settle the claim. In exchange for this sum of money, the settlement forever resolves all past, present or future medical and compensation issues and liabilities in the claim, whether known or unknown. BWC administers and approves all claim settlements. The Industrial Commission of Ohio may review a settlement within 30 days following the agreement date to ensure that the settlement is fair to all parties.
Vocational rehabilitation is an individualized, comprehensive program focused on the safe, permanent and cost-effective return of injured workers to the workforce. Vocational rehabilitation, a voluntary program, benefits the injured workers through programs that assist them in returning to work and maintaining their jobs.