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 an illness or injury has been reported to BWC. Providers will be reimbursed for the treatment of an injured worker only when BWC allows the claim. If BWC disallows the claim, provides will not receive payment for any treatments provided to the injured worker.

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 substantiate the claim or clarify medical issues related to the workplace injury. The MCO again will transmit this information electronically to BWC.

The question of allowed diagnosis and causal relationship are medical issues that require your opinion for resolution by BWC. We must obtain evidence from a physician who has examined or treated the employee 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, called a 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 make determinations within 18 days of the initial notification of injury, 10 days earlier than the law requires. This means the injured worker will receive entitled benefits, and you will be reimbursed for your services quicker.

A 14-day appeal period follows this determination. 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.

Click here to access the claims flow chart.