Procedural Guide for Self-Insured Claims Administration

Governor John R. Kasich Administrator/CEO Stephen Buehrer

Workers Compensation Acronyms

ADR AWW AWWR BWC DOI DOI FROI FWW FWWR IC IME IW LDW LM LMWL LSA LSS LT MMI MO NTHWW OD POR PTD QHP RTW S&A SHO DWRF SI TPA TT VSSR WL C-86 %PPD Alternative dispute resolution Average weekly wage Average weekly wage rate Bureau of Workers Compensation Date of Injury Date of injury First Report of an Injury, Occupational Disease or Death form Full weekly wage Full weekly wage rate Industrial Commission of Ohio Independent medical exam Injured worker Last day worked Living maintenance Living maintenance wage loss Lump sum advancement Lump sum settlement Lost-time claim Maximum medical improvement Medical-only claim Net take home weekly wage Occupational disease Physician of record Permanent total disability Qualified Health Plan Return to work Sick & Accident Insurance/ Short-term disability Staff hearing officer Disabled Workers Relief Fund Self-insured Third-party administrator Temporary total disability Violation of a specific safety violation Wage loss compensation Motion Percentage of permanent partial disability

BWCs self-insured department produced this manual. For additional information call Jenny Johnson, audit/complaint supervisor, at 614-644-9937, or you may submit your questions to SIINQ@bwc.state.oh.us. The information contained within this guide is current as of January 2011. Please refer to ohiobwc.com to obtain updates and fee schedule changes.

Table of Contents
Introduction I. Defining a Compensable Claim A. What is an injury? Exclusions 2. Special circumstances B. What is an occupational disease? 1. Schedule of diseases C. Dual causation D. Last injurious exposure E. What is a cumulative trauma claim F What is an aggravation claim . G. Statute of limitations 1. Injuries 2. Occupational diseases 3. Exceptions 4. Open claims H. Who can file a claim? 6 6 6 6 6 7 7 7

7 8 8 10 10 10 11 12 13 14 15 16 16 17 17 18 18 18

II. Processing Medical-Only Claims A. Incident report B. Medical reports C. Initiating medical-only claims D. Certification or rejection of a medical-only claim E. Request for authorization F Free choice of physician . G. Medical fee bills H. Pharmaceuticals I. Payment verification/proof of payment J. Required claim file content K. Paperless/electronic claim file check list III. Processing Lost-Time Claims A. First Report of an Injury, Occupational Disease or Death (FROI-1) B. Supporting medical documentation C. Application for payment of compensation D. Computing and paying compensation 1. Computing the full weekly wage (FWW) Full weekly wage worksheet 2. Computing the net take home weekly wage (NTHWW) 3. Computing the average weekly wage (AWW) Average weekly wage worksheet 4. Paying temporary total disability (TTD) compensation 5. Overpayments of compensation

E. F . G. H.

Stopping payment of TTD Maximum medical improvement (MMI) Court ordered family support Transitional/light-duty program Sample job offer I. Required claim file content J. Paperless/electronic claim file check list IV. Other Types of Compensation A. Percentage of permanent partial B. Permanent partial awards (scheduled loss) C. Facial disfigurement D. Wage loss E. Permanent total compensation F Change of occupation . G. Death benefits H. Violation of specific safety requirements (VSSR) I. Full and final settlements J. Lump sum advancements V. Specialized Areas A. Industrial Commission hearings B. Motions C. Additional allowances D. Re-activation of a dormant claim E. Rebuttable presumption F Statewide disability evaluation (90-day exam) . G. Vocational Rehabilitation H. Subrogation I. Disabled Workers Relief Fund (DWRF) J. Complaints/ [procedures K. Interpreter services L. Availability of claim files M. Handicap Re-imbursement N. Occupational diseases O. Self-Insured Review Panel (SIRP) VI. Suggestions for Effective Self-Insured Programs A. SI Compliance audit process 1. Claims audit 2. Administrative program review 3. Sample audit report B. Paid compensation/SI 40 audits VII. Case Law VIII. BWC/IC Locations IX. Glossary X. Forms

25 25 26 26 27 28 29 29 31 33 33 37 39 39 40 42 42 45 45 46 46 47 47 47 48 56 56 56 58 58 58 59 60 61 61

63 64 68 71 74

Introduction
Welcome to the Procedural Guide for Self-Insured Claims Administration. This manual is a reference and training guide for the employer BWC has granted the privilege of self-insurance in the state of Ohio. This manual outlines concepts for establishing administrative policies, detailed instructions concerning claims management and claims-processing procedures. The rules, regulations, forms and procedures described in this manual are in effect as of the date of this publication. These procedures are subject to change, pending the outcome of court cases and other legal interpretations. We have based this procedure guides content upon Ohio laws, rules, policies, legal opinions, etc. You can find this information on BWCs Web site, ohiobwc.com and the Industrial Commission of Ohios (ICs) Web site, www. ic.state.oh.us. 5. Representatives The employer may retain an individual or third-party administrator (TPA) to assist in handling workers compensation claims and authorizing settlements. However, the ultimate responsibility for the administration and processing of workers compensation claims resides with the self-insuring employer. 6. Claim file location The self-insuring employer must house workers compensation claim files at an Ohio location. However, should the self-insuring employer wish to maintain claim files out of the state or at a TPAs office, the employer must obtain prior permission from BWCs self-insured section. 7 Required postings The employer must post a copy . of his/her Certificate of Employers Right to Pay Compensation Directly (self-insured certificate) at each work site. The name, title and department location of the company individual responsible for administering its workers compensation program must accompany the certificate. Additionally the employer must display the Notice To Employees at all Ohio locations. Employers can obtain these from BWCs self-insured section at self-insured inquiries e-mail siinq@bwc.state.oh.us or (614) 466-8433. 8. Providing medical service The self-insuring employer must furnish or arrange for reasonable medical services during working hours in accordance with BWC rules. 9. Assisting injured workers The employer will assist the employee in completing the necessary forms and informing him/her of the requirements for processing a workers compensation claim. You can download forms or copy them from BWCs Web site. Go to Ohio Employers then Forms. You can also obtain these forms by calling 800-644-6292.

Self-Insured Claims Administration

Below are descriptions/explanations of workers compensation terms that apply to self-insuring employers. They are in accordance with Ohio Revised Code (ORC) 4123.35 and Ohio Administrative Code (OAC) 4123-19-03. 1. Coverage Every employee in Ohio must have workers compensation coverage, either through the state fund or from an employer who BWC granted the privilege of self-insurance. 2. Self-insurance A self-insuring employer agrees to abide by the BWC and IC rules and regulations. In addition, the employer agrees to provide accurate and timely payments of compensation and benefits, equal to or greater than is provided for in sections of the Revised Code 3. Self-insured administrator The self-insuring employer will designate one or more employees who are knowledgeable and capable of administering an efficient workers compensation program. 4. Claims administration The claims administration process includes, but is not limited to, the allowance or disallowance of claims, payment of compensation and benefits, maintaining claim files. The administrative process also includes making the appropriate information available to the injured worker and/or his/her representatives for inspection. In addition, it includes assisting employees in filing their applications for benefits. BWC has developed a fact sheet, titled Common Questions About Self-Insurance that might be useful in this area.

10. Ohio bank account The self-insuring employer must have an Ohio bank account from which indemnity payments are drawn. If there is no in-state account established, the employer should draw compensation checks on the same bank as the employers payroll account, or state clearly a specific bank within Ohio will honor the checks. Reference ORC 4123.35(1) (H).

I. Defining a Compensable Claim

A. What is an injury? ORC 4123.01(C) (1)
Injury includes any injury, whether caused by external accidental means or accidental in character and result, received in the course of, and arising out of, the injured employees employment. Injury does not include: (1) Psychiatric conditions, except where the claimants psychiatric conditions have arisen from an injury or occupational disease sustained by that claimant or where the claimants psychiatric conditions have arisen from sexual conduct in which the claimant was forced by threat of physical harm to engage or participate; (2) Injury or disability caused primarily by the natural deterioration of tissue, and organ or part of the body; (3) Injury or disability incurred in voluntary participation in an employer sponsored recreation or fitness activity if the employee signs a waiver of the employees right to compensation of benefits under this chapter prior to engaging in the recreation or fitness activity; (4) A condition that pre-existed an injury unless that preexisting conditions is substantially aggravated by the injury. Such a substantial aggravation must be documented by objective diagnostic findings, objective clinical findings, or objective test results. Subjective complaints may be evidence of such a substantial aggravation. However, subjective complaints without objective diagnostic findings, objective clinical findings or objective test results are insufficient to substantiate a substantial aggravation. An injury may result from special circumstances/situations such as: Parking lot cases; Going and coming rule; Fixed-situs/non fixed-situs employees; Zone of hazard; Horseplay; Initiator of an altercation unrelated to employment; Employee who intentionally injures himself/herself; Rebuttable presumption.

B. What is an occupational disease?

ORC 4123.01(F) and ORC 4123.85 A disease contracted in the course of employment, which, by its causes and the characteristics of its manifestation or the condition of the employment results in a hazard, which distinguishes the employment in character from employment generally, and the employment creates a risk of contracting the disease in greater degree and in a different manner from the public in general. For the full schedule of occupational diseases, see Section 4123.68 of the ORC.b Below are examples of the diseases listed in that section by paragraph letter. (K) Infection or inflammation of the skin on contact surfaces due to oils, cutting compounds or lubricants, dust, liquids, fumes, gases or vapors Any industrial process involving the handling or use of oils, cutting compounds or lubricants, or involving contact with dust, liquids, fumes, gases, or vapors. (R) Tenosynovitis and prepatellar bursitis Primary tenosynovitis is characterized by a passive effusion or crepitus into the tendon sheath of the flexor or extensor muscles of the hand, due to frequently repetitive motions or vibrations, or prepatellar bursitis due to continued pressure. (W) Cardiovascular, pulmonary, or respiratory diseases Incurred by fire fighters or police officers following exposure to heat, smoke, toxic gases, chemical fumes and other toxic substances. (AA) Asbestosis A disease caused by inhalation or in gestion of asbestos, demonstrated by X-ray examination, biopsy, autopsy, or other objective medical or clinical tests.

C. Dual causation
When an occupational disease combines with a nonoccupational condition resulting in disability, BWC considers the disability work related.

D. Last injurious exposure

When an employee may have been exposed to elements causing a respiratory occupational disease while working for multiple employers, the claim is attributed in whole to the employer with whom the employee had the last injurious exposure.

E. What is a cumulative trauma claim?

An injury that develops gradually as the result of the performance of the injured workers job related duties is compensable under revised ORC 4123.01(C).

F. What is an aggravation claim?

Its a claim in which a workers compensation claimant has proven a work-related aggravation of a pre-existing condition. He or she is not required to prove the aggravation is substantial for the employer to evaluate the claim for compensability. The self-insuring employer may allow claims with date of injury on or after Aug. 25, 2006, for substantial aggravation of a pre-existing condition. Per ORC 4123.54, if an injury substantially aggravates a condition that pre-existed the injury, and objective diagnostic findings, objective clinical findings or objective test results documents the substantial aggravation, the self-insuring employer may pay compensation. However, no compensation of benefits are payable once the pre-existing condition has returned to a level that would have existed without the injury. Please see Substantial aggravation of a pre-existing condition for more information.

jury or occupational disease, and have paid wages in lieu of compensation for total disability; If you furnished treatment by a licensed physician in your employ (Note: this treatment does not constitute recognition of a compensable claim); If you paid benefits. These include payment by you for the employees hospital bills, medical bills to a licensed physician or hospital, or for orthopedic or prosthetic devices.

Self-insuring employers must report injuries or occupational diseases that result in eight or more days of total disability to BWC within a week of acquiring knowledge of such injury or occupational disease [ORC 4123.28]. For every day the employer fails to file the report, the statute of limitations increases by one day, up to a maximum of two years. OAC 4123-19-03 (K) (10) requires a self-insuring employer to inform the injured worker, and BWC, in writing, within 30 days from the filling of the claim, as to what conditions it has recognized and denied, if any, as it relates to the injury or occupational disease. The same time frame shall apply when the employer rejects a medical-only claim. 4. Open claims time lines Section 4123.52 of the ORC specifies the time frame in which a self-insured employer can pay benefits or the IC can adjudicate a claim. On or After Aug. 25, 2006, the time frame for all claims is five years from the last payment of compensation or benefits. If the self-insuring employer makes no payments on a claim, it remains open for five years from the date of injury. For claims with injury dates from Dec.11, 1967 to , Aug. 24, 2006 lost-time claims are active for 10 years from the date of the last payment of compensation or benefits. Medical-only claims are active for six years from the last medical payment or six years from the date of injury in the absence of medical benefits. Prior to Dec. 11, 1967 lost-time and medical-only , claims are active for 10 years from the last payment of compensation or benefits.

G. Statute of limitations or when must a claim be filed?

1. Injuries: Pursuant to ORC 4123.84, injured workers must file a claim within two years of the date of injury. See exceptions below. Occupational disease: Pursuant to ORC 4123.85, in all cases of occupational disease or death resulting from occupational disease, claims for compensation or benefits are forever barred. This holds true, unless the injured worker or his survivors in the case of his/ her death files and application with the IC, BWC or you within: Two years after the disability due to the disease began; Such longer period as does not exceed six months after diagnosis of the occupational disease by a licensed physician; Two years after death occurs.

2.

H. Who can file a claim?

Injured worker and/or their authorized representative Employer and/or their authorized representative Medical provider on behalf of an injured worker

3. Exceptions: If any of the following occur, a claim filed: If you have knowledge of a claimed compensable in-

II. Processing Medical-Only Claims

A medical-only claim is categorized as a claim in which an injury or occupational disease disables an injured worker for seven or fewer calendar days from work. These seven days do not have to be consecutive. These include weekends and non-scheduled work days.

B. Medical reports
1. Medical release

A. Incident report (Joint Resolution June 4, 1980

and Resolution R87-1-66) (See example next page.) 1. When to complete

ORC 4123.651 establishes the right of self-insuring employers to copies of medical records relating to an employees workers compensation injury or occupational disease. In many cases, a formal medical release is not necessary because the providers understand self-insuring employers need the reports and notes to manage the claim and pay the medical bills. However, BWC has created a form that complies with the federal governments HIPAA (American Health Insurance Portability and Accountability Act of 1996) privacy laws. The injured worker can sign the Authorization for the Release of Medical Information (C-101). It allows you access to pertinent medical information. You are not required to use the BWC form, but any request used must be limited to requesting records related to the alleged injury or occupational disease. 2. Initial and continuing medical reports

When an injured worker notifies you that an injury or occupational disease has occurred during the course of arising out of his employment or employer-sponsored function, the injured worker or a company official must complete an accident report. He/she must forward the report to your workers compensation administrator. The following incident report is a sample form only. Any form created by you for use within your company or an OSHA 300 compatible form is acceptable. 2. Internal company policies

You should establish internal policies and procedures for reporting industrial injuries. Communicate them to your employees to ensure timely and accurate reporting of all incidents. 3. Who must complete

When it becomes necessary for an injured worker to receive medical treatment from a medical provider, always obtain medical reports for the claim file. The medical provider should include in the medical report a diagnosis and estimated return to work date. a. Medical reports may consist of: Diagnostic test reports (i.e. X-ray, MRI, CT etc. reports); Office progress notes from treating providers; Physical/occupational therapy notes; Emergency department records; Operative records; BWC forms such as the Request for Temporary Total Compensation (C-84), Physicians Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9), Physicians Report of WORK ABILITY (MEDCO-14), etc.; Vocational training records; Certificate of Disability from the physicians record; The self-insuring employers own medical form to be completed by the medical provider. You may request and obtain copies of medical reports before paying the applicable fee bills. You must make your request within 30 days of receipt of the bill. You must retain these reports in the employers claim files (Joint Resolution June 4, 1980). You should establish this procedure with each medical provider to avoid delays in payment.

An incident report should be completed for all work-related injuries and occupational diseases. The injured worker and/or a company representative (e.g. supervisor, safety manager, etc.) can complete the report. BWC suggests you have the injured worker sign and date their report. 4. Retaining required incident report

After completion of the incident report: a. If the injured worker receives no medical treatment and no lost time results from the injury or occupational disease, BWC recommends you retain the report in your files as a record only or incident only claim; If the injured worker receives medical treatment from a medical provider, and if seven or fewer calendar days of lost time results from the injury, this report becomes the basis for establishing a medical-only claim file. Include all medical information obtained from the provider, (diagnosis, period of disability, treatment plan and prognosis, etc. in the medical-only claim file.

b.

Sample incident report

Company name_________________________________ Self-insured No____________________________________________ Address ________________________________________ City/State/ZIP code________________________________________ _ Employee name _____________________________________________ Social Security No. ____________________________ Address ________________________________________ City/State/ZIP code________________________________________ _ Date of injury________________________________________________ Occupation___________________________________ Time of injury_______a.m.________p.m. Date reported to employer _____________________________________________ Witness (if any)____________________________________________________________________________________________ Incident location if different from company location____________________________________________________________ __________________________________________________________________________________________________________ Address ________________________________________ City/State/ZIP code ________________________________________ Description of incident describe in detail: (E.G., approximate weight, size, trip, fall or any substances involved oil, water, etc.) __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Give the exact nature of injury and part of body affected (E.G., fracture of right hand, etc.)___________________________ __________________________________________________________________________________________________________ Was employee treated in the plant? Yes No No

Did employee receive outside medical treatment? Yes

Give name of hospital, clinic and/or physicians name___________________________________________________________ __________________________________________________________________________________________________________ Last date worked ________________________________ Return to work (if known) _________________________________ Did the injury result in death? Yes No

Signing this report does not constitute certification of an industrial claim. Employees signature__________________________________ Employers signature_________________________________ Date___________________________ Title ____________________________________Date_____________________________

C. Initiating medical-only claims

1. a. Filing requirements: OAC 4123-19-03 K (10) OAC 4123-3-03 BWC does not require self-insuring employers to file a medical only claim unless it is contested. However, the injured worker and/or you have the option of filing a claim with BWC. If either party exercises the option, you must assist the injured worker in completing the First Report of an Injury, Occupational Disease or Death (FROI-1). We suggest you mark clearly Medical Only on the FROI-1.

benefits if no compensation or wages in lieu of compensation. 3) Prior to Dec. 11, 1967 lost-time and medical-only , claims are active for 10 years from the last payment of compensation or benefits.

c.

Section 4123-3-23 of the ORC establishes the limitations on the filing of fee bills.

