Claims determination process
After managed care organizations (MCOs) receive a report of an injury — from you,
the injured worker or employer — they electronically transmit important information
about the injury to BWC.
Then, BWC automatically assigns a claim number to the reported injury.
If you file your claim online,
you will receive a claim number immediately. Otherwise, the injured worker and employer
will receive written notice of the claim number. If you submit your provider number
with the injury report to the MCO, you and the treating physician (if someone different)
also will receive written notice of the claim number. Claim number assignment does not
mean BWC has allowed the claim and medical bills will be paid. It just indicates that
BWC has received the report of injury or illness.
Providers will receive payment for treating an injured worker only when BWC allows the
claim. If BWC disallows the claim, providers will not receive payment for any treatments.
Click here to learn more about claim status.
The MCO will work with BWC to resolve any medical and legal issues that could delay
claim determination or facilitate a timely, safe return to work for the injured worker.
The MCO may ask you to supply additional medical information to help support
the claim or clarify medical issues related to the workplace injury. The MCO again will
transmit this information electronically to BWC.
The question of allowance and
causal relationship are medical issues that require your opinion for BWC to resolve.
We must obtain evidence from a physician who has examined or treated the injured worker
for the condition. BWC will allow a claim only for a work-related injury. The diagnosis
reported must be causally related to the alleged accident. When the provider reporting
the injury to the MCO includes a specific diagnosis in the report, or submits it soon
thereafter, BWC can more quickly consider the diagnosis for allowance.
Click here to learn
more about diagnosis codes.
BWC considers both verbal and written documentation before making a decision that is
impartial and objective, and based on Ohio law. Once we make the decision, one of our
customer service teams must issue a written legal notice, BWC Order, to
the injured worker and employer and their representatives. BWC electronically sends
the claim, or medical condition allowance or denial to the MCO.
BWC’s goal is to determine claims within 18 days of receiving notice of the injury, 10
days earlier than the law requires. This means the injured worker will receive
entitled benefits, and you will receive payment for your services quicker.
A 14-day appeal period
follows this initial decision. If the injured worker and the employer agree, and both
waive the appeal period, the claim becomes formally allowed. That means medical and
compensation benefits can be paid.
When a claim becomes inactive, injured workers, employers and providers should contact
the MCO to request further medical services.
to access the claims flow chart.