Claims Process Responsibilities

BWC is responsible for:

• Claim determinations and allowances;
• Paying lost time compensation;
• Second level of dispute resolution;
• Educating injured workers, employers and providers about HPP.

MCOs are responsible for:

• Provider management;
• Utilization review;
• First level of dispute resolution;
• Determining reimbursement eligibility and paying providers for services;
• Educating injured workers, employers and providers about HPP.

NOTE:HPP will not affect fee bills for marine fund or black lung claims, family caregivers, and BWC/Industrial Commission (IC) examinations. BWC retains responsibility for payment of these services.

Self-insuring employers are responsible for:

• Authorizing and determining medical necessity;
• Paying or reviewing fee bills and medical documentation;
• Authorizing guidelines.

Self-insuring employers may choose to form their own Qualified Health Plans (QHP) to deliver medical services to their employees, however, they are not required to do so.