The correct employer name and risk policy number, including the location sub-code, (for example: #200098761) should be on the FROI-1 under employment information. This will ensure subsequent mailings regarding the claim are directed to the correct employer location. These claims are processed and housed in BWCs central office in Columbus. Section 4123.84 of the ORC governs the filing of medical-only claims. It requires self-insuring employer notify BWC within two years of the date of injury or occurrence of an occupational disease with the following exceptions: 1) If you have knowledge of an alleged compensable injury and has paid wages in lieu of compensation for total disability; If you have furnished treatment by a licensed physician in the employ of an employer, (the treatment of this nature does not constitute recognition of a claim as compensable), but shall satisfy the requirements of this section of law; If you have paid or furnished benefits for the employees hospital bills(s), medical bill(s) or orthopedic or prosthetic device(s).

Providers will file fee bills requesting payment for medical or other services rendered in a claim with BWC, the IC or self-insuring employer within two years of the date of service or be forever barred. In cases where the employer disallowed the claim and by later action allows it, providers will file fee bills within six months from the date of the mailing of the final order allowing the claim or be forever barred.

D. Certification or rejection of a medical-only claim

Certification - If you accept the claim, you do not have to file the FROI-1 with BWC. However, if the FROI-1 is used, you must check the certification box. You must forward a copy of a completed FROI-1 to the injured worker for his/her records. 2. Clarification If you accept the claim, but want to clarify the allowed condition (Ex: Lumbar sprain 847 .2 instead of back sprain 847 you must forward a co.9), py of the completed FROI-1 to the injured worker for his/her records. Contesting a medical-only claim A contested claim is one in which the employer does not fully certify a claim under the Ohio Workers Compensation Act. If you contest the claim, you must check the Rejection box on the FROI-1 form. You must forward a copy of the completed FROI-1 to the injured worker for his/her records. If you contest all or part of the claim, you must notify the injured worker and BWC within 30 days. You can do this by filing the FROI-1, by calling it in via telephone or by submitting it online at ohiobwc.com. You must assist the injured worker in the completion of the FROI-1 application. After you file the application with BWC, we assign it a claim number. We then refer the claim to the IC, which will conduct a formal hearing to determine the allowance of the claim.

2)

3.

3)

a.

b.

Section 4123.52 of the ORC specifies the time frame in which self-insuring employers can pay benefits and/or the IC and adjudicate claims. 1) Effective Aug. 25, 2006, for claims occurring on or after that date, no modification or change, nor any finding or award, can be made five years from date of last payment in a claim in which no compensation has been paid. You must retain claim files for the same period of time. 2) From Dec. 11, 1967 through August 24, 2006, , lost-time claims are active for 10 years from the last payment of compensation, wages in lieu of compensation or benefits. Medical-only claims are active for six years from the last payment of b.

c. d.

10

e.

If you do not specify certification, clarification or rejection of the claim, BWC will send you a certification letter requesting the status. You must send copies of your response to BWC, the injured worker and the injured workers representative. 1) If BWC receives certification within 30 days, we update our computer system and forward the claim to the file room for housing. You or your representative may also update the claim via BWC Web site, ohiobwc.com. BWCs Web site will generate a confirmation of the update to the employer/representative. If BWC receives a rejection within 30 days, we forward the claim to the IC within seven days of receipt of the notification of rejection. If the claim is not fully certified, we will refer it to the IC. If you fail to respond to the BWC letters, we will forward the claim file to the IC for a hearing.

cian of record, you may use the C-9 form or a letter outlining the requested information. b. If you deny the request, you must document the reason on the form, and notify the provider of the decision along with the injured worker and his or her authorized representative. BWC requires you to notify the injured worker of his or her right to a hearing before the IC to resolve the disputed matter, on a Motion (C-86).

2)

For those employers who became self-insured on or after Nov. 14, 2003, and opted for medical management in lieu of a Qualified Health Plan (QHP), there are additional requirements for denying a C-9. You must make the denial on a recommendation from a clinicians review. The ORC defines a clinician as a physician, registered nurse or other Ohio certificate holder acting within the scope of his or her license. This includes medical case managers as defined in Rule 4123-6-02.2(C) (38) of the ORC. You must notify the provider, injured worker and his or her representative in writing of the reason for denial within 10 days of receipt of the request. The notification must also indicate the injured worker has the right to request a hearing before the IC to resolve the dispute. The claim file shall have documentation of the name of the Clinician, the Clinicians credentials, and the Clinicians opinion regarding reimbursement for treatment. 5. a. Prior approval is required for these categories of service. Diagnostic testing, including, but not limited to: MRI; CT Scans; Bone Scans; PET Scans. Hospitalization, including transfers between facilities Inpatient and outpatient surgery except emergency surgery Therapy, including: Physical therapy (after the first 10 treatments prior authorization is needed); Therapeutic radio log Work hardening (reconditioning) programs; Back school; Acupuncture; Bio feedback. Durable medical equipment, such as: Rental/purchase of Tens Units; Continuous passive motion devices; 11

3)

E. Request for authorization

OAC 4123-19-03(K) (5) 1. There is no presumptive authorization for self-insuring employers. You must authorize most medical procedures prior to the physician of record conducting the procedure. The physician of record should submit the request for authorization to the employer using the C-9. The physician can also submit a request for authorization in writing on his or her letterhead. You have 10 days from receipt of the request to respond to the physician of record. If there is no response generated within the allotted time, the provider can assume you granted the request and may proceed accordingly. You will make payment for medical services rendered within 30 days of receipt of the bill. However, if the 10th day falls on a state holiday (i.e. Christmas Day), the response is due the next business day. You may approve the request, deny it or request the provider explain the necessity of the requested procedure. You must act upon the request within 10 days of receipt. You can not condition treatment authorization on an employees agreement to utilize a company selected vendor or facility. OAC 4123-6-06.2 allows injured workers freedom of choice. If you require additional information from the physi-

2.

3.

b. c. d.

4.

a.

e.

 f. g.

Neuromuscular stimulator; Bone stimulators in the spine; Prosthetic devices and repairs of the device - Paid by BWC, contact the assigned claims specialist. b.

physician. BWC has the Change of Physician Notice (C-23) for this purpose. You may also use any other notification from the injured worker. You should respond to the request to change physician within seven days of receipt. The request should include the name and address of both the former and new physician of record, along with the reason for the request. In Ohio, BWC recognizes the medical providers below. They can be the physician of record in workers compensation claims. Doctor of Medicine Psychiatrist Doctor of Osteopathy Doctor of Chiropractic Doctor of Podiatric Medicine Doctor of Dental Surgery Doctor of Optometry Doctor of Mechanotherapy QHP for self-insured claims The QHP became effective Sept. 5, 1996, and self-insuring employers who qualified for the plan could create a QHP for their employees. You are not required to have a QHP If you have a QHP you may opt out during . , their renewal period. You must notify BWC in writing at least 30 days prior to the date of the renewal. a. QHP is an individual employers unique health-care network that can provide all the necessary medical care and services to injured workers. You develop a QHP and submit the plan to BWC for certification. Once BWC certifies the plan, you must educate your employees about the QHPs services and benefits, as well as the employees right and responsibilities. BWC requires you to provide the injured worker with a list of BWC-certified physicians for selection. An employee must first use a provider who is a member of your provider network. If the employee is displeased with the network provider, he or she may change physicians. This request must be in writing, outlining the reason for the request, and submitted you. When an employee leaves the network of providers, he or she must obtain services from a BWCcertified provider. When this situation occurs, you will continue to manage the medical part of the case. Refer to OAC 4123-6-06.2 BWC requires all self-insuring with a QHP to have an alternative dispute resolution (ADR) process. ADR

Chronic pain/stress programs Nursing care, including: Nursing home care; Private duty nursing or attendant care; Home health nursing care; Oxygen services; Chelation therapy; Respiratory services; Traction; Outpatient or home IV therapy. Dental/orthodontic such as: Repair or replacement of dental restorations or prostheses previously approved by BWC or you; Periodontal treatments and services; Orthodontic surgeries; Orthodontics; Dental implants; Maxillofacial prosthetics; Temporomandibular joint treatment; Vocational Rehabilitation services. Transportation: All non-emergency transportation, including ambulance and air.

4.

h.

5.

i.

F. Free choice of physician: OAC 4123-6-06.2

1. In the absence of an approved QHP any injured , worker who is injured or disabled in the course of his employment has free choice in selecting a physician, medical, surgical, nursing and hospital services. The cost of these services is the obligation of the self-insured employer and rehabilitative regardless of whether the employer furnishes the medical services. For exclusions and exceptions, refer to this manuals Request for authorization section. Choice of provider for employees of self insuring employers with a QHP is governed by 4123-6-06.2 OAC. Once an injured worker goes to a private physician for treatment (three times) other than on an emergency basis, that provider becomes the physician of record. Change in physician of record: 4123-19-03 K (5) You may require the injured worker to provide notification in writing of any change in his or her attending

b.

c.

2.

3. a.

d.

12

handles medical disputes regarding quality assurance, utilization review, medical necessity and other treatment and provider issues. 1) All parties initiating a medical dispute should contact the administrator of the QHP or you directly.

2. a.

Denying payment of a fee bill Within 30 days of receipt of a medical fee bills, you must notify the service provider and the injured worker in writing of the reason(s) for withholding payment. Reasons could include a contested claim, unauthorized treatment, unrelated services and duplicate billings, or requesting additional information. Maintain a copy of this notification in the claim file. The employer must notify the injured worker they have the right to request a hearing before the IC on the denial bill.

2) Medical disputes may arise between: 3) Employer; Injured worker; Provider; MCO; Medical management vendor. ADR provides due process regarding conflicts in medical treatment issues, but this does not include fee schedule grievances. Disputed issues may include: Quality assurance; Utilization review; Determination that a service is or is not covered; Treatment/service necessity; Issues involving health care providers. There are at least two levels of peer review by the QHP administrator. BWC and IC are not involved in this process. Self-insuring employers who do not have a QHP may not use the ADR process. If there is a dispute, the injured worker should file a C-86 to request a hearing with the IC. b.

If the injured worker contests the denial, either party (the injured worker or you) has the right to request a hearing by completing and filing a C-86. This will have the issue set for a hearing before the IC (See OAC 4123-3-16). Medical payments OAC 4123-6-01.1 The rules of this chapter govern payments to health care providers in claims before you and the industrial commission. However, nothing in the rule shall inhibit or diminish the commissions right to establish adjudicatory policy or otherwise prevent the full adjudication of claims properly before the commission or its hearing officers. Effective April 1, 1991, BWC implemented the use of usual and customary fee guidelines (UCR) for the payment of medical services. Providers covered by these guidelines include, but are not limited to physicians, dentists, chiropractors, mechano therapists, physiotherapists, neurologists, podiatrists and optometrists. These providers are authorized to practice within their respective fields. An explanation of benefits or review (EOB) or (EOR), or similar form should be included with each medical payment. Maintain a copy in the claim file, to identify how you applied the BWC UCR guideline to the fee bill. You may negotiate payment rates with health-care providers for services and supplies provided in the treatment of workers compensation claims as permitted by 4123-6-46 OAC. You also may enter into volume-based contracts with medical providers for services, including, but not limited to, the purchase or rental of durable medical equipment and supplies. However, you may inform injured workers of the availability of services, supplies or equipment from particular health-care providers where you have a contract,

4)

3.

5)

G. Medical fee bill OAC 4123-19-03(K) (5)

A medical fee bill is a request for services rendered to treat allowed conditions in a claim. These can be for office visits, X-rays, pharmaceuticals, orthotic and prosthetic devices, physical or occupational therapy, physical modalities and hospital expenses. The provider should submit bills on the appropriate forms with enough information to warrant payment (i.e. HCFA form). 1. Processing a. You must date stamp all fee bills must upon receipt. In addition, you must act on these fee bills within 30 days of receipt. Action can be either payment of the fee bill, a request for further information from the provider, or denial of the fee bill. Maintain a copy of the fee bill in the claim file. Date stamp any additional requested information received upon receipt and maintain in the claim file. Take action within 30 days of receipt of the additional information.

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a discount or where cost effective payment levels, or where you obtained rates, so long as access to quality and convenient medical services or supplies is maintained for injured workers. Providers should file fee bills for services rendered in a claim with BWC, IC or you within two years of the date of service. In disallowed claims that later were allowed, providers should file the fee bills within six months from the date of the mailing of the final order allowing the claim or be barred. Therefore, for BWC or you to consider a fee bill filed timely, the provider must file a fee bill for services rendered within two years from the date of service or within six months from the date of the mailing of the final order of allowance of the claim, whichever period is longer or be forever barred. (4123-3-23 OAC) For further information regarding medical issues, please contact the BWCs medical policy department at 614-995-5023 or medpol@bwc.state.oh.us. BWC updates its Billing and Reimbursement Manual regularly and is available at ohiobwc.com. 4. QHPs - When a QHP program is involved, you can negotiate payment rates below the UCR within the provider network through contractual arrangements. Chiropractic guidelines - Effective April 1, 1991, chiropractic fee bills are reimbursable using BWCs UCR fee schedules. You can find chiropractic treatment in the section for physical modalities. You may forward disputed chiropractic treatment to the IC for adjudication.

pharmacy provider is required to bill medication at his or her usual and customary charge. You shall pay the lesser of the providers usual and customary charge or the reimbursement allowed as determined in paragraph (E) of this rule, unless you negotiated a payment rate with the provider pursuant to rule 4123-6-46 of the OAC. You can find the reimbursement formula at ohiobwc.com. Select medical provider, services, and then select: BWCs Billing and Reimbursement Manual. The outpatient Medication and Prior Authorization Program is in section 3, under reimbursement rates. Reimbursements to injured workers for medications will at least be equal to BWCs established rate for the medication, unless you have negotiated a payment rate with the pharmacy provider used by the claimant pursuant to rule 4123-6-46 of the OAC. In this case, the claimant reimbursement will be at least the rate negotiated with the provider. You must pay requests for reimbursement within 30 days of receipt of the request. (I) You must obtain a drug utilization review from a physician before terminating payment for current medications as described below.

5.

(1) Before terminating payment for current medications, you will notify all parties to the claim that a physician drug review is being performed or was performed, regarding the necessity and appropriateness of the continued use of current medications (by therapeutic drug class). Parties to the claim include the authorized representatives and the prescribing physician. (2) The written notice will inform all parties to the claim that they have 21 days from receipt of the notice to provide additional information and/or medical documentation to justify the need for continued use of the medications (by therapeutic drug class). Parties to the claim include the authorized representatives and the prescribing physician. (3) You will provide all medically-related information regarding the medications to an independent physician reviewer for review and opinion as to the necessity or appropriateness of the medications. If you obtained an independent physician reviewers report prior to sending the notice required by paragraph (I) (1) of this rule and subsequently receive additional information and/or medical documentation pursuant to paragraph (I) (2) of this rule, you will provide the additional information and/or medical documentation to the independent physician reviewer and obtain an addendum. The independent physician reviewers report (and addendum, if applicable) shall address the medical rationale, necessity and appropriateness of the drug treat-

H. Payment for outpatient medication

OAC 4123-6-21 .1 Medication must be for treatment of an occupational injury or disease in a claim either allowed by an order of BWC or the IC, or recognized by you. The physician of record must prescribe medication or by the treating physician, or by such other treating provider as may be authorized by law to prescribe such medication. You may approve and reimburse for various drugs as a part of a comprehensive treatment plan submitted by the physician of record or a treating physician when reasonably related to and medically necessary for treatment of the allowed conditions in the claim. Such approval and reimbursement shall not constitute the recognition of any additional conditions in the claim even if such prescribed treat conditions not allowed in the claim. Payment to the pharmacy providers shall include a product cost component and a dispensing fee component. The 14

ment in the control of symptoms associated with that allowed conditions in the claim. (4) When the independent physician reviewers report (and addendum, if applicable) indicates the drug treatment is not medically necessary or appropriate for the treatment or in the control of symptoms associated with the allowed conditions in the claim, you may terminate reimbursement for the medications by therapeutic drug class. The termination is effective as of the date of receipt of the independent physician reviewers report or addendum if you obtain one. In the case that a drug is in a therapeutic class that requires a weaning-off period, the termination is effective at the date as agreed to by you and the prescribing physician. (5) In the event you terminate reimbursement for the medications as set forth in paragraph (I) (4) of this rule, you or your authorized representatives shall provide all parties to the claim with a copy of the independent physician reviewers report (and addendum, if applicable) Parties to the claim include the authorized representatives and the prescribing physician. In addition, you will notify the employee and the employees representative in writing of your decision to terminate. Your notification to the employee and employees representative shall indicate the employee has the right to request a hearing before the IC. In the event there is a dispute as to whether the drug treatment is medically necessary or appropriate for treatment of the symptoms associated with the allowed conditions in the claim, the disputed matter shall be adjudicated in accordance with Rule 4123-19-03(K)(5) of the OAC. Through internal development or through vendor contract, you may implement a point-of-service adjudication system. Upon implementation, you may require pharmacy providers to submit bills for medication by an online point-ofservice authorization terminal or a host-to-host link with the established bill processing system as a condition of reimbursement. You may refuse submission by paper or by tape-to-tape. If you use a point of service adjudication system, you may apply the maximum allowable cost list of the point of service adjudication system vendor to medications, which are pharmaceutically and therapeutically equivalent. This means they contain identical doses of the active ingredient and have the same biological effects as determined by the food and drug administration (FDA). In addition, the

FDA designates them an A in Approved Drug Products With Therapeutic Equivalence Evaluations. Claimants who request a brand-name drug or whose physician specifies a brand-name drug designated by dispense as written on the prescription for a medication, which has applicable maximum allowable cost price will be liable for the product cost difference. The cost difference will be between the established maximum allowable cost price of the drug product and the average wholesale price, plus or minus BWCs established percentage of the dispensed brandname drug.

I. Payment verification/proof of payment

1. Payment verification is the record of each and every fee bill and/or billing statement paid. The internal system used to provide the records may vary by employer (such as copy of issued check(s), computer printouts and annotated bill). Whichever system you use, it must provide the following minimum required verifiable information: Check number; Date of check; Name of payee/provider; Date of service/period of indemnity payment; Amount of the check.

Maintain payment verification in the claim file during the time that the file is legally active. 2. Proof of payment is documentation to prove you issued checks in the amounts and on the dates recorded in the claim files. The most commonly accepted evidence and/or record of payment is the appropriate canceled check or a photocopy (front and back) of the canceled check. When requested, you are to provide this proof of payment. Section 4123.35 of the Ohio Revised Code authorizes BWC to request this information.

