A narrative description of the accident or exposure which resulted in the injured worker’s injury,
occupational disease or death. Ideally, injured workers should provide their written accident
descriptions, unless, it is provided by either the injured worker or the employer when the claim is
Additional Conditions/Subsequent Decision
To issue compensation to injured workers and medical payments to providers, all medical conditions
must be included and allowed in the claim. After a claim is allowed, it is possible for new medical
conditions (i.e., additional conditions) to arise in addition to those already included in the claim.
Additional conditions can be considered at the request of the injured worker, employer, their
authorized representatives, medical providers, the assigned managed care organizations or BWC. By law,
before including additional conditions in a claim (i.e., making a subsequent decision), BWC researches
the request, makes a determination and provides due process to all interested parties. Regardless of who
initiates this process, all decisions are based on medical evidence provided in support of the request.
Alleged Condition/Alleged Injury
Under Ohio workers’ compensation law, when a claim is filed with BWC, all medical conditions requested in
a claim are considered alleged until a determination is made either allowing or disallowing them.
Allowances/Allowed Conditions/Allowed Diagnosis
Allowances are medical conditions recognized as directly resulting from a compensable work-related injury
or occupational disease. Allowances are supported by medical documentation submitted by providers.
Allowances are also referred to as allowed conditions and allowed diagnoses.
BWC-Required Data Elements
When reporting a claim, pursuant to the Ohio Administrative Code and BWC Provider Agreement, providers are
required to submit a number of key pieces of information to the injured worker’s managed care organization
(MCO). This data is specific to the injured worker, injury, employer and provider. Required information
that cannot be submitted when the claim is filed must be forwarded to the MCO no later than five days from
the date of initial treatment.
Case management is a cornerstone in the successful resolution of workers’ compensation claims. BWC’s and
the managed care organization’s (MCO’s) case management standards and practices adhere to the definition
established by the American Accreditation HealthCare Commission/URAC. In its Case Management Organization
Standards, version 1.2, case management is defined as “A collaborative process that assesses, plans,
implements, coordinates, monitors, and evaluates options and services to meet a client’s health needs
through communication and available resources to promote quality, cost effective outcomes.”
The MCO case management plan is an essential tool in the management of the claim’s allowed conditions. The
case manager develops the plan in collaboration with the injured worker, members of the health-care team
and employer, if applicable. The plan represents a mutual commitment to the primary goal of return to work
or resolution of the claim. The plan will identify: short- and long-term goals; time frames for response to
referrals, follow up, and evaluation; resources to be used; collaborative approaches to be used; criteria
for case closure; and anticipated case results. The plan elements identified here are identical to the case
management plan elements identified in URAC’s Case Management Standard No. 23.
Under Ohio law, for a workers’ compensation claim to be allowed, the injured worker’s injury or
occupational disease must be caused by a work-related accident or exposure. Burden of proof requirements
are typically placed upon the injured worker to show that this causal relationship exists.
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.
A claim allowance is a medical condition recognized as a direct result of a compensable work-related
injury or occupational disease.
A claim history is a record of all claims filed with BWC for an injured worker. This history contains
information, such as allowances, dates of injury, demographic data and the claim’s status. BWC’s Web site
allows injured workers, their authorized representatives and medical providers to look up histories for
individual injured workers. Additionally, employers and their authorized representatives can look up this
information, as well as all of the employer’s claim history for all employees.
A claim number is a unique number containing the year of assignment and a sequential six- digit number
used to identify and track that claim (i.e., 02-123456).
When BWC receives a claim, it assigns it a status describing where it is in the decision making process.
For purposes of provider reimbursement, it is important to remember that neither BWC or the injured worker’s
managed care organization pay bills until a claim is in an allowed status.
Date(s) of Injury
The date of injury is the date on which a work-related injury occurred.
Date of Death
The date of death is the date that an injured worker died as the result of either a work-related injury or
occupational disease. Date of death is confirmed by providing BWC with a copy of the injured worker’s death
certificate or a Physician’s Certificate in Proof of Death (C-44).
Date of Diagnosis
The date of diagnosis is a term that should be applied exclusively to occupational disease (OD) claims.
The date of diagnosis is the date that an injured worker is first diagnosed with an OD. It is important to
report the correct date of diagnosis to BWC and the injured worker’s managed care organization because it is
used to establish the time limit for filing the claim, setting wages and other vital claim elements.
Date of Disability
The date of disability is the first day that an injured worker is unable to work due to either an injury
or occupational disease (OD). When used in reference specifically to OD claims, date of disability is a
legal term used in conjunction with date of diagnosis. Date of disability and date of diagnosis must be
established for BWC to establish the injured worker’s compensation (i.e., wages).
A diagnosis is the description of the injury or illness that an injured worker sustained during the course
The diagnosis code is the standard medical code and description associated with the injury or illness
sustained by an injured worker during the course of employment.
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. Examples of this include, the submission of an application for an additional
condition, a bill for medical services is paid or a treatment plan is received. It is also important to note
that while a claim may be inactive, the applicable statute of limitations is not superceded. Specifically,
for medical-only claims, the statute of limitations is six years from the last date that a medical payment
was issued. With lost-time claims, the statute of limitations is 10 years from the last date that either
medical or compensation was paid, whichever is later.
An injury description is a written narrative of an injury or occupational disease sustained by the
injured worker. Injury descriptions, accident descriptions and thorough medical documentation are all
valuable aids in determining claims and authorizing the appropriate medical services needed by an injured
A workers’ compensation claim becomes lost time when eight or more calendar days are lost from work due
to an industrial injury or occupational disease. The eight days do not need to be consecutive.
A workers’ compensation claim becomes medical only when seven or fewer calendar days are lost from work
due to an industrial injury or occupational disease.
A motion is used by injured workers or employers and/or their authorized representatives to request a
decision by either BWC or the Industrial Commission of Ohio.
Under Ohio law, parties to a workers’ compensation claim are the injured worker, the employer, the
injured worker’s authorized representative, the employer’s authorized representative, and BWC’s
Administrator. Medical providers are not parties to workers’ compensation claims.
Primary Diagnosis/Principal Diagnosis
The primary diagnosis is the most significant injury or condition in a workers’ compensation claim.
Primary ICD-9 codes must be specified for all claims and only one primary diagnosis can be identified per
claim. This may also be referred to as a claim’s principal diagnosis.
Self-insured claims are covered by employers who have been authorized by BWC to administer their
employees’ workers’ compensation claims.
Type of Accident
Type of accident describes if the claim resulted from a work-related injury, occupational disease or death.
Type of accident is more commonly referred to as accident type.
For a claim to be a workers’ compensation claim, either a physical injury or occupational disease must be
related to an injured worker’s employment. As specified by Ohio law, the claim must arise from and be in
the course of employment (i.e., work-related). While all claims received by BWC are considered, those not
clearly related to the injured worker’s employment will be denied. When a claim is filed, the injured
worker bears the burden of proof for demonstrating that the claim directly or proximately resulted from
his or her employment. Burden of proof standards are met by providing BWC with thorough documentation,
particularly all medical evidence developed by providers who have provided services to the injured worker.