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J. Required claim file content

(Joint Resolution June 4, 1980) Keep all notes and/or correspondence related to a claim in the claim file. This includes e-mail messages, doctors return to work slips, fax cover sheets, and telephone messages. The joint resolution requires you to include the documents below. 1. If you accept the claim, include: a. Incident report; b. Medical report(s); c. Service provider medical fee bill(s) (stamped with date received by employer); d. Copy of notification to employee and/or service provider if a payment is delayed or a fee bill has not been paid in full; e. Payment verification; f. Notification of change of physician (if used); g. Quit and return-to-work date (where applicable); h. Authorization for the release of medical information (Optional); i. Requests for authorization for treatment (C-9) and responses. 2. a. b. c. d. e. f. 3. If you contest the claim, include the following documents in addition to those listed above: Copy of the FROI-1; BWC letters; Copy of the notice of hearing; Copy of hearing orders, including district hearing, staff hearing, IC, court order; Copy of notice of appeals(s); Copy of C-86s. If an Application for the Determination of the Percentage of Permanent Partial Disability (C-92) is filed, include the following documents in addition to those listed above (refer to the lost-time section for computing the FWW and AWW): Company payroll printout showing employees wages or a Wage Statement (C-94-A); A C-92; Related medical information; An Agreement as to Award for Permanent Total Disability (IC-GC-1 (OIC 3013) when parties to the claim have agreed to the percentage of impairment.

K. Paperless/electronic claim file check list

We designed the check list to provide information to selfinsuring employers and/or their third-party representatives regarding the administration and audit of paperless workers compensation files. We do not intend it to be all-inclusive. ___ All scanned information must be legible. ___ The paperless file must contain all claims information presently maintained in a hard copy workers compensation claim file (examples: FROI-1, accident report, C-84, medical bills, C-86, hearing orders, ages, C9, payment verification for compensation and medical bills, payroll records used to establish the full and average weekly wage). ___ Injured worker should be able to review their workers compensation claim file within 72 hours. ___ Your date stamp should be visible on all documents in the electronic claim file (includes fax or scan dates). ___ If a provider or injured worker requests additional information, upon receipt, date stamp the request and include it in the electronic claim file. ___ Verification of medical payments should easily match a specific fee bill. ___ Office notes should easily match a specific fee bill. ___ The EOB should easily match each medical bill. ___ Make available multiple terminals/computers to accommodate an audit team. ___ Provide written instructions on accessing the electronic claims system, including codes and definitions to the BWC auditors, injured workers and or their representatives. ___ If the system is controlled by the third party administrator, there should be procedures in place to transfer information should the employer change to a different third party administrator. ___ Written job offers for light duty ___ Include written communications to the injured worker, authorized representatives and providers in the electronic claim file. ___ Make hard copies of any or all claims information available on the day of an audit if necessary.

a. b. c. d.

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III. Processing Lost-Time Claims

BWC defines a lost-time claim as a claim in which an injured worker has missed eight or more calendar days from work due to an injury or occupational disease. The missed days do not have to be consecutive. For every day that you fail to report the injury, the law adds an additional day to the statute of limitations for filing the claim, up to a maximum of two additional years. Failure of the injured worker to promptly complete and return the FROI-1 application does NOT stay the notification requirement for the employer as set forth in ORC 4123.28. 4. Why you complete it

A. First report of an injury, occupational disease or death (FROI-1)

Completion of the FROI-1 1. Who should complete?

You and your injured worker should complete and sign the FROI-1. The forms Treatment Info section is not mandatory since you will receive other medical documentation is. If an injured worker is unable to sign because of physical or mental conditions, you can submit the form to BWC accompanied by an explanation. Any time you file a FROI-1 with BWC, you comply with ORC 4123.28 in reporting the industrial injury. 2. When to complete

ORC 4123.52 specifies the time frame in which you can pay benefits or the IC can adjudicate. In approved losttime claims, the claim remains open for five years from the date of the last payment of compensation or medical fee bills. 5. Where to file the FROI-1 You may file the FROI-1 in person or by mail at any BWC customer service office or online at ohiobwc.com. 6. a. Certification, clarification or rejection of the application Options for accepting or rejecting the claim If you accept the claim, check the Certification box on the FROI-1 and specify the diagnostic code(s) (ICD-9) for the condition(s) certified in the claim. If you elect to accept certain medical conditions but reject others, check the Clarification box. List the accepted conditions, and clearly mark the others as rejected. If you contest the claim, check the Rejection box. The claim will be set for a hearing to determine allowance before the IC. BWC intervention If you do not certify, clarify or reject the claim, BWC sends an Employer Certification Request Letter asking the status. Send copies of your response to BWC, the injured worker and the injured workers representative. If certification is received within 30 days, BWC updates its computer system and forwards the claim to the file room for housing. Your representative may also update the claim via our Web site at ohiobwc. com. If a rejection is received within 30 days, BWC forwards the claim to the ICO within seven days of receipt of the notification of rejection. If the claim is not fully certified, we will also refer it to the IC. If you fail to respond to the BWC letters, we will forward the claim to the IC.

You and the injured worker complete the FROI-1 when the injured worker has missed eight or more calendar days from work due to an industrial injury. ORC 4123.84 specifies you must file a claim with BWC within two years from the date of the injury or death. Exceptions to this rule are: If you have knowledge of a claimed compensable injury and paid wages instead of compensation for total disability; If you furnished treatment by a licensed physician in your employ (this treatment does not constitute recognition of a compensable claim); If you have paid or furnished benefits. Benefits include payment by you for the employee's hospital bill(s), medical bill(s) to a licensed physician or hospital, or orthopedic or prosthetic device(s). Filing requirements

b.

3.

ORC 4123.28 requires you report lost-time injuries to BWC within one week after acquiring knowledge of the injuries. However,OAC 4123-19-03 (K-10) outlines the following guidelines: Within 30 days of notification of an injury resulting in eight or more calendar days of disability; Within 30 days of an injury that results in death; For all contested claims regardless of whether or not there is lost time.

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1.

BWC claim numbers

After receiving a completed FROI-1 application, BWC assigns a claim number. The claim number begins with the year of the injury followed by no more than six digits. The letters SI indicate a self-insuring employer employs the injured worker, e.g. 05-123456 SI. Retain this notification of the claim number in the claim file. Use it in all future correspondence regarding the claim. In the event that we assign you more than one claim number to the same injury, you or your employee should immediately notify BWC and request a correction.

a. Use the guidelines below to compute the full weekly wage (FWW). For injured workers who have been either continuously employed for six weeks before the date of injury or who have worked at least seven days before the date of the injury, the FWW shall be the higher amount of either: The gross wages, including overtime pay earned over the aforementioned six week period, divided by six; or, The employee's gross wages, excluding any overtime pay earned for the seven days before the date of injury. This formula ordinarily excludes wages from the pay period that includes the date of injury because the injured worker may not have completed his or her scheduled hours for that week due to the injury. You can include those wages if they benefit the injured worker. However, in most cases, you should exclude the pay period ending on or after the injury date from the FWW calculation. Always use pay-ending dates, rather than pay-dates or check-dates when calculating the FWW. Example: If the injured workers earnings for the six weeks prior to the injury were: $480 (week prior to the date of injury, includes no overtime) $424.50 $480 $480 $591.04 $549.40 $3,004.94 6 = $500.82 The FWW is $500.82, which is the average of the wages earned for the six weeks prior to the date of injury. This is greater than the wages from the week prior to the injury, which was $480. The full weekly wage rate (FWWR) is determined by multiplying the FWW by 72 percent (.72). Formula: FWW x 72 percent = FWWR Example: $500.82 x .72 = $360.59 b. Compute the FWW for an injured worker who has not been continuously employed for six weeks prior to the date of the injury and who has not worked at least seven days prior to the date of injury by multiplying the injured workers hourly rate of pay times the number of hours scheduled to work for the week in which the injury occurred. Hourly rate X scheduled hours = FWW c. To calculate the FWW for an injured worker who is

B. Supporting medical documentation

You must retain all supporting medical documentation in the claim file. Please refer to this manuals medical-only section for details. This would include all treatment notes; tests results, C-84s; C-9s; MEDCO-14 and all related correspondence.

C. Application for payment of compensation (C-84) (MEDCO-14)

You should obtain medical documentation to support the alleged injury and disability period. You may request this on the C-84 form, or you may use other documents that provide the same information. If the C-84 is required, provide the blank form to the injured worker or medical provider. They should complete it in its entirety, and they both should sign it and submit it to you. Effective Nov, 5, 2009, injured workers must sign the Request For Temporary Total Compensation (C-84) or an equivalent form to support disability and assure regular payments. When compensation cant be paid for lack of medical proof, you must immediately notify the injured worker in accordance with 4123-18 OAC. Verify the information below before making temporary total payments. The form lists ICD-9 code(s) allowed conditions in the claim. The C-84 lists the specific dates of disability. The medical providers signature on the claim is the physician of record.

D. Computing and paying compensation

1. Computing the Full Weekly Wage (Joint Resolution June 4, 1980 [R80-7-48])

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paid two times per month (i.e. paid on the 15th and 30th), you should use the wages from the three pay periods prior to the date of injury. Add the wages from those periods, multiply this figure by seven, and then divide by the number of days (45, 46 or 47) in the pay period. Multiply this amount by six for the six- week wage. To arrive at wages for the seven days prior to the injury, use the wages for the pay period prior to the injury, deduct any overtime, then divide by the number of days in the pay period. Multiply that figure by seven for the seven days prior wage. d. An injured worker who works for two employers at the same time and who sustains an injury while in the course of employment at one of the jobs is entitled to workers compensation. Base compensation upon both incomes so long as she or he is totally or partially disabled from both jobs. Calculate compensation based upon wages from both employers. If this issue is in dispute, file a C-86 requesting a hearing with the IC. Example: The employee works during the day for employer A and at night for employer B. The employee is injured while working for employer A and medical proof substantiates the employee cannot work for A or B. The injured worker is entitled to temporary total disability based on earnings from both employers. e. We will consider additional earned benefits for bonuses, tips, laundry, rent or other services and goods that are part of the remuneration of the injured worker as wages upon satisfactory proof. Fraction of weeks Ohio workers compensation benefits are based upon a seven-day workweek. When you cannot pay compensation in even weekly amounts, compensate the injured worker for the partial weeks, by using the formula below. One day = 1/7 = .1429 Two days = 2/7 = .2857 Three days = 3/7 = .4286 Four days = 4/7 = .5714 Five days = 5/7 = .7143 Six days = 6/7 = .8571 g. Seasonal workers

or income derived from unemployment benefits in the temporary total disability calculation (Baker Concrete Construction case). h. School employees

Teachers employed for nine months during the academic year may elect to receive their earnings over a pro-rated 12-month period (summer break). According to Crim v. BWC, a teacher is not entitled to temporary total over the summer months unless he or she can show intent to work during those months. This also applies to other school employees such as cafeteria workers or custodians working a nine-month schedule. Generally, an injured worker is not entitled to receive both wages in lieu of temporary total and temporary total compensation for the same period. However according to the Crim case, if a teacher receives wages in the summer, which he or she earned during earlier periods, temporary total is not offset because the wages were earned during a prior period. i. Examples of FWW calculations To calculate the full weekly wage, begin with the six weeks of gross wages prior to the date of injury; include overtime (A). Compare the six weeks average to the wages earned one week prior to the injury; exclude overtime (B). The full weekly wage is the higher of the two figures. In most cases, you should exclude the pay period ending on or after the injury date from the FWW calculation. 1) Date of injury July 30,2006 Pay period ending: August 4, 2006 (These are the July 28, 2006 correct weeks July 21, 2006 to use for this July 14, 2006 FWW July, 7 2006 , calculation) June 30, 2006 June 23, 2006 Gross wages $358.22 $450 (no overtime) $492.13 $477 .20 -0$450 $418.22

f.

$1,837 6 = $306.25 .55 FWW = $450 x 72% = $324 = FWWR The last day the injured employee worked was July 30, 2006. He or she remained on disability through Aug. 26, 2005, and returned to work on Aug. 27 2006. , This is a total of three and 6/7 weeks of disability. 3.8571 x 324 = $1,249.70, the total compensation due 2) Date of injury March 25, 2009 19

If you can show an injured workers repeated unemployment from his seasonal occupation is a lifestyle choice, the weeks of unemployment are not beyond a claimants control. Thus, you can include those weeks of $0 income

Pay period ending: Gross wages 1.March 21, 2009 $800.37 (w/o OT 674) 2. March 14, 2009 $674 3. March 7 2009 , $674 4. Feb. 28, 2009 $674 5. Feb. 21, 2009 $800.37 (w/o OT 674) 6. Feb. 14, 2009 $674 Total = $4296.74 6 = $716.12 x 72% = $515.60 FWW = $716.12 x 72% = $515.60 = FWWR The last day worked was April 3, 2009. The injured worker remained on disability through May 27 2009. He or she , returned to work on May 28, 2009. This is a total of seven and 5/7 weeks of disability. 7 .7143 FWW Worksheet To calculate the FWW, begin with wages from the six weeks prior to the date of injury, including overtime. (Note: You should ordinarily exclude the pay period ending on or after the injury date from the FWW calculation.) Add these up, and find the average figure for the six weeks. Compare this figure with the wages earned by the injured worker for the week prior to the injury, excluding overtime. The FWW is the higher of the two figures. Always use the week ending dates, rather than the pay dates or check dates when selecting the wages to use for calculating the workers compensation benefits.

For injured workers who have not been continuously employed for six weeks prior to the date of injury and For inFor injured workers who have not worked for at least one full week prior to the date of injury, compute the FWW by multiplying the injured workers hourly rate of pay times the number of hours he or she was scheduled to work for the week in which the injury occurred. Check the statewide minimum and maximum rates for the year of the injury. Use the FWW rate for the first 12 weeks of disability. j. Computing the minimum awards

BWC establishes minimum and maximum compensation rates annually. See Grids/Charts on ohiobwc.com or go directly to Compensation Rates Chart. The date of injury dictates the rates BWC will use for the life of the claim. 1) When the injured workers calculated FWW is higher than the minimum statewide rate, but the injured workers FWW rate is not higher than the minimum rate, he or she receives the minimum statewide rate. Example The statewide minimum rate is $255.67 for 2009 injuries. The injured workers FWW is $256.60 (above minimum rate). Seventy-two percent of the FWW is $184.75 (below minimum rate). The injured worker is paid $255.67 (the statewide minimum rate). 2) When the injured workers FWW is less than the minimum statewide rate, the employee receives the calculated FWW. Do not calculate the 72 percent. Example: The 2009 statewide minimum rate is $255.67 . The injured workers FWW is $175.50 (already below the minimum rate).The injured worker is paid $175.50. k. Occupational disease claims (ORC 4123.85)

Week ending date 1._______________ 2._______________ 3._______________ 4._______________ 5._______________ 6._______________

Wage amount ___________ ___________ ___________ ___________ ___________ ___________

Total___________ / 6 =______________ (A)

Wages earned the week prior to the injury (excluding overtime) _______________ (B) The higher of (A) or (B) is multiplied by 72 percent to establish the FWWR

_____________ X

.72

= ________________

Compensation benefits in an occupational disease claim are paid in accordance with the laws in effect on the established date of disability. See ORC 4123.68 for the full listing and description of the diseases. The White v. Mayfield case established the date of disability in an occupational disease claim using the latest of the dates available at the time the physician reported the disease to BWC: The date the physician informed the injured worker of the medical diagnosis of the condition(s); The date the injured worker first received medical treatment for the condition(s); or, The date the injured worker first quit work because of the condition(s).

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Example May 21, 2009, the employee reports rash on his hands to the supervisor. May 23, 2009, the injured worker seeks medical attention, and the medical provider diagnoses him or her with the occupational disease, contact dermatitis. June 30, 2009, the attending physician takes the injured worker off work and reports the disease to BWC. June 30, 2009, is the date of disability and wages. BWC uses the date just prior to that date to calculate the FWW and the average weekly wage (AWW). 2. Computing the Net Take Home Weekly Wage ORC 4123.56(A) Net take home weekly wage (NTHWW) refers to the amount obtained by dividing an employees total remuneration by the number of weeks worked during those four quarters, less the amount of local, state, and federal income taxes deducted for each such week. Total remuneration paid includes the first four of the last five completed calendar quarters, which immediately precedes the first day of the injured workers entitlement to benefits. Y may elect to consider the NTHWW when calculating the FWW. ou This means the injured worker will receive 72 percent of his or her FWW up to a maximum of the lesser of the statewide average weekly wage (SWAWW) or 100 percent of his or her net take home weekly wage, whichever amount is less, for the first 12 weeks of total temporary compensation. For the setting of the NTHWW, it is necessary to obtain wage information for the first four of the last five completed calendar quarters preceding the first day of entitlement. Do not consider the quarter in which the lost time occurred, as one of the five quarters. Then calculate as follows: Add the gross wages from the first four of the last five completed calendar quarters = $20,000; Step 2 Subtract the federal, state and local taxes withheld from the injured workers wage for this same period = $5,000; Therefore, the total NTHWW = $15,000. Note: Do not deduct hospitalization, retirement, union dues, Social Security taxes, credit union deductions etc., to arrive at the injured workers NTHWW. Divide by the actual number of weeks worked or paid in the first four quarters $15,000.00/52 = $288.46.

Therefore, $288.46 is equal to the NTHWW. 3. Computing the AWW ORC 4123.61 a. Determine the average weekly wage by using the total gross earnings for the 52-week period preceding the injury date. Include all earnings from any other employers during this period. Total these wages and divide by the number of weeks worked. Omit any periods of unemployment due to sickness, industrial depression, strike, lockout or other cause beyond the employees control. Divide the actual wages earned by the number of weeks worked if the injured worker was injured while holding his or her first job. Use the same calculation if the injured worker by choice recently came into the labor market and has not worked for 52 weeks. b. If the employee is a seasonal worker (for example, a fruit or vegetable picker), use the full year, 52 weeks, as the basis for computing the AWW. c. Teachers employed for nine months during the academic year may elect to receive their earnings over a pro-rated 12-month period (summer break). According to Crim v. BWC, a teacher is not entitled to temporary total over the summer months unless he or she can show intent to work during those months. This also applies to other school employees such as cafeteria workers or custodians working a nine-month schedule. Figure the AWW for a teacher by computing the teachers entire salary for 52 weeks, whether or not you pay him or her over nine months or 12 months. Teachers may work and earn wages from other sources during the summer months. Include the wages from the other sources/employers in calculating the AWW if the teacher cannot work for the other employers. d. The formula: total earnings number of weeks worked = AWW. Example of AWW calculation If the injured workers earnings for the prior 52 weeks were $30,000, then, $30,000 52 = $576.92. You determine the rate by multiplying the AWW times 66 2/3 percent. Example: $576.92 x 66 2/3 percent = $384.63 e. Include the additional earnings of injured workers who are also self-employed in the computation of the

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AWW as long as you can substantiate them as earnings rather than investment income. f. In the case of special circumstances, such as apprentices, journeymen and minors, in which the usual rules cannot justly determine the wage, the employer should use such method as will enable it to do substantial justice to the claimant as cited in ORC 4123.61. If the injured worker is not in agreement with the method used, request a hearing with the IC. When compensation is not payable in even weekly amounts, to compensate the injured worker for the partial weeks, use the formula below. One day = 1/7 = .1429 1/3* = .3333 3 days Two days = 2/7 = .2857 2/3* = .6666 5 days Three days = 3/7 = .4286 Four days = 4/7 = .5714 Five days = 5/7 = .7143 Six days = 6/7 = .8571 (scheduled loss awards only) *Applicable to permanent partial compensation Note: See AWW Worksheet example next page h. Computing the minimum awards See Compensation Rates Chart 1) When the injured workers calculated AWW is higher than the statewide minimum rate, but not high enough that 66 2/3 percent of it is greater than the minimum rate, pay the injured worker at the statewide minimum rate. Example: The 2009 statewide minimum rate is $255.67 The injured workers AWW is $260.25 66 2/3 percent of injured workers AWW is $173.50 The injured worker is paid $255.67 2) When the injured workers calculated AWW is less than the minimum statewide rate, pay the injured worker the calculated AWW. Example: The 2009 statewide minimum rate is $255.67 The injured workers AWW is $169.24 The injured worker is paid $169.24 4. a. Paying TTD compensation An injured worker receives temporary total compensation (TTD) when the attending physician certifies him or her as unable to work as a direct result of the allowed condition and is not working or receiving wages or sick leave while disabled (ORC 412356). The injured worker may receive vacation pay, e.

compensatory time, holiday pay and temporary total compensation over the same period, but you cannot require him or her to take these benefits in lieu of temporary total compensation. b. If you allow the claim, you must pay compensation or benefits no later than 21 days from acquiring knowledge of the claim, or receipt of the C-84 form, whichever is later (OAC 4123-19-03 (K) (5)). The first seven days are not compensable (paid) until after the injured worker has been off work for 14 consecutive days or more (ORC 4123.55). Those first seven days do not have to be consecutive to classify the claim as lost-time. For example: An injured worker loses four days due to a knee injury; He returns to work, but then misses another two days because of the injury (documented with medical slips); He comes back to work but continues to have problems with the knee so misses another five days; The first seven days of his disability period are not paid, but he is entitled to TTD for the following four days (at this point he missed a total of 11 days all together); He continues to work for three months and then his physician schedules him for surgery. Following surgery, hes temporarily disabled for four weeks following surgery; Once he misses 14 consecutive days of this period, you must go back and pay the first seven days of lost time. c. After the initial payment, pay compensation in either weekly or biweekly installments for the duration of the total disability based on medical reports, MEDCO-14 and/or C-84 forms from the attending physician. OAC 4123-5-20 states injured workers can receive vacation pay, holiday pay, jury duty pay, etc., while also receiving temporary total benefits for the same period. You may pay an injured worker his or her regular salary/wages during all or part of the period of disability, in lieu of compensation. BWC still considers the claim lost time if the injured worker was disabled for eight or more calendar days. As such, you must report it to the BWC. Refer to OAC 4123-19-03 (J).

g.

d.

The period in which regular (full) salary/wages were paid will count toward the weeks of disability.

22

AWW Worksheet
To calculate the AWW, begin with the 52 weeks of wages prior to the date of injury, normally eliminating the wages earned during the week in which the injury occurred. Include all bonuses, wages from other employers and anything else considered taxable income. Total these up and divide by the number of weeks worked, excluding any weeks of unemployment due to illness, industrial depression, strike, lockout or other cause beyond the employees control. Then multiply the AWW by 66 2/3% to arrive at the average weekly wage rate (AWWR). Week ending date 1.____________ 2.____________ 3.____________ 4.____________ 5.____________ 6.____________ 7 .____________ 8.____________ 9.____________ 10.___________ 11.___________ 12.___________ 13.___________ 14.___________ 15.___________ 16.___________ 17 .___________ 18.___________ 19.___________ 20.___________ 21.___________ 22.___________ 23.___________ 24.___________ 25.___________ 26.___________ 27 .___________ Wage amount _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ Week ending date Wage amount 28.____________ _________ 29.____________ _________ 30.____________ _________ 31.____________ _________ 32.____________ _________ 33.____________ _________ 34.____________ _________ 35.____________ _________ 36.____________ _________ 37 .____________ _________ 38.____________ _________ 39.____________ _________ 40.____________ _________ 41.____________ _________ 42.____________ _________ 43.____________ _________ 44.____________ _________ 45.____________ _________ 46.____________ _________ 47 .____________ _________ 48.____________ _________ 49.____________ _________ 50.____________ _________ 51.____________ _________ 52.____________ _________ _____________ _________ _____________ _________ Total Total earnings _______ / ______ (number of weeks worked) = _________ AWW. AWW _________ X .6667 = __________________ AWWR. Check the statewide minimum and maximum rates for the year of the injury. Use the AWWR starting the 13th week of disability. ____________

23

Example: Injured worker receives full salary for two weeks of the period of disability and temporary total benefits four more weeks. All six weeks of compensation count toward the period of disability. You must maintain proof of salary continuation/wages in lieu of TTD in the claim file. You must also report the calculated compensation amount (TTD) to BWC on the annual Report of Paid Compensation (SI-40). Note: The injured worker is not required to accept salary continuation/wages in lieu of TTD compensation. f. When a claim is contested and the injured worker receives sickness and accident benefits (S&A) under a plan fully funded by you, these net benefits are then offset from any TTD that is later awarded for that same period of time (ORC 4123.56). You must maintain verification of the S&A benefits in the claim file. You cannot force, or pressure injured workers to use their sick leave in lieu of workers compensation benefits. This does not prohibit you from paying sick leave pending a determination of compensation. However, if you or the IC later allows the claim, you must restore leave hours and make up pay adjustments to the equivalent of the compensation due. An injured worker may use sick leave instead of receiving compensation, provided the injured worker voluntarily requests to use sick leave. The injured worker must make the request in writing, and you must maintain a copy in the claim file. BWC will consider collective bargaining agreements regarding the use of sick leave. With the exception of child support, you cannot withhold payment of compensation. (See ORC 4123.67). An injured worker incarcerated in any county, state or federal institution in this or any other state due to a conviction for violation of a state or federal law in claims with dates of injury on or after Aug. 22, 1986, cannot receive TTD. In claims with dates of injury on or after August 25, 2006, TT compensation is not payable to an injured worker during the period of confinement in a county jail in lieu of incarceration in a state or federal institution, whether in this state or any other state for conviction of violation of any state or federal criminal law. If the injured worker is incarcerated in a local or city jail, you must determine if it meets the standards set by the Ashcraft case.

Ashcraft v IC determined the injured workers incarceration was voluntary abandonment of the injured workers former position of employment. 5. Overpayments of compensation

If an injured worker receives compensation from an IC order and it is reversed upon subsequent appeal you can withhold any overpayments from past, present or future claims pursuant to the following criteria under 4123.511ORC: (1) No withholding for the first 12 weeks of temporary total disability compensation; (2) 40 percent of all awards of compensation paid pursuant to ORC 4123.56 and 4123-57; (3) 25 percent of any compensation paid pursuant to section ORC 4123.58; (4) If the court of appeals or the Ohio Supreme Court reverses the allowance of the claim, then you cannot withhold any amount of any compensation. You are subject to the repayment schedule only with respect to an order to pay compensation, which is subsequently reversed upon appeal (ORC 4123.511 (J)). You can also apply this schedule to overpayments made due to calculation errors or found during claims reviews. In some cases, you may be eligible for reimbursement from BWC on overturned claims. The Sysco Supreme Court Decision allowed a self-insuring employer to receive reimbursement on a claim where the IC had ordered the employer to pay compensation to the injured worker, which the court overturned. You can submit a request to the self-insured department for reimbursement for the overturned amount. You must submit all of the relevant information (hearing orders, proof of payments, etc) to the self-insured departments underwriting section. The section will review and either issue a check or send a denial order. You can appeal the denial order to the Self-Insured Review Panel. Effective June 30, 2006, self-insuring employers may elect to withdraw from the claims reimbursement fund. By doing so, they forfeit any reimbursement for claims processed after the effective date of their application. Complete the SI-44. The decision to withdraw from the fund is irrevocable. However, it will result in a reduction in premium assessments by the administrative costs associated with the reimbursement fund.

g.

h. i.

E. Stopping payment of TTD

IC Rule 4121-3-32 (B)

24

1.

You may terminate TTD in the event of any of the following: a. b. The employee returns to work; The employees treating physician finds the employee is capable of returning to his former position of employment or other available suitable employment; The employees treating physician finds the employee has reached maximum medical improvement (MMI). If the report indicates MMI, you may submit a copy of that report to the physician of record to determine if he or she agrees with the medical exam. You can also submit provide a copy to the injured worker and his o her authorized representative. If the injured workers physician agrees in writing, you can terminate TTD benefits without a hearing. You should pay for the cost of this exam, along with the injured workers travel and meal expenses, if applicable. You can document these costs on the Injured Worker Statement for Reimbursement Travel Expense (C-60). You can find the appropriate rates on the Injured Worker Reimbursement Rates for Travel Expense (C-60-A). You are also to compensate the employee for any loss of wages incurred due to the exam (See ORC 4121.43 (F)). If there is conflicting medical evidence, you should file a motion with the IC to request a finding of MMI. TTD payments must continue as long as medical evidence from the provider of record supports disability related to the allowed condition(s) in the claim. 3. Other benefits available

c.

2.

You also may terminate TTD following an IC hearing as follows: a. Upon the finding of a hearing officer that either of the conditions in (a) or (b) above has occurred; b. Upon the finding of a hearing officer that the employee is capable of returning to his or her former position of employment; c. Upon the finding of a hearing officer that the employee has reached maximum medical improvement (MMI) Resolution R98-1-04]; d. Upon the finding of a hearing officer that the employee has received a written job offer of suitable employment.

F. MMI: IC Rule 4121-3-32

1. Definition

When the provider of record or the IC determines MMI, you terminate TTD benefits. However, the injured worker may be entitled to other benefits, which you should explain. a. Wage loss compensation - If the provider of record provides medical evidence that the injured worker has physical restrictions as a result of the work-related injury, and he or she returns to employment at a lesser rate of pay or less hours as a direct result of the restrictions, he or she may be entitled to wage loss compensation. In addition, if you cannot provide a job within those restrictions or if the injured worker cannot find employment within their restrictions, he or she may be entitled to non-working wage loss (See BWC policies). Percentage of permanent partial disability award If there is a residual disability resulting from the work related injury that is permanent and partial in nature, BWC and/or the IC determines entitlement. Permanent total disability - When an injured worker cannot return to any form of employment because of the industrial injury. The IC has jurisdiction to determine entitlement. Rehabilitation - The injured worker may participate in an approved rehabilitation plan to facilitate returning to employment. Full and final settlement - The injured worker and 25

MMI indicates the allowed condition has stabilized and further functional improvement is unlikely, despite continued medical treatment or physical rehabilitation. MMI refers to the allowed medical condition and not the ability to return to work. Ohio workers compensation law states that once an injured worker reaches MMI, TTD compensation is not payable. However, medical treatment can continue to maintain stability of the condition. You can reinstate TTD in the future if the injured worker proves new or changed circumstances causing him or her to become temporarily and totally disabled. MMI can only be determined by the physician of record (POR) or by an IC hearing officer. 2. Independent medical examination d.

b.

c.

An employer can require an independent medical exam (IME) be performed by a physician of his or her choice, to determine continued entitlement to TTD benefits. You should notify the injured worker, his or her authorized representative, and the BWC or the IC of the exam and the purpose of the exam.

e.

the employer may reach an agreement to a final lump sum payment for the claim. You must file the settlement forms with the IC for review within five days of signing. If the IC denies the settlement, notice will be mailed to all parties. No settlement agreed to you and your employee can take effect until 30 days after you and your employee sign the final settlement agreement and filed it with the IC. (ORC 4123.65). This manuals Section IV explains in detail these additional types of compensation.

pensation) for a person who is supporting a family, plus an additional 5 percent for any arrearages; 2. 60 percent of the disposable income (wages or compensation) for a person who does not support another family, plus an additional 5 percent for any arrearages.

If the injured worker desires to have the support payments reduced while receiving compensation, he or she must contact the appropriate support enforcement agency for assistance. You must maintain a copy of the court order in the claim file, along with verification of the support payments made. For a listing of county child support offices and contacts, see the Ohio Department of Job and Family Services.

G. Court ordered family support

Workers compensation benefits are exempt from attachment according to ORC 4123.67 However, ORC 3121.03 . allows support deductions from a workers benefits. If an employee pays child/family support through regular payroll deductions, those payments should continue while the employee receives workers compensation benefits. Family support enforcement agencies receive support payments, including arrearages, directly from the selfinsuring employer. That agency, in turn, distributes the amount paid to the family. You must give notice to the appropriate support enforcement agency for lump sum awards exceeding $149.99. If the injured worker is in arrears, the support enforcement agency can use100 percent of the lump sum award to clear the arrearage. For injuries on or after June 30, 2006, this section of the law permits you to deduct attorneys fees from a lump sum payment of child support prior to paying the family support agency. The attorney of record should complete the Affidavit for Attorney Fees (IC-32 A or C-255), and submit to you. The following types of compensation are considered lump sum awards: accrued portion of percentage of permanent partial; initial accrued permanent partial (amputation); lump sum settlements; facial disfigurement; initial accrued temporary partial and lump sum advancements, except hose awarded for attorney fees. Temporary total; wage loss; living maintenance; living maintenance wage loss; permanent total disability and violation of specific safety requirement are weekly awards of compensation Under the Federal Consumer Credit Protection Act, the federal government has issued the following guidelines to determine the maximum amount a support enforcement agency can be deduct from an injured workers earnings for family support: 1. 26 50 percent of the disposable income (wages or com-

H. Transitional/light-duty programs
You can establish light-duty or transitional-duty programs that provide jobs for injured workers who cannot physically return to their former positions of employment, but who are capable of doing some remunerative work. You should have written job descriptions so you can provide the physician of record with them. He or she will determine if a position is within the injured workers physical capabilities. The MEDCO-14 should clearly document the injured workers restrictions, or written out in detail by the medical provider. If the doctor believes the injured worker can return to work in a light-duty position, a medical release is given. If you are the employer of record, you must make any offers of employment in writing. The offer must contain a description of the job duties, hours and rate of pay. The light-duty job should meet all of the physical restrictions outlined by the physician of record - i.e. No lifting over 10 pounds, able to stand or sit as needed, etc., (See sample letter on this page). Once the injured worker returns to work in this light-duty position, TTD benefits stop. If the injured worker receives his or her regular rate of pay and has no reduction in hours, then there is no additional compensation due. However, if the injured worker is suffering an impairment of earnings due to a lesser rate of pay, and/or is working fewer hours and/or earning less money, then the injured worker may be entitled to working wage loss compensation. The employer is obligated to assist the injured worker in obtaining benefits to which he or she may be entitled and in providing the necessary forms. This would include providing wages earned while working light duty to a TPA for the calculation of the wage loss compensation.

According to ORC 4123.56, if the injured worker is capable of work activity, but the employer is unable to offer the injured worker any employment, the injured worker will register with the ODJFS. ODJFS will assist the injured worker in finding suitable employment. For a listing of county offices and contacts, please see the ODJFS Web site, http://jfs.ohio.gov/county/cntydir.stm.

Light-duty job offer sample letter

June 14, 200X Dear Jane: Your doctor has released you for light-duty employment. Since you have not yet reached maximum medical improvement and cannot return full time to your former position, we would like to include you in our transitional-duty program. Please consider this a formal offer of employment at the ABC Nursing Home. We will place you in a nursing position, but will only expect you to work from 7 to 11 a.m., four hours per day, and five days per week. We will modify the duties of the job to be consistent with the restrictions imposed by Dr. Robert Spine. Your job responsibilities will be checking patients blood pressure and temperature, and making chart notations; dispensing medication and giving injections, and making appropriate chart notations. In addition, you will answer phones, send and receive faxes, and use the computer for scheduling, sending and receiving work-related e-mails. We will prohibit you from moving or lifting patients. You cannot lift or work above shoulder level. The position is available as of July 1, 200X, and you will receive your normal rate of pay. Since this is less than the regular number of working hours, wage loss will supplement your wages through our workers compensation program. Please sign the bottom of this sheet to acknowledge your acceptance of this position. If you have any questions, you can reach me at 123-8889999 or via e-mail at wgreen@abc.com. Sincerely,

I. Required claim file content

You should include all correspondence and/or notes related to the claim in the file i.e. e-mail messages, fax cover sheets, call-in sheets, etc. In addition, include the following information in lost-time files: Incident report; Doctors diagnostic statements that give estimated return to work dates (C-84); Completed FROI-1, along with your determination on the claim, and the allowed condition(s); Wages for the year prior to the date of injury; FWW and AWW, along with calculations done to obtain those figures; Working wages and worksheets used to calculate wage loss compensation; Service provider fee bills stamped with the date you received them; Explanation of benefits if medical fees were reduced per BWC guidelines; Copy of notification to the injured worker, service provider, and BWC/IC if, and why you denied or delayed a medical payment; Copies of all narrative medical reports; Copies of all C-9s, physicians reports/treatment plans, along with documentationshowing your response; Medical documents to show physical restrictions placed on the injured worker by the physician of record (MEDCO-14); Verification for all compensation and medical payments made (this must include the check number, the date issued, the amount, the period covered and the payee); Copies of transfers made from one account to another regarding payments resulting from industrial injuries, such as group insurance (or sick pay paid pending allowance of a claim; Change of physician notifications and employers responses; Copies of applications for benefits, motions, notices of hearings, orders, appeals and continuances and reconsiderations; Copy of family support court orders; Copies of all correspondence to or from the BWC;

William Green
William Green, W.C. Administrator ABC Nursing Home Emergency Drive Anytown, OH 99988 I accept the position and terms as described above. Signed,

Jane Smith

6-14-0X

27

Authorization for the release of medical information (Optional); Written job offer made to the injured worker if a transitional/light duty position is necessary and available.

___ Written job offers for light duty. ___ Include written communications to the injured worker, authorized representatives and providers in the electronic claim file. ___ Make available hard copies of any or all claims information on the day of an audit upon request. ___ Implement policies to ensure the security of injured workers claims information.

This same information is required if you maintain the claim files on a paperless system.

J. Paperless/electronic claim file check list

This check list provides information to self-insuring employers and/or their TPAs regarding the administration, and audit of paperless workers compensation files. We do not intent it to be all-inclusive. ___ All scanned information must be legible. ___ The paperless file must contain all claims information presently maintained in a hard copy workers compensation claim file. Examples include FROI-1, accident report, C-84, medical bills, C-86, hearing orders, ages, C9, payment verification for compensation and medical bills, payroll records used to establish the full and average weekly wage along with all related correspondence. ___ Injured worker should be able to review his/her workers compensation claim file within 72 hours of their request. ___ Your date stamp should be visible on all documents in the electronic claim file (includes fax or scan dates). ___ Correspondence to request additional information from a provider or injured worker, upon receipt, date stamp it and include it in the electronic claim file. ___ Verification of medical payments to a specific fee bill. ___ Office notes to a specific fee bill. ___ Explanation of benefits or reimbursement to providers =EOB/EOR for each medical bill. ___ Provide access to terminals/computers to accommodate BWCs audit team. ___ Provide written instructions on accessing the electronic claims system, including codes and definitions to BWC Auditors, injured workers and or their representatives. ___ If the TPA controls the system, have procedures in place to transfer information should you change to a different TPA. 28

IV. Other types of compensation

A. Percentage Permanent Partial
Percentage of permanent partial (%PPD) is a compensation award an injured worker may be entitled to when he or she suffers a residual disability because of an allowed injury or disease. This applies to lost-time and medical-only claims. Medical findings must support this award. Example: A shoulder injury, which permanently limits the use of the arm Use the Application for Determination of the Percentage of Permanent Partial Disability (C-92) to apply. 1. When to file an application An injured worker may not file an application for determination of the % PPD until he or she meets one of the conditions. For claims with dates of injury on or after June 30, 2006: Twenty six weeks after the termination of the last period of temporary total compensation; Example: An injured worker has received five weeks of compensation paid under ORC 4123.56 of TTD or wage loss. He or she returned to work. Three months later, the injured worker was hospitalized for the condition, and he or she received another 10 weeks of TTD or wage loss. The 26-week period would start the end of the second period of TTD or wage loss compensation received by the employee; Twenty six weeks after the DOI when the IW received full wages in lieu of compensation; Twenty-six weeks from the DOI or the contraction of an occupational disease if no lost time has occurred. Forty weeks after the DOI when the injured worker received full wages in lieu of compensation; Forty weeks from the DOI or the contraction of an occupational disease if no lost time has occurred.

BWC will dismiss a C-92 application filed earlier than specified. The scheduled occupational diseases listed in ORC 4123.68: (W) Cardiovascular, pulmonary or respiratory diseases incurred by firefighters or police officers following exposure to heat, smoke, toxic gases, chemical fumes and other toxic gases; (X) Silicosis; (Y) Coal miners pneumoconiosis; require a total disability before a C-92 application may be filed. 2. Where to find the C-92 application

An injured worker can request the C-92 application from you, a BWC customer service office or from BWCs Web site, ohiobwc.com. He or she can call 1-800-OHIOBWC to get the address of the nearest office. 3. a. How to file an application The injured worker can submit the C-92 application directly with BWC. He or she can also submit it to you for you to file it with BWC. BWC will copy and mail you the C-92 application filed directly with it along with any accompanying documentation. When the injured worker wishes to file for a %PPD award for a claim not previously filed with BWC, he or she must first file the FROI-1, for BWC to process the application. Medical Exam OAC rules 4123-3-09 and OAC 4121-3-09 Required medical exam 1) Once BWC receives the C-92 application, it will schedule a medical exam for injured worker. BWC will mail a letter to him or her providing notice of the date and time of the examination,along with the name of the examining physician. You and your representatives will receive a copy of the letter, along with the appropriate explanations. If BWC cannot locate an appropriate specialist within the injured workers geographic area, the agency may reimburse the following: Meals; Mileage (round trip if greater than 45 miles); 29

b.

4. a.

BWC will dismiss a C-92 application filed earlier than specified. For claims with dates of injury prior to June 30, 2006: Forty weeks after the termination of the last period of TTD compensation; Example: An injured worker has received five weeks of compensation paid under ORC 4123.56 of TTD or wage loss. He or she returned to work. Three months later, the injured worked was hospitalized for the condition. He or she received another 10 weeks of TTD or wage loss. The 40-week period would start the end of the second period of TTD or wage loss compensation received by the employee;

2)

Lodging (if pre-authorized); Wages lost because of the examination.

6. a.

The hearing process An IC district hearing officer makes the determination of (%PPD) is. He or she solely bases his or her conclusion on the medical findings, specifically expressed in the physicians report(s). The hearing officer has the discretion to set the percentage based on the medical evidence. A party to the claim may present medical evidence at the hearing.

BWC will provide the injured worker with a C-60 for this purpose. b. Employers defense examination 1) You are entitled to have the injured worker examined by a physician of his or her choice upon receipt of the C-92 application directly from the injured worker or upon receipt of notice from BWC that the injured worker has filed a C-92 application. OAC 4123-3-09(C) (5) and OAC rule 4121-3-09-(A) (5) allow this action. Submit a copy of the examination report to BWC and to the injured worker or their representative. 2) 5. The following expenses are reimbursable from the employer: Meals; Mileage (portal to portal); Lodging (if pre-authorized); Wages lost because of the examination.

b.

If either party disagrees with the percentage awarded by the district hearing officer, they may file an objection with the IC. File an object on the Application for Reconsideration (IC-88) within 10 days of receipt of the district hearing officers decision. The IC will then set the issue before a staff hearing officer. The extent of disability (percentage awarded) as determined by the hearing officer is not subject to the appeal process. There is no appeal from a decision of a staff hearing officer on the reconsideration of a %PPD. Make payment within 21 days of receipt of this order. Calculation and payment of the PPD award For claims with dates of injury on or after Aug. 22, 1986, calculate compensation by multiplying the medical percentage awarded at the hearing by two. This establishes the number of weeks, which you then multiply by 2/3 of the injured workers AWW, not to exceed the minimum SWAWW for the year in which the injury occurred or the occupational disease resulted in a disability. Example 1: Hearing order awards a 10 percent permanent partial disability Injured workers AWW = $400 2009 Statewide minimum AWW = $255.67 10% x 2 = 20 weeks $400 x 2/3 = $266.67 (exceeds the statewide minimum) Actual payment to injured worker: 20 weeks x $255.67 = $5,113.40 Example 2: Hearing order awards a 10 percent permanent partial disability

c.

Tentative orders 7.

After the physician has conducted BWCs examination, BWC will issue a tentative order (TO) as to the percentage of permanent partial disability awarded. BWC bases the TO upon the evaluation of all medical reports in file. A copy of the BWCs examination report is included with the TO. a. b. If all parties agree, then payment is required within 21 days of your receipt of the order. If the injured worker or you disagree with the results of the TO, then you or the injured worker may file an objection with BWC and the award is not payable. File the Objection to Tentative Order Awarding Permanent Partial Disability Compensation (IC-167-T). You must file this form with BWC within 20 days of receipt of the order. Filing the objection will cause BWC to schedule the claim for an IC hearing before a district hearing officer. Include the following information on the IC-167-T: 1) 2) 3) 4) 5) Name and address of party filing objection, including street address, city and ZIP code; BWC customer service office that generated the tentative order; The date BWC generated the TO; The date the objecting party received the TO; Signature to indicate the objecting party mailed copies of the C-167-T to all parties.

30

Injured workers AWW = $216.75 2009 Statewide minimum AWW = $255.67 10% x 2 = 20 weeks $216.75 x 2/3 = $144.50 Actual payment to the injured worker: 20 weeks x $144.50 = $2,890 8. Election of benefits b. For claims with injury dates prior to Aug. 22, 1986, the injured worker may elect the manner in which he or she receives compensation. After the hearing or upon agreement of the percentage of disability, the injured worker can file a C-86, indicating whether he or she desires to receive benefits under paragraph A or B of ORC 4123.57 . After the injured worker files this election, only the IC has jurisdiction to change it. For further information, please go to BWCs Web site, ohiobwc.com. 9. Filing for an increase in PPD

medical reports. You may also use form OIC 3010/ IC-GC-1 Agreement as to Compensation for Permanent Partial Disability, available from the Industrial Commission. You should begin payment of the scheduled loss award as soon as the physician of record provides medical evidence. When the employer does not agree with the scheduled loss, file a C-86 with BWC, along with the medical reports. BWC will schedule a hearing with an IC district hearing officer to resolve the issue. An aplication for a Scheduled Loss (SL) award filed on of after October 12, 2010 is to be paid in a lump sum according to OAC 4123-3-15 (C), unless an appeal is filed to an IC order awarding payment. Calculation of the award For claims occurring on or after Nov. 3, 1989, the compensation rate is 100 percent of the maximum statewide AWW. BWC does not use the injured workers own calculated AWW in calculating these awards. For claims occurring between Aug. 22, 1986, and Nov. 2, 1989, the compensation rate is 66 2/3 percent of the injured workers average weekly wage. It cannot exceed the maximum statewide AWW, nor be less than 40 percent of the statewide AWW for the year in which the injury occurred. For claims occurring before Aug. 22, 1986, the compensation rate is 66 2/3 percent of the injured workers AWW. However, this rate should not exceed 50 percent of, nor be less than 25 percent of, the maximum statewide AWW for the year in which the injury occurred. Schedule of loss of members

c.

2. a.

An injured work may file for an increase in his or her %PPD award after the initial finding, as there is no waiting period. Along with the C-92 application, the injured worker must submit medical evidence confirming new and changed circumstances. Upon receipt of the application and medical report, BWC will submit the information to a BWC physician reviewer. This person determines if a physical exam is required or if a file review is appropriate. Once he or she renders a medical opinion issues a tentative order. The objection and hearing process is the same as described previously.

b.

c.

B. Permanent partial scheduled loss awards ORC 4123.57(B)

A permanent partial scheduled loss award is an award for the loss of, or the loss of the use (ankylosis) of specific parts of the body, due to an industrial injury or occupational disease. Example: The loss of the use of a limb, total loss of hearing in one ear, or the partial or total loss of sight in one eye 1. a. How to file and begin payment When you agree with the scheduled loss, file the medical evidence that designates the exact point at which the amputation or ankylosis occurred, or notes the extent of the impairment of vision/hearing with BWC. You can use BWCs Amputation/Loss of Use Diagram (C-196) in leiu of or in addition to other 3.

Scheduled loss awards are payable beginning the date of the loss. The initial check should be for an accrued amount. The balance due should be paid in weekly or biweekly installments until the award is paid. Scheduled loss awards are payable concurrently with temporary total compensation. Pay multiple scheduled losses for multiple body parts consecutively. Effective Oct. 12, 2010 the award is paid in a lump sum. BWC pays for all prosthetic devices or its repair. Please contact the assigned claims specialist.

31

Schedule of loss of members

Arm Leg Hand Foot Eye First finger (Thumb) Second Finger (Index) 2/3 1/3 Third Finger (Long) 2/3 1/3 Fourth finger (Ring) 2/3 1/3 Fifth finger (Little) 2/3 1/3 Great toe** Other toes** Hearing (one ear) Hearing (total) Metacarpal* 225 weeks 200 weeks 175 weeks 50 weeks 125 weeks 60 weeks 30 weeks 35 weeks 23 1/3 weeks 11 2/3 weeks 30 weeks .20 weeks 10 weeks 20 weeks 13 1/3 weeks 6 2/3 weeks 15 weeks 10 weeks 5 weeks 30 weeks 10 weeks 25 weeks 125 weeks 10 weeks

er is entitled to the loss of arm or leg. The injured worker must prove he or she cannot apply the appliance without making these joints useless. On March 7 2001, The Ohio Supreme Court held in the , Welker case that the claimant was not eligible for the scheduled loss award due to successful reattachment. The courts stated a scheduled loss award might be possible in the future, if the reattachment fails. The court relied on several medical reports that indicated the reattachment was successful. Further, the court stated that the appropriate time to determine eligibility is at the time of reattachment and recovery, rather than at time of injury. The court made a determination based on what actually happened at the time of the request, and not the situation, as it existed at the time of injury. 5. a. b. c. d. 6. a. Loss of hearing The loss of hearing must be 100 percent in at least one ear to entitle the injured worker to an award under this section. Total loss of hearing - one ear (25 weeks) Total loss of hearing - both ears (125 weeks) The IC must determine the award for loss of hearing. Loss of vision BWC will make no award for a loss of less than 25 percent of uncorrected vision. Loss of uncorrected vision means the percentage of vision lost as the result of the injury or occupational disease. Total loss of sight in one eye (100 percent) entitles the injured worker to an award of 125 weeks. For the permanent partial loss of vision, the percentage of vision lost determines the percentage of 125 weeks awarded to an employee.

Example Injured workers AWW = $400 2009 Statewide maximum AWW = $767 Injured worker lost fifth finger of left hand =15 weeks Actual payment to injured worker: $767 per week for 15 weeks for a total of $11,505.

b. c.

4.

Exceptions and variances

*The loss of the metacarpal bone (bones of the palm) for the corresponding thumb or finger, add 10 weeks. In no case shall the amount received for the loss of one or more fingers exceed the amount provided in this schedule for the loss of a hand. **There must be two-thirds loss of the second, third, fourth or fifth toes, or one-half loss of the great toe before an injured worker can receive any permanent partial disability payment. If the level of amputation of the hand or foot is such that an artificial appliance, when it is applied, would render the elbow joint or the knee joint stiff, then the injured work32

A loss of vision award requires a medical report by an ophthalmologist. The report is to include the injured workers pre-injury uncorrected vision in addition to post-injury uncorrected vision. The injured worker may submit the report, or a BWC specialist exam may obtain it. If the injured worker submits the report, BWC schedules a file review. Example Date of injury Feb. 15, 2009, statewide AWW $767 Right eye - 45 percent vision lost Left eye - 55 percent vision lost Right eye = 125 weeks x 45% = 56.25 x $767 = $43,143.75 Left eye = 125 weeks x 55% = 68.75 x $767 = $52,731 .25 Total award for both eyes $95,875

This award is payable in weekly or biweekly installments. The IC must determine this award for loss of vision. d. The Permanent Total Disability section covers the total loss of sight in both eyes.

C. Facial disfigurement
Facial disfigurement is a one-time award granted under ORC 4123.57 for visible damage to the face or head. Such an injury has the potential to impair the injured workers ability to secure or retain employment. 1. Application and payment b.

Disfigurement is an altered or abnormal appearance. This may be an alteration of color, shape, structure, and function, or any of these in combination. There is usually no loss of body function and little or no effect on the activities of daily living. Disfigurement may cause social rejection, which can result in a withdrawal from any social contact, an unfavorable self-image, life-style alteration, or other behavior changes. In some instances, medical providers may restore function without improving appearance, or appearance may improve without altering function. Scars are skin abnormalities that result from the healing of burned, traumatized, or diseased tissue and represent a special type of disfigurement. In determining the amount of the award, consider the following: The seriousness and nature of the disfigurement; The permanency and/or reparability of the disfigurement, regardless of whether it is actually repaired or not; The type, size (length and width) or discoloration; Whether a scar or other serious disfigurement previously existed.

An application for a facial disfigurement award is not required. You may initiate and pay this award without benefit of a hearing, unless there is a dispute. You pay such an award in a lump sum. In claims with injury dates of June 30, 2006, or later, the amount of the award can be up to $10,000. In claims with dates of injury prior to June 30, 2006, awards could not exceed $5,000. This award is in addition to other types of partial disability or scheduled loss awards. Take care to avoid causing any further embarrassment or trauma to the injured worker during this process. If there is no dispute, you should pay the award within 21 days of receipt of the medical evidence. 2. Employment

See the chart on the next page. c. The living spouse will receive awards made after the death of an injured worker. If the spouse is also deceased, you will determine whether you will pay the award to dependent children or other dependents. Hearing process

It does not matter whether the injured worker is gainfully employed in any occupation or trade at the time of the facial disfigurement determination. 3. Disfigurement impairment evidence

2.

You should not require the injured worker to present themselves for personal viewing to determine the extent of injury(s) and/or award. The physician of record should submit photographs to assist in the determination, as well as an impairment evaluation report, including medical, vocational and psychological assessments, as necessary. 4. Award determination

When this is a disputed issue, you should complete a C-86, and file it along with related medical evidence with the IC. An IC hearing officer then determines the award. The hearing officer bases his or her conclusion solely on the medical or clinical findings specifically expressed in the physicians reports. You are to pay any compensation ordered within 21 days of receipt of the hearing order.

D Wage loss compensation

ORC 4123.56 (B) (2) OAC 4125-1-01 Wage loss is payable in medical-only or lost-time claims with dates of injury on or after Aug 22, 1986. You may pay wage loss compensation to an injured worker that suffers a reduction in earnings because of a physical or psychological allowed condition in the claim when they: Return to employment other than his or her former position of employment due to reduced physical capabilities; 33

If there is an impairment, make awards regardless of whether the disfigurement is permanent and/or repairable. The amount of the award may vary depending on the extent to which the disfigurement is permanent and/ or repairable. a. The disfigurement impairment

Structural Facial Disfigurement Impairment Chart

Structural facial disfigurement impairment (after treatment)
Unilateral total facial paralysis (one side) Mild

Facial Disfigurement Award (recommended range)

Not to exceed $1,000 DOI on June 29, 2006, or prior: $1,000 to $5,000 DOI on June 30, 2006, or after: $1,000 to $10,000

Unilateral total facial paralysis (one side) Severe

Bilateral total facial paralysis (both sides) Mild

DOI on June 29, 2006, or prior: $1,000 to $5,000 DOI on June 29, 2006, or prior: $1,000 to $5,000

Bilateral total facial paralysis (both sides) Severe

DOI on June 30, 2006, or after: $1,000 to $10,000 DOI on June 29, 2006, or prior: $5,000 DOI on June 30, 2006, or after: $10,000

Deformity of outer ear or nose Severe disfigurement above the brow line Severe disfigurement below the upper lip

$0 to $2,500 $0 to $1,000 $1,000 to $2,500

Unable to find employment consistent with his or her physical/psychological capabilities; Return to former position of employment but at reduced hours due to reduced physical capabilities; Return to work at the former employer but at a different job or reduced hourly rate due to their reduced physical/psychological capabilities.

Wage loss is payable as a weekly benefit. The weekly beginning and ending dates may vary, based on the work schedules of the injured worker. You typically encounter partial weeks of wage loss at the onset and at the end of wage loss. Maintain the wages earned by the injured worker you used in calculating the wage loss due in the file along with verification of wage loss payment. The ORC has made many changes regarding wage loss. Therefore, the length of time an injured worker may receive wage loss and the manner in which you calculate wage loss is dependent on the date of injury. 1. a. Length of time wage loss is payable For claims with a date of injury on or after August 25, 2006, an injured worker may receive a maximum of 200 weeks of wage loss. These 200 weeks includes both working and non-working wage loss, as well as

Injured workers declared at maximum medical improvement (MMI) and released to return to work with restrictions that you cannot accommodate may be eligible for wage loss. However, the injured worker may also be eligible for temporary total. Its the injured workers choice wage loss or remains on temporary total. A release to return to work with restrictions does not require an injured worker change from temporary total to wage loss. You may elect to pay salary continuation when an injured worker returns to work with restrictions. In this case, as the injured worker is receiving full salary, there is no wage loss payable. 34

living maintenance wage loss (LMWL), regardless of which type of wage loss you pay first. You may extend the 200 weeks of wage loss up to 226 weeks, if you paid 26 weeks of non-working wage loss. Non-working wage loss is limited to 52 weeks; you exclude the first 26 from the 200 weeks maximum. Example 1 Type wage loss Non-working Working Total eligible Weeks paid 52 174 226 c.

up to the maximum compensation rate for the year in which the injury occurred. There is no minimum amount set for paying wage loss. Current earnings as recognized by BWC Gross hourly wages Gross salaries Paid sick leave Wage replacement program fully funded by the employer (long term disability) Personal time Compensatory time Holiday pay Overtime pay Shift and holiday differential pay Bonus payments, including stock given as a bonus* Profit sharing Commissions on sales Tips Per diem and travel allowances Severance pay

Example 2 Type wage loss Weeks paid Non-working 15 Working 200 Total paid 215 Additional eligible 11 of non-working b. For claims with date of injury from Aug. 22, 1986, through August 24, 2006, the injured worker may receive up to 200 weeks of wage loss (combination of working and non-working) regardless of the number of weeks of LMWL previously paid in the claim. You may not reduce this 200 weeks by any LMWL paid. Example 1 Type wage loss Weeks paid Non-working 52 LMWL 148 Working 48 Maximum payable 348 Weeks paid 200 200 400 Wage loss calculations For claims occurring on or after May 15, 1997 calcu, late wage loss using the injured workers previously calculated AWW, less the current earnings. This amount is the wage loss, and you pay the injured worker at a rate of 66 2/3 percent of that amount, up to the maximum compensation rate for the year in which the injury occurred. There is no minimum amount set for paying wage loss. For claims occurring prior to May 15, 1997 calculate , wage loss using the greater of the previously calculated FWW or AWW, less the current earnings. This amount is the wage loss, and you pay the injured worker at a rate of 66 2/3 percent of that amount, Example 2 Type wage loss LMWL Working

*When you pay bonuses based on performance over a specified period, you apportion the bonus over the same time frame in which the injured worker earned it. Per section 4123-5-20(C), BWC does not consider vacation pay present earnings. 3. a. Good faith job offer When you make an offer of restricted duty employment to the injured worker, it should be in writing. The offer should establish a date, time and location to report, and explain the duties the employee will perform. You should maintain a copy of this offer in the claim file. A sample letter offering a light duty position is on this page. This offer should indicate it is within the limitations noted by the physician of record. This offer cannot be for a shift other than that the injured worker originally worked. It also cannot be at a location that requires the injured worker to travel farther than to the regular employment. If the injured worker refuses a good faith job offer, he or she may still receive wage loss, although at a reduced amount. Alternate duty/restricted duty/restricted hours When an injured worker returns to work for the same employer with limitations, it is not necessary for him 35

2. a.

b. c.

d.

b.

4. a.

or her to complete an Initial Application for Wage Loss (C-140), nor to submit weekly payroll information, since the employer is already in possession of this information. b. When the employer is unable to accommodate the current restrictions the physician of record lists, the injured worker has the option to remain on temporary total or to receive wage loss. If the restrictions become permanent, and the employer is unable to accommodate, then the injured worker is to seek employment elsewhere within the established restrictions to be eligible for non-working wage loss. Non-working wage loss The injured worker should complete the (C-140) and the Wage Loss Statement for Job Search (C-141), and register with the ODJFS*. This registration must remain active throughout the job search period. *See Job and Family Services contact information in the temporary total section. To continue to be eligible for non-working wage loss, the injured worker must continue to submit the form C-141 at least every four weeks and continue to have updated restrictions provided by the physician of record to the employer. Factors to consider when determining if the injured worker is making a good faith job search include: Number of employers contacted each week; Number of hours spent seeking employment should approximate the number of hours worked prior to the injury, unless current restrictions limit the number of hours permitted to work; Method used in contacting employers. In person is preferred. If other method is used, then the injured worker should provide documentation, such as printout of the e-mail submission; The C-141 should be completed fully for each of the employers contacted and be signed by the injured worker; The positions applied for should be within the physical capabilities of the injured worker and his or her skill and educational levels; You have the right to verify all job searches.

Light-duty job offer sample letter

June 14, 200X Dear Jane: Your doctor has released you for light-duty employment. Since you have not yet reached maximum medical improvement and cannot return full time to your former position, we would like to include you in our transitional-duty program. Please consider this a formal offer of employment at the ABC Nursing Home. We will place you in a nursing position, but we will only expect you to work 7 to 11 a.m., five days per week. We will modify the duties of the job to be consistent with the restrictions imposed by Dr. Robert Spine. Your job responsibilities will include checking patients blood pressure, temperature and making chart notations; dispensing medication and giving injections, and making appropriate chart notations. In addition, you will answer phones, send and receive faxes, and use the computer for scheduling, sending and receiving work-related e-mails. We will prohibit you from moving or lifting patients. You cannot lift or work above shoulder level. The position is available as of July 1, 200X, and you will receive your normal rate of pay. Since this is less than the regular number of working hours, wage loss will supplement your wages through our workers compensation program. Please sign the bottom of this sheet to acknowledge your acceptance of this position. If you have any questions, you can reach me at 123888-9999 or by e-mail at wgreen@abc.com. Sincerely, Sincerely,

c.

5. a.

b.

c.

William Green
William Green, W.C. Administrator ABC Nursing Home Emergency Drive Anytown, OH 99988 _____________________________________________ I accept the position and terms as described above. Signed,

6. a.

Wage loss calculation examples Injured worker returns to employment with restrictions and reduced earnings. The earnings noted are for a full week.

Jane Smith

6-14-0X

36

AWW - earnings = wage loss x 66 2/3 = wage loss payment $875.50 - $423.70 = $451.80 x 66 2/3 = $301.20 b. Injured worker returns to work for a partial week. A daily rate can be established for the AWW and wage loss calculated accordingly. This typically occurs at the onset and at the end of wage loss. Injured worker returns to work, but unexpectedly has to take off for a family emergency for two days. Do not use this time away from work against the injured worker as there is no established pattern of abuse. AWW - earnings = wage loss x 66 2/3 = wage loss payment $875.50 - $270 = $605.50 x 66 2/3 = $403.66 d. Injured worker returns to work but routinely misses one or two days of work per week for any number of reasons. You could consider this a pattern of abuse. You should note that the injured worker is voluntarily limiting the number of hours worked per week. In this case, you add the amount the injured worker could have earned while working restricted duty to what he or she did earn. Injured worker offered 30 hours at $8.50/hr = 255 AWW - earnings = wage loss x 66 2/3 = wage loss payment worked 20 hours x 8.50 = $170 limited 10 hours x 8.50 = $ 85 $ 255 $875.50 - $255.40 = $620.50 x 2/3 = $413.67 e. Injured worker returns to work and takes unpaid vacation leave for one week. In this situation, compute the wage loss as voluntarily limiting earnings. Injured worker offered 40 hours at $8.50/hr = $340 AWW - earnings = wage loss x 66 2/3 = wage loss payment $875.50 - $340 = $535.50 x 66 2/3 = $374 f. Injured worker refuses a good faith job offer. In this instance, compute the wage loss as voluntarily limiting earnings. Injured worker offered 40 hours at $8.50/hr = $340 AWW - earnings = wage loss x 66 2/3 = wage loss payment $875.50 - $340 = $535.50 x 66 2/3 = $374 7. Stopping the payment of wage loss

b. c.

Injured worker finds suitable employment at the same rate of pay and same number of hours as the former position of employment; When the statutory period of 200 weeks has occurred.

c.

The IC may terminate benefits when: a. Injured worker fails to accept good faith written job offer of suitable employment (work within the injured workers physical capabilities and which the injured worker may perform, subject to all physical, psychiatric, mental and vocational limitations to which the injured worker is subject at the time of the injury, which resulted from the allowed conditions in the claim); b. The hearing officer finds one of the above situations.

E. Permanent total disability compensation

The IC bases the determination of permanent total disability (PTD) upon medical documentation and other evidence that an injured workers compensable injury has become totally disabling. In addition, the condition likely will remain unchanged for an indefinite time and prevents the injured worker from engaging in any type of substantially remunerative employment. The IC would also consider PTD if the injured worker sustained the loss or loss of use of any combination of two of the following: hands, arms, feet, legs, or eyes (Statutory PTD). However, in claims with dates of injury on or after Aug. 25, 2006, according to ORC 4123.58(C) (1), the loss of a limb does not constitute the loss or loss of use of two body parts. Thus, the injured worker is not entitled to statutory PTD based on the earlier Thomas v. Industrial Commission case. The decision to grant PTD is under the total jurisdiction of the IC staff hearing officers unless you voluntarily accept PTD. 1. a. Processing The injured worker should complete the Application for Compensation for Permanent and Total Disability (IC-2) to obtain PTD. He or she should file the IC-2 along with along with medical proof of the permanent condition to the IC. If the injured worker receives temporary total benefits when he or she files the application, you should continue temporary total as long medical documentation supports it. After the injured worker files the application, the IC refers him or her for a specialist examination. Once completed, the IC reviews all documentation and determines the award based on the evidence in the file. 37

You may terminate benefits when: a. Injured worker returns to full duty at his or her former position of employment;

b.

If it seems clear that the injured worker cannot engage in any employment due solely to his or her medical conditions, it may issue a tentative order without a hearing. If neither party objects to the tentative order within 14 days, it becomes final, and you should pay it once the appeal period ends. c. d. e. If you file an objection, then the claim is set for a hearing before a staff hearing officer. The injured worker or you may appeal staff hearing officers decision to the IC. In all cases where the IC grants PTD = you should pay compensation within 21 days after receipt of the final hearing order. Duration

3. 4. 5. 6.

AWW is under the minimum, the minimum is the PTD rate; If 2/3 of the AWW is above the minimum, but below the offset amount, 2/3 of the AWW is the PTD rate; If 2/3 of the AWW is above the offset rate, SSD could affect the PTD rate; If 2/3 of the AWW is less than the offset rate, then SSD will not impact the PTD rate; If 2/3 of the AWW is more than the offset, then we add the weekly SSD amount (monthly amount x 12 /52) to offset rate (2/3 of the SAWW) and If that total exceeds the max (SAWW) then the PTD rate is the offset; If that total is less than the max, then the PTD rate is the 2/3 of the AWW (which will be between the max and the offset.

2.

ORC 4123.58 authorizes PTD compensation. It is payable for the life of the injured worker. If circumstances arise that indicate the injured worker is no longer permanently and totally disabled, and then you may terminate compensation only if ordered by an IC hearing officer. You or the injured worker may appeal the staff hearing officers decision to the IC. 3. Calculation of the award and rate of payment

Examples Example for 2005 date of injury: SAWW (max or high max) is 678 2/3 SAWW (offset or low max) is 452. Minimum is 339 AWW is $305 declared rate would be $305 (AWW is below the minimum, so we use the minimum). AWW is $345 2/3 is $230 declared rate would be $339 (AWW is above the minimum but 2/3 of the AWW is below, so we use the minimum). AWW is $650 2/3 is $433.33 declared rate would be $433.33 (AWW is above the minimum, 2/3 of the AWW is above the minimum, but below the offset (2/3 SAWW), so SSD doesnt affect the calculation, so we use 2/3 of the AWW). AWW is $750 2/3 is $500 because 2/3 of AWW is above the offset (2/3 SAWW), SSD amount may impact the rate. o Monthly SSD is $500, weekly SSD is $115.38. ($452 + $115.38 = $567 .38; below SAWW). Declared rate will be $500. AWW is $750 2/3 is $500 because 2/3 of AWW is above the offset (2/3 SAWW), SSD amount may impact the rate. o Monthly SSD is $985, weekly SSD is $227 .31. ($452 + $227 .31 = $679.31; above SAWW). Declared rate will be $452 AWW is $1,050 2/3 is $700 because 2/3 of AWW is above the offset (2/3 SAWW), SSD amount may impact the rate. o Monthly SSD is $500, weekly SSD is $115.38. ($452 + $115.38 = $567 .38; below SAWW). Declared rate will be $678. AWW is $1,050 2/3 is $700 - because 2/3 of AWW is above the offset (2/3 SAWW), SSD amount may impact the rate. o Monthly SSD is $985, weekly SSD is $227 .31. ($452 + $227 .31 = $679.31; above SAWW). Declared rate will be $452.

Base the rate of compensation on the employees AWW at the time of injury or the date of disability due to an occupational disease, the injured workers age, and if he or she receives Social Security Disability (SSD) payments. The IC hearing officer will calculate these awards only if a dispute arises between the injured worker and the employer. The PTD rate calculation worksheet is available from BWC upon request. The PTD declared rate calculation quick reference: 1. AWW for the claim; 2. Two-thirds of the AWW for the claim; 3. The maximum amount allowed for the date of injury (SAWW); 4. The offset amount allowed for the date of injury (2/3 SAWW); 5. The minimum amount allowed for the date of injury (50% SAWW); 6. The % of PTD payable in the claim. PTD rate calculations are based on the same rules that are used for TT (except for the impact that Social Security benefits have on the calculation). If the IW is not receiving SSD, the PTD rate is calculated as follows: 1. If the AWW is below the minimum, the AWW is the PTD rate; 2. If the AWW is above the minimum, but 2/3 of the 38

SSD amount to be used for calculation is the SSD effective on the PTD begin date (PTD begins March 23, 2006, the SSD amount for March 2006 is used) no matter when the PTD is granted. Even if the SSD wont affect the rate, we encourage the practice of obtaining the SSD (required if using the Rate Calculation Worksheet). The PTD rate is recalculated if the SSD amount decreases and/or stops or starts (originally $0.00, but then IW begins receiving). See example below. c. Injured worker not receiving SSD on PTD begin date March 23, 2006, use $0 SSD. Injured worker begins receiving SSD on July 1, 2007 , use that amount. Any rate change as a result of the recalculation is effective July 1, 2007 . Injured worker SSD decreases effective April 1, 2008, use that amount. Any rate change as a result of the recalculation is effective April 1, 2008. Injured worker SSD increases, PTD rate is not recalculated. Along with the PTD benefits, the injured worker may also be entitled to Disabled Workers Relief Fund (DWRF) benefits based on the PTD rate and the Social Security benefits. BWC pays the injured worker these benefits. As of Aug. 22, 1986, BWC bills all selfinsuring employers dollar for dollar for DWRF payments (See ORC 4123.411). See additional information in this guides DWRF section. Statutory permanent and total disability

5.

Traumatic brain injury

Effective Aug. 25, 2006, ORC 4123.58(F) specifies an injured worker receiving compensation for PTD due to a traumatic brain injury is entitled to receive that compensation regardless of the employees subsequent employment in a sheltered workshop. This applies as long as he or she does not receive more than $2,000 in compensation from the job per calendar year. For more information on permanent total disability, please refer to the BWC Web site, ohiobwc.com and PTD Guidelines.

F. Change of occupation
ORC 4123.57 (D) (E) When an injured worker has contracted or suffers from silicosis, coal miners pneumoconiosis or asbestosis, he or she may file an application for a change of occupation award. This also applies to fire fighters and police officers who have contracted a cardiovascular or pulmonary disease due to exposure in their jobs. The IC will consider determination of the award when: It has found the injured worker h to have contracted one of the above occupational diseases; Its determined the change of occupation is medically advisable to decrease exposure; The injured worker has changed or shall change his or her joccupation to one in which the exposure substantially decreases.

4.

An injured worker is automatically entitled to PTD compensation if the injury resulted in the loss or loss of use of: a. Both hands; Both arms; Both legs; Both feet; Both eyes; Any combination of two of the above.

File the application for this award on the C-86 and submitted it to BWC or the IC. The issue will be set for a formal hearing before a district hearing officer. If granted, the IC bases the change of occupation award on the date established at the IC hearing. See BWCs Web site for the calculation and determination of the award. No injured worker is entitled to receive more than one allowance for change of occupation, and he or she cannot receive this award at the same time as receiving temporary total benefits for the occupational disease.

To avoid the hearing process, you and the injured worker can sign and submit the IC-22 to the IC for approval, along with the application IC-2. A statutory permanent total disability award is payable for the life of the injured worker even if he or she can return to some type of work. Effective Aug. 25, 2006, ORC 4123.58(C) clarifies the loss or loss of use of one limb does not constitute the loss of two body parts when considering compensability of statutory PTD.

b.

G. Death benefits ORC 4123.59, 4123.60

When an injured worker dies because of a work-related injury or occupational disease, those persons wholly or partially dependent upon the deceased for support at the time of death are entitled to benefits. This could include a weekly award of compensation, medical and funeral expenses, and any compensation accrued prior to death.

c.

39

Use the FROI-1 as the first notice of death for benefits in a claim. Acceptable submissions include a letter requesting benefits, online notification or telephone notification. The injured worker can also sue the BWC Additional Information for Death Benefits (C-5) to provide more documentation. 1. Applying for benefits

3. a. b.

Disputed claim You report the death to the BWC and indicate you reject the claim. BWC investigates the claim is investigated and obtains a death certificate, marriage license, birth certificate(s), an autopsy report when available and other pertinent information if not previously submitted. Once BWC obtains all pertinent information, the matter is set for a hearing before the IC. If allowed by the district hearing officer, payments must start within 21 days after receipt of the hearing order. Death benefit awards

c. d. 4.

When preparing to file a claim, the injured workers dependents must provide various proofs, including: a. Proof that the death was work related, or that the death resulted from an earlier work-related accident or occupational disease. If the death resulted after a period of work-related disability, the attending physician must submit a statement explaining the relationship of the disability and subsequent death; A death certificate is required; Proof of dependencies is required if members of the deceaseds family are to qualify for benefits. Such proof includes: 1) 2) 3) A marriage certificate for dependent spouse; Birth certificates for dependent children; A statement from the academic institution to support full-time attendance for children ages 18-25; 4) A statement from a licensed physician attesting to mental or physical incapacitation for dependent children over age 18; 5) Birth certificates or baptismal records in absence of birth certificates for all other dependents such as parents or brothers and sisters; Proof of wages earned by the deceased for the year prior to the injury is necessary to establish the rate of compensation.

b. c.

If an injury or an occupational disease causes the death, you pay the weekly award at 66 2/3 percent of the deceased workers AWW. This wage will not exceed the statewide maximum average weekly wage for the year of the death. Regardless of the injured workers actual earnings, the weekly rate will not be less than 50 percent of the SWAWW for the year the worker dies. This applies regardless of the AWW at the time of the injury or date of disease. 5. Funeral expenses

d.

When there are multiple dependents, they should use the Self-Insurers Agreement as to Compensation on Account of Death (C-59) or the Application for Adjustment of Claim in Case of Death Due to Occupational Disease (OD-58-22). 2. a. b. c. Allowed claim The employer reports the death to BWC. The AWW is calculated. You review the proof of dependency and apportion the benefits to the appropriate individuals. Allocate benefits based on the relationship and the total number of dependents. Pending the actual apportionment, you may pay the entire compensation amount to the dependent spouse.

The funeral benefit award is payable in allowed death claims, regardless if death occurred suddenly or a considerable time passed between the initial work-related cause and eventual death. You are responsible for reimbursement, not to exceed $5,500, to a funeral director, family member or volunteer who has paid or otherwise incurred funeral expenses for claims with the date of feath on or after April 9, 2003. For claims with the date of death prior to April 9, 2003, the maximum amount payable is $3,200. ORC 4123.66 and OAC 423-5-13. 6. Reapportionment of benefits

In the event that the number of dependents eligible to receive benefits changes, you reapportion the death benefits to the remaining dependents if you and the remaining dependents agree upon the arrangement. Changes could result from when a widow remarries, a child reaches the age of 18 or drops out of school, a death occurs, etc. Should the surviving spouse re-marry, he or she is entitled to a two-year dowry (equal to benefits paid over a twoyear period), then you reapportion benefits to any other dependents. 7. Statute of limitations

The IC will only become involved if there is a dispute.

Dependents must file a death claim within two years of the date of death in accordance with ORC 4123.84. 40

8.

Lump sum advancement on a death claim Per ORC 4123.64 and OAC 4123-3-37 you may grant , lump sum advancements from a death claim to a surviving spouse, but not the dependent children. You can make advancement for any amount up to the present day value of the two-year dowry. However, you cannot make lump sum advancement to a surviving spouse for an amount that exceeds the amount of death benefits payable over a two-year period. The maximum amount payable from death benefits, which equals to the two-year dowry, includes attorney fees.

c.

After completion of the inspection, BWC will schedule a settlement conference with all parties to resolve the matter or obtain additional information. If the matter is not resolved, the IC will hold a hearing. Once the IC or a staff hearing officer renders a decision, you and the injured worker will receive and order via the mail. There is no appeal from an IC order concerning the percentage of the award, but if either party is dissatisfied with the results of the order, they may file aC-86 for a rehearing. At that time, they must list reasons for the rehearing, and provide additional proof if applicable. Computation of the award

d.

H. Violation of specific safety requirement

A violation of a specific safety requirement (VSSR) is an additional award that you may pay to an injured worker when proven you were in VSSR adopted by BWC. The violation must have occurred prior to the date of the accident or prior to the recognition of the occupational disease. The Ohio Constitution provides for the additional safety violation award for only those injuries arising from a violation of a VSSR. Specific Safety Requirements in effect concern: 1. a. The operation of elevators; Construction industry; All workshops and factories; Metal casting; Steel mills; Laundering and dry cleaning; Rubber and plastic industries; Window cleaning; Fire fighting. Application and process The injured worker or his or her dependent(s) must apply for the VSSR award within two years of the date of injury, disease or death. They complete and submit the Application for Additional Award for Violation of Specific (IC 8/9) to BWC. Note: The injured worker or his or her dependents may not file the application for additional safety award before filing a claim for workers compensation benefits. b. After filing the application, BWC notifies you, and sends you a copy of the form. BWC sets a date by which you must respond to the application for the additional award. At that time, you may submit any evidence in your defense for BWC to consider. Upon receipt of the employers response, BWC will schedule a site inspection.

2.

Any safety award is in addition to compensation paid under the other provisions of the Workers Compensation Act. The award will range from 15 percent and 50 percent of the maximum award payable at the time of the injury. BWC computes the VSSR award on the percentage awarded times the statutory maximum rate allowable on the date of the injury, times the number of weeks of compensation paid. This applies to all types of compensation paid. Example Date of injury: Jan. 2, 2006, BWC awards temporary total compensation for a three-week period, from Jan. 3, 2006, to Jan. 23, 1996, at a rate of $452 per week. The maximum rate allowable for the year of the injury was $704 per week. VSSR awarded by the IC is 25 percent Formula: $704 x 25 percent = $176 x 3 weeks = $528 The first payment accrues to date and issued, and then you should pay the remainder in biweekly installments. It is possible that the employees weekly amount from the regular compensation award, plus the additional award, could total more than the employees normal working wage. BWC and the IC consider this award as a penalty against the employer. Each additional period of compensation paid in the claim will trigger the calculation and additional payments of the VSSR award. 3. Civil penalties

In addition to determining VSSR awards, the staff hearing officer has the authority to issue an order for you to correct a VSSR within a fixed period. He or she can also assess a civil penalty against you in an amount up to a maximum of $50,000 for each violation when at least two violations occur within 24 months of each other. 41

To assess a civil penalty against the employer, the following must occur: The violations must have occurred on or after Aug. 26, 1996, at the same workplace, but can be of a different type or kind of violation; If the violations occur at two or more workplaces, they must violate the same safety requirement(s).

c. d.

When determining the amount of the civil penalty, the staff hearing officer will base the decision on the size of the employer as measured by the number of employees, assets, and earnings of the employer. An employer may appeal the penalty as follows: Staff hearing officer order to the IC commissioners; IC commissioners can refuse the appeal under ORC 4123.511 (E); Decisions of the IC commissioners to a Court of Common Pleas.

e.

You are responsible for filing the application with the appropriate IC office for consideration. The IC then has 30 days to approve or deny the settlement. The IC considers the 30-day waiting period a cooling-off period for the settlement parties. Either party can withdraw from the settlement and re-negotiate any changes in the terms during this period. Per ORC 4123.65, the parties may not waive the 30-day waiting period. The IC deems the settlement approved if it has not issued a denial within the 30-day period as defined in 4123.65(C) ORC. You should make payment to the injured worker immediately after the 30 days expire.

J. Lump sum advancements

A lump sum advancement is the pre-payment of future compensation from previously awarded compensation benefits. The IC awards advancements based on the guidelines in ORC 4123.64 and OAC 4123-3-37 The only . applicable benefit types are: Permanent total disability; Death benefits.

The payment of any fine assessed can be held in abeyance pending the final appeal to the VSSR orders. 4. Temporary employees

When an employee of a temporary employment agency becomes injured while on assignment, and receives a VSSR award, BWC will charge the client employer with the VSSR award. BWC defines the client employer as the employer who contracted with the temporary employment agency for services by a temporary agency employee. The temporary agency must pay compensation and medical benefits, but the client employer pays the VSSR award.

You may process lump sum advancements requested by injured workers, however, the determination of the request for lump sum advancement for attorney fees remains the jurisdiction of the IC for determinations and awards per OAC 4121-3-10. Use the Application for Lump Sum Advancement (C-32) for this request. Effective Dec. 1, 2004, BWC permitted injured workers to elect the period over which they could recoup the lump sum advancement five years, 10 years, 20 years or lifetime. If the injured worker selects lifetime, the reduction in his or her benefits is permanent, otherwise, once the term expires, BWC will reinstate the original benefit amount. 1. Eligibility

I. Full and final settlements

Final settlements, also known as lump sum settlements, are under the ICs jurisdiction (See IC Resolution R94-1-16 and 4123.65 ORC). a. b. A final settlement can include all of an injured workers open claims, one claim, just a part of one claim or any combination of claims. Initially you and injured worker negotiate the terms of the settlement. Both parties complete and sign the Self-Insured Joint Settlement Agreement and Release (SI-42).The injured worker must also complete and sign the Acknowledgment of the Self-Insured Joint Settlement and Release (SI-43). Submit both forms within five days of the date of the agreement.

Injured workers may only use lump sum advancements under special circumstances. They must use the money for either financial relief or rehabilitation. They should provide documentation to substantiate the need for financial relief. These can include household bills, estimates of emergency repairs or purchases, school tuition, handicap lift installation, transportation, etc. You may deny advancements for luxury items, down payments or automobiles unless submitted evidence supports the purchase is necessary for the injured workers health, well-being or rehabilitation.

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2.

Benefit reductions and computations

Divide the total requested amount by the PV factor of 458: $30,000 458 = $65.50. Determine the maximum allowable reduction: One-third of the original $300 PTD is $100. $100 is the maximum reduction allowable in the example given. As the calculated amount in this request was $65.50, the injured workers $300 per week PTD rate will permanently decrease by $65.50 to $234.50. b. Lump sum advancement reduction for scheduled loss claims *Effective Oct.12, 2010 scheduled awards are payable in a lump sum. In scheduled loss claims, the advancements cannot exceed the balance of the unpaid award. The lump sum advancement request is generally for the balance of award. You may advance the balance of the award so there is no remaining amount left to pay. Determine the balance available from the scheduled award. Example Assume an award has been made of 175 weeks for an amputated hand, paid at $730 per week. You have paid 40 weeks totaling $29,200. 135 weeks remain unpaid for a balance of $98,550. If the lump sum advancement is for the balance of award, use the right side of the Present Value Factor Chart to calculate the present value of the unpaid award from which you can make a balance of award advancement. Convert the unpaid weeks to years. 135 unpaid weeks 52 = 2.5 years Using the right side of the Present Value Factor Chart, find the PV factor for 2.5 years. 2.5 years = 2.2817 Present Value Factor Convert the weekly rate to an annual rate. $730 weekly rate x 52 = $37 ,960 annual rate Multiply the annual rate by the present value factor to establish the present value of the balance of the award. $37 ,960 x 2.2817 = $86,613.33 $86,613.33 is the present value of $98, 550.00, if prepaid by 2 and one-half years. If you advance the balance, you will make no future payments for the scheduled loss award. 43

Lump sum advancement may create a permanent reduction in the weekly benefit rate. Therefore, you must inform the injured worker of the full financial impact before issuing the requested advancement. When you deny or grant a lump sum advancement, you must notify the parties, in writing, of the decision regarding the request, which provides: The reason for the decision; The amount of any advancement; The amount and duration of any rate reduction.

Any decision may be appealed to the Industrial Commission within 14 days of receipt of the decision but is not appeasable to the courts. a. Lump sum advancement reduction for PTD claims In PTD claims, each lump sum advancement awarded, or the sum total of all advancements awarded, cannot exceed more than one-third of the injured workers original weekly rate for compensation excluding the amount for attorney fees. The advancement will reduce the weekly rate for the balance of the injured workers life. This reduction is regardless of whether the injured worker outlives the life expectancy table on which the reduction in benefits is calculated. The examples in this manual use BWCs Lump Sum Settlement Net Present Value Factors Chart to find the factor for the injured workers current age and PTD type (Survivor, PTD-Non Occupational Disease (OD), PTD-OD Lung or PTD-OD Non Lung.). The NPV chart is available on BWCs Web site, ohiobwc.com. Example Assume the injured worker has elected a permanent reduction, his or her current age is 56, and the PTD type is OD Lung. The PV factor for an injured worker, age 56, PTD-OD Lung, is 458, with a life expectancy of 13.4 years. The original PTD rate is $300. Determine the weekly PTD rate reduction by dividing the total lump sum advancement amount by the PV factor. Assume the injured worker requested a lump sum advancement of $30,000 payable for transportation and handicap lift installation.

c.

Lump sum advancement reduction for death claims In death claims, advancements to the surviving spouse cannot exceed the amount equivalent to two years of death benefits. If the spouse has not remarried, the Present Value Chart will discount the twoyear dowry. d. Example Assume the spouse of a deceased injured worker receives $460 per week in survivor benefits. The two=year dowry would have resulted in benefits of $460 x 104 weeks = $47 ,840. Convert the weekly rate to an annual rate. $460 x 52 = $23,920 annual rate

In the case of re-marriage, the Present Value Chart cannot discount the two-year dowry. However, upon re-marriage of the spouse, you must offset the two-year dowry payment based on any previous advancement(s) already paid as a lump sum advancement to the spouse that still affects the claim. Lump sum advancement for attorney fees (ORC 3121.03.111 and OAC 4121-3-10) The approval for a request for a lump sum advancement for the payment of attorney fees is under ICs jurisdiction of the Industrial Commission, which will determine the need, and make approvals as warranted. Use the Application for Lump Sum Advancement (C-32) for this request.

Using the right side of the Present Value Factor Chart, find the PV factor for two years. Two years = a present value factor of 1.8528 Multiply the annual rate by the present value factor to establish the present value of the dowry. $23,920 x 1.8528 = $44,318.98 present value $44,318.98 is the present value of $47 ,840, if prepaid by two years. You can make advancement for any amount up to the present value of the dowry. Determine the reduced weekly rate of the dowry. Assume the spouse requests $15,000. Establish the present value factor, by using the spouses current age in the survivor column of the PV Chart. Age 30 - present value factor is 913 Determine the weekly reduction by dividing the advancement by the present value factor. $15,000 913 = $16.43 Determine the new weekly rate by subtracting the reduction from the current weekly rate. $460.00 - $16.43 = $443.57 In accordance with ORC 4123.59(B) (1), when a dependent spouse remarries, you must pay a two-year dowry to the dependent spouse in a lump sum.

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V. Specialized areas
A. The Industrial Commission of Ohio (IC) hearings
Facts about the IC (www.ohioic.com) BWC and the IC are the two agencies that make up Ohios workers compensation system. The IC provides a forum for resolving claims fairly and impartially; determining eligibility for permanent total disability (PTD) benefits; adjudicating claims that involve possible employer violations of specific safety requirements (VSSR); and resolving disputed claims/claims issues. A three-person board of commissioners leads the IC. The governor appoints them for staggered terms of six years each. One commissioner represents employees, one represents employers, and the third represents the public. One commissioner also serves as the IC chairperson. He or she oversees the agencys administrative functions. 1. Hearing process 29 falls on Memorial Day (when IC and BWC offices are closed), the party will have until May 30 to file the appeal. The IC must receive all appeals by the end of the business day they are due. If the IC rules on a case and one or both parties did receive the hearing notice in a timely manner, the parties may ask for a new hearing by submitting a Request for .522/.52 Relief (IC-52) form. Parties may also request a new hearing online through I.C.O.N. (see IC Resolution R94-1-19). a. District hearing A district hearing officer (DHO) presides over this firstlevel hearing. Each party can present his/her position and the hearing officer may ask questions to get additional information, or to clarify points. The DHO may render a decision at the table, but must also issue it in writing within seven days following the hearing. At times, the hearing officer may issue an Interlocutory Order extending this timeline. Upon receipt of the DHO order, either party may file an appeal within the 14-day timeline outlined above. b. Staff hearing If either party files an appeal to the order the DHO issues, the next hearing will be with a staff hearing officer (SHO). This must happen within 45 days after the filing of an appeal. This hearing is de novo, meaning that all evidence presented is heard as new. Parties may present evidence again and submit additional information. The SHO may also ask questions and render a decision at the table. However, he or she must issue a written order within seven days of the hearing. The SHO may also issue an Interlocutory Order at this level, extending the timelines. Upon receipt of the SHO order, either party may file an appeal within the 14-day timeline outlined above. c. Industrial Commission hearing An appeal to the three-member Industrial Commission is discretionary. This means the IC may decline hearing an appeal if it appears there is no new evidence to review. These appeals must meet certain criteria. If the IC accepts the appeal for hearing, either the three-member commission or a deputy officer assigned by the IC will hear the case. Most hearings at this level take place in Columbus. As with the previous levels, the IC puts the decision in writing in a Notice of Findings and mails it to all parties.

The IC holds hearings to resolve claims disputes. Hearings take place at the IC service office nearest to the injured workers residence. All hearing officers are attorneys, and generally conduct four hearings per hour. There are three levels of hearings within the IC, starting with the district level and ending with the Industrial Commission. a. b. c. District hearing Staff hearing Industrial Commission hearing (discretionary)

The hearing process is informal. The injured worker, the employer or their representatives can present information to the hearing officer. Each party may choose to be represented by an attorney. The hearing must take place within 45 days of the filing of the claim, or the Motion (C-86). The IC puts the final decision in writing and mails copies of the Notice of Findings order to all parties (and their representatives) within seven days of the hearing. Either party has the right to file a Notice of Appeal (IC-12). The parties can file at any IC or BWC office. Either party also may complete and submit the IC-12 online at www.ohioic.com. Parties must file an appeal within 14 days from the date of receipt of the hearing officers order. The 14day time frame starts the day after the party receives the order. If the 14th day falls on a Saturday or Sunday, or on a state holiday, parties may file the appeal on the next business day. For example, if the party receives the order on May 15, the 14-day count starts on May 16. Technically, the appeal would be due no later than May 29. However, if May

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d.

Court of Common Pleas If the injured worker or employer is not satisfied with the ICs decision, or if the IC refuses to hear an appeal resulting from a staff hearing, then either party may file an appeal in the appropriate state court (as long as the dispute does not involve a decision on extent of disability). The parties must file in state court within 60 days of receiving the Refusal or the order. Parties must file the Notice of Appeal in the county where the injury or the occupational disease occurred.

Effective Aug. 25, 2006, you can opt out of the Self-Insured Employers Reimbursement Fund (Senate Bill 7). If you no longer participate in the fund, BWC will reduce your semi-annual assessment accordingly. But, you would not be entitled to reimbursement from BWC for any overturned claims. Furthermore, you cannot reverse your decision to opt out of the fund once youve made it. If you have questions, please contact BWCs self-insured underwriting department at 614-644-5062l.

B. Motions C-86 OAC 4123-3-16

1. Definition

2.

Payment of benefits during the hearing process

Employers do not have to pay compensation and/or medical benefits pending a district hearing officers order. However, if the DHO rules in favor of the injured worker, the employer must pay compensation regardless of any further appeal. The employer must start paying compensation no later than 21 days after receiving the order (OAC 4123-19-03 (K)(5)). Also, IC Resolution R96-1-03 mandates that the employer must make payments prior to the next hearing, if the DHO was appealed. If any party appeals the DHO, the employer can hold medical payments pending receipt of the order from the staff hearing officer. If the SHO rules in favor of the injured worker, the employer must pay hospital, medical, nursing and pharmacy bills for the claimant within 30 days after receipt of the order. 3. Recouping overpaid benefits following adjudication

Use a Motion (C-86) form whenever a dispute or disagreement arises between you and the injured worker in an allowed claim, and there is no specific application to address the issue. The form should fully explain the dispute and the action of relief sought, and it must include accompanying evidence to support the motion. If you initiate a motion, you must copy the injured worker and his or her representative. You may use a motion to request action on these and other issues. a. b. c. d. e. f. 2. Payment or termination of compensation benefit(s) Adjustment of full weekly wage or average weekly wage Request for allowance of additional condition(s) Request for allowance of psychiatric condition(s) Authorization for medical treatment(s) Payment of medical bill(s) How to file

The final ruling may find the injured worker received more compensation than he or she was entitled. You may withhold this amount from future awards to the injured worker. This applies to any claim, past, present or future (ORC 4121, 4123, 4127 or 4131). However, recovery of funds , must meet the criteria listed below. a. b. c. No withholding for the first 12 weeks of temporary total disability compensation No more than 40 percent of all awards of temporary total, and permanent partial compensation, until the overpaid amount is recovered No more than 25 percent of any permanent total compensation paid, until the overpaid amount is recovered

You, the injured worker or an authorized representative may file the motion with BWC or the IC and send a copy to the opposing party. [C-86]

C. Additional allowances
1. Definition

A final ruling by the IC or court may also find that the injured worker was not entitled to any compensation for the conditions sought. If so, you may apply for reimbursement from BWCs Surplus Fund for any compensation and benefits youve already paid (ORC 4123.34(B).

An injured worker is entitled to benefits for any new conditions related to his or her injury. Medical evidence must support this award for an additional allowance. The additional condition may be a direct cause of the original injury. It may also be an aggravation of or flow-through from the original injury. The physician of record should request this in writing from you. In some cases, you may pay to treat conditions not recognized in the claim. However, the medical services must be reasonably related to and necessary for the treatment of the allowed condition (per the Miller Case). Again, this

46

means you may pay for the treatment; but it does not mean you must add or allow new condition(s) to the claim. 2. Requesting an additional allowance

C-86 to request a formal hearing by the IC. Or, you must notify the injured worker of the denial in writing, and explain that he/she has the right to file a C-86 to have the issue heard before the IC. You may not use the ADR process if you do not have a QHP in place. Instead, you must inform the injured worker in writing of his or her appeal rights. You must let the injured worker know that he or she can file a C-86 to request an IC hearing.

When medical evidence supports an additional allowance, you may simply accept the new condition(s) and pay benefits accordingly. You may also choose to request an independent medical evaluation of the injured worker. This will help to determine if the additional condition has any relation to the original injury. However, you must advise the injured worker in writing if you think the medical evidence does not support the existence of a new condition. You must also notify the injured worker in writing if you do not agree an alleged additional condition relates to the claim. You must let the injured worker know that he or she has the right to file a C-86 with the IC to request the additional allowance. The IC will then adjudicate the motion per the hearing process outlined in Section A of this chapter.

E. Rebuttable presumption

ORC 4123.54

Ohio law allows you to disallow a claim filed by an injured worker who tests positive for drugs or alcohol, or refuses to be tested. This creates a rebuttable presumption that the employees intoxication is the proximate cause of the workplace injury. This shifts the burden of proof to the injured worker who must prove that any drugs or alcohol in his/her system did not cause the injury. To apply rebuttable presumption, you must post written notice of the policy before using it as a reason to deny a claim. You must post the notice in the same area as your certificate of workers compensation coverage. Postings are available from BWC.

D. Reactivation of a dormant claim

[Reactivate a claim] OAC 4123-3-15 An injured worker may request treatment or compensation for an injury in a dormant claim. If the claim has had no activity for 13 months, you must use the medical information the injured worker submits to evaluate the request.* Effective Oct.12, 2010 the period of inactivity has been changed to 24 months. 1. Granting the request

F. Statewide disability evaluation system (90-day examination) ORC 4123.53

1. Definition

You may grant the request without an order from the IC. This means you will authorize further treatment and pay medical fees and compensation, as applicable. 2. Denying the request

You may deny the request due to a lack of medical evidence or proof that the new conditions resulted from the original injury. If so, you must notify the injured worker in writing. This includes informing the worker of his or her right to appeal your denial to the IC and set a hearing. 3. Alternative Dispute Resolution OAC 4123-6-69

BWC makes sure that injured workers who receive temporary total benefits for 90 consecutive days will receive independent medical examinations by an approved panel of physicians. These exams are available to self-insuring employers if you have a QHP The exams determine: . The injured workers entitlement to continued temporary total compensation; The appropriateness of the medical treatment being given the injured worker; Whether the injured worker would benefit from a rehabilitation program. To schedule this exam, contact the BWC examiner assigned to your injured workers claim. 2. Failure to appear

If you have a Qualified Health Plan (QHP), you already have an alternative dispute resolution (ADR) process in place. This process allows you to determine the appropriateness of treatment in the ongoing care of injured workers. If you deny further or continuing treatment, you must complete two levels of appeal and review within 30 days. If both levels of review uphold the denial, you may file a

BWC will set up another appointment if the injured worker does not appear for his or her exam. BWC will send notices to all parties about scheduling for a second and final exam. If the injured worker does not appear for the second exam, you may suspend his or her compensation that day. The suspension would remain in effect until he or she completes the exam. 47

3.

Billing information

The physician who conducts the disability evaluation will submit the billing and the examination report to you. You must pay the bill within 30 days. 4. Travel expenses

cess the reimbursement through the surplus fund. Bankrupt self-insuring employers shall be assigned, by risk numbers, to an MCO. Who is eligible? An injured workers participation in a vocational rehabilitation program is voluntary. An injured worker is eligible for vocational rehabilitation services when the referred claim is allowed by a BWC or IC order with eight or more days off work due to a workrelated injury; or the claim is certified by a state university or state agency; or a claim is certified by a self-insuring employer; and the allowed injury creates a significant impediment to employment or to maintaining employment (job retention), and one of the following is true: The injured worker is receiving or has been awarded temporary total, non-working wage loss, or permanent total compensation, for a period of time that must include the date of referral (the first date a request for rehab services is received from anyone which is verified by a date stamp or note in the claim file). For purposes of this section, payments made in lieu of temporary total compensation (e.g. salary continuation) shall be treated the same as temporary total compensation; or The injured worker was granted a scheduled loss award under ORC 4123.57 (B); or The injured worker received or was awarded under division ORC 4123.57 (A) and has documented job restrictions as a result of that award documented by the physician of record and dated not more than 180 days prior to the date of referral; or The injured worker was determined to have reached maximum medical improvement in the claim (with eight or more days of lost time due to a work-related injury) by a BWC or IC order, or the injured workers physician of record has documented in writing that the injured worker has reached maximum medical improvement in the claim, and the injured worker is not currently receiving compensation and continues to have job restrictions in the claim as documented by the physician of record and dated not more than 180 days prior to the date of referral; or The injured worker is currently receiving job retention services to maintain employment or satisfies the criteria to receive job retention services on the date of referral; or, The injured worker has sustained a catastrophic injury and a vocational goal can be established; or The injured worker was receiving living maintenance wage loss not more than 90 days prior to the date of referral, has continuing job restrictions documented by the physician of record as a result of the allowed condition in the claim, and has lost his or her

You must reimburse injured workers who must travel more than 45 miles round trip for an exam. Please provide the injured worker with the forms needed to apply for reimbursement. These are the Injured Worker Reimbursement of Travel Expenses (C-60) and Reimbursement Rates (C-60-A) forms.

G. Vocational Rehabilitation
Introduction Vocational rehabilitation is the process of restoring the vocational functioning of a worker who experiences an industrial injury or occupational disease. It provides a comprehensive, focused program directed toward returning an injured worker to competitive employment. Vocational rehabilitation may help employers reduce claim costs by increasing return-to-work probability, reducing lost time, decreasing medical expenses and reducing the employers risk. Ohio Revised Code (ORC) sections 4121.61 through 4121.69 and sections 4123-18-01 through 4123-18-22 as well as applicable rules within chapters 4123-6 and 412317 of the Ohio Administrative Code (OAC) pertain to workers compensation vocational rehabilitation. According to OAC 4123-18-03, BWC is responsible for developing guidelines to aid in rehabilitation service delivery. Guidelines for MCOs are outlined in BWCs MCO Policy Reference Guide. As outlined in OAC 4123-18-16 (A), employees of self-insuring employers who opt to participate in a vocational rehabilitation program, and who are found to be both eligible and feasible to do so, shall be furnished vocational rehabilitation services through their employer. Such services shall be equal to or greater in quality and content than the services administered by BWC and managed by the MCO. This rule obligates the self-insuring employer to provide its injured workers with the opportunity to participate in individualized vocational rehabilitation programs. If a self-insuring employer participating in the rehabilitation surplus fund wishes to use vocational rehabilitation services, the disability management coordinator (DMC) in BWCs customer service office will approve/disapprove the vocational rehabilitation plans. The DMC will then pro48

job through no fault of his or her own; or The injured worker must not be working on the date of referral, with the exception of referral for job retention services.

Job retention services An injured worker is eligible for vocational rehabilitation services in a job retention status when currently working and experiencing a significant work-related problem as a direct result of the allowed conditions of the claim, and: The injured worker has received temporary total compensation or salary continuation from an allowed losttime claim (eight or more days off work due to workrelated injury); The physician of record provides a written statement, in office notes or correspondence, indicating that the injured worker has work limitations related to the allowed conditions in the claim that negatively impact the injured workers ability to maintain the injured workers employment; The injured workers employer describes the specific job task problems the injured worker is experiencing and these problems are documented in the claim. A statement describing why the injured worker needs job retention services should be documented.

tion would be beneficial, the injured worker should be referred to a vocational rehabilitation case manager. The case manager helps to determine if the injured worker is eligible and/or feasible for a vocational rehabilitation program. If the injured worker is eligible and feasible for vocational rehabilitation and wishes to pursue a rehabilitation program, the employer will work with the injured worker to set up a program. When the review of a referral results in the decision that there is no reasonable probability that the injured worker will benefit from rehabilitation, the reasons for that decision and notification of the appeals process shall be given in writing to all parties to the claim. Facts supporting the decision should be adequately documented and explained to the injured worker and the other parties to the claim. Vocational rehabilitation service providers Vocational rehabilitation case management must be delivered by qualified providers. OAC 4123-6-02.2(C)(36) identifies the type of credentials a vocational/medical case manager must maintain. The provider shall hold and maintain one of the following credentials through a nationally recognized accreditation committee: Certified rehabilitation counselor; Certified disability management specialist; Certified rehabilitation registered nurse; Certified vocational evaluator; Certified occupational health nurse; Certified case manager.

Non-eligibility for vocational rehabilitation services The injured worker is not eligible for vocational rehabilitation services and such services shall be terminated: After the effective date of a lump sum settlement; or If the claim is subsequently disallowed on appeal by an order of the IC, its district or staff hearing officers, or by an order of the court.

Feasibility determination and plan An injured worker may be determined eligible, but services may not be feasible (see Feasibility Determination and Plan). Referral An injured worker should be considered for a vocational rehabilitation program if there is an impediment to returning to or maintaining employment. Also, when the injured worker does not readily respond to medical treatment alone, vocational rehabilitation should be considered as the injured worker approaches medical stability. Anyone, including BWC, can refer an injured worker for vocational rehabilitation. Information or statements received about the injured workers need for vocational rehabilitation services are considered referrals for vocational rehabilitation. When it has been determined that vocational rehabilita Education; Medical history; Work history; Incentives as well as disincentives for rehabilitation and employment; Barriers to employment or program participation; Next best steps regarding re-employment. The vocational case manager meets with the injured worker to assess the injured workers current situation. Topics may include the injured workers:

According to OAC 4123-18-03, an injured worker may be determined eligible, but may not be feasible for services. Feasibility for vocational services means that there is a reasonable probability that the injured worker will benefit from services at this time and return to work as a result of the services. Feasibility is initially determined at the time of referral and is assessed throughout the rehabilitation process. 49

An injured worker is feasible for vocational rehabilitation services when a review of all available information demonstrates that it is likely the provision of such services will result in the injured worker returning to work. The injured worker is not feasible for vocational rehabilitation services when a review of all available information demonstrates that, in spite of services, it is unlikely the injured worker will return to work. All available information means records, documents, written and oral statements, and any and all medical psychological, vocational, social and historical data of any kind whatsoever, developed in the claim through which vocational rehabilitation is sought or otherwise, that is relevant to the determination of an injured workers feasibility for vocational rehabilitation services. A determination of feasibility shall be written and shall enumerate all available information used to make the determination. The vocational rehabilitation case manager may schedule evaluations, as necessary, to further assess the appropriateness of vocational rehabilitation interventions and/or establish case direction. Vocational rehabilitation plan Once the injured worker is both eligible and feasible for vocational rehabilitation services, a written rehabilitation plan is developed outlining how the return-to-work goal is to be accomplished. These services occur as the injured worker becomes medically stable and the physician of record indicates the worker is ready for an active vocational rehabilitation program focused on the goal of return to work. A vocational rehabilitation plan is a written outline of the expectations of both the employer and the injured worker. If the plan is to be successful the injured worker, employer and the rehab case manager should all agree on its contents. This plan establishes: The injured workers goals; The services that will be used to accomplish these goals; Those who will provide services; When services will take place and for how long. It is also important to include the physician of record when writing a vocational rehabilitation plan. The physician must be in agreement with the chosen services and provide prescriptions for services where necessary. The plan is to be signed by the injured worker. OAC 4123-1816 (B) indicates that the self-insuring employer shall submit a copy of the approved vocational rehabilitation plan to the injured worker and the injured workers representative. 50

Where possible, rehabilitation plans should reflect that the injured worker will approximate a 40-hour work week, or that the injured worker participates at least three days per week in plan activities. Return-to-work hierarchy An attempt should be made to return the injured worker to employment to as close to pre-injury wages as possible to prevent increased wage loss. Research has shown the use of the return-to-work hierarchy provides the most cost effective, efficient and permanent re-employment of injured workers. To help facilitate the most appropriate and cost-efficient return to work, the vocational case manager shall consider and address each step of this hierarchy sequentially. The documentation should support why any step can be ruled out in the rehabilitation plan narrative. Skill enhancement, remedial or short-term training may be used at any level of the hierarchy, when appropriate, to aid injured workers in successfully returning to work. The return-to-work hierarchy OAC 4123-18-02 states that the goals of vocational rehabilitation are to return the injured worker to: Same job, same employer The first goal is to return the injured or disabled worker to his or her former employer in his or her original job; Different job, same employer To encourage the employer to modify the original job or to provide employment in a different job with that employer; Same job, different employer To assist the injured worker in finding employment with a different employer in a related industry; Different job, different employer To assist the injured worker in finding a new job in any industry. Amended plans A plan amendment is written when the initial rehabilitation plan does not result in employment and/or the vocational rehabilitation case manager identifies a new barrier before completion of the current plan. An amended plan continues within the framework of the existing return-towork goal, or it establishes a new one and outlines how the injured worker will proceed with the next steps in the vocational rehabilitation program. Copies of any approved plan amendments must also be sent to the injured worker and the injured workers representative. Interruptions during plan OAC 4123-18-04(B) allows a vocational rehabilitation plan in progress to be interrupted due to an injured workers medical instability. The medical condition causing the instability does not have to be related to the allowed condition. The following are the two types of plan interruption.

Medical interrupt A rehabilitation plan may be interrupted for no more than 30 days to allow the injured workers medical instability to resolve, or to collect information about the condition. The vocational rehabilitation case manager will advise as to the appropriateness of continuing living maintenance during this 30-day period based on the injured workers diagnosis and prognosis. If plan closure is determined, other forms of compensation should be made available to the injured worker when possible. Medical hold A medical hold is a temporary closure of the rehabilitation plan. It occurs when an injured worker experiences a medical event that is anticipated to last longer than the medical interrupt. A medical hold will retain the injured workers eligibility for vocational rehabilitation service for up to a maximum of two years from the date of plan closure. Plan closure procedure Closure of a vocational rehabilitation plan should occur after: The injured worker has completed a vocational rehabilitation plan; or The injured worker has failed to fulfill the responsibilities outlined in the vocational rehabilitation plan; or The injured worker is unable to attain the goals for the vocational rehabilitation plan; or The injured worker has refused, without good cause, to accept an offer of employment within the vocational goal of the rehabilitation plan; or The injured worker is no longer living; or The injured worker does not agree with the (employers) MCOs or BWCs decision to approve or deny specific vocational rehabilitation plan services; or The claim is subsequently disallowed by an IC order, its district or staff hearing officers, or by an order of the court; or The claim is settled (medical and/or indemnity); or The injured worker has been found to be eligible/feasible, has been notified of the decision but chooses not to participate. A written determination shall be given on all referrals and will include the reason for the closure and the process to be followed should the decision be appealed. This notification should be sent to all parties to the claim. Parties to the claim have the right to appeal a rehab case closure decision. During the established appeal period no further action should be taken on the vocational rehabilitation case. A closure may be rescinded during the appeal time period if the employer and injured worker agree to keep the vocational rehabilitation case open.

Careful consideration for closure should be taken to avoid premature closures. Once closed, an injured workers rehab file should not be reopened within 30 days of the closure date unless documentation can be provided to justify a significant change in circumstances and eligibility still exists. Compensation Self-insuring employers shall pay living maintenance or salary continuation (i.e., wages in lieu of compensation) directly to the injured worker where necessary while he or she participates in a vocational rehabilitation plan. Payments shall be made in accordance with paragraph (A)` of OAC 4123-18-04. Living maintenance payments shall be issued in weekly amounts not to exceed what the injured worker received in temporary total, but not less than, fifty percent of the current state weekly wage. Payments shall commence when the injured worker begins to participate in the approved rehabilitation programs. If salary continuation is offered by the self-insured employer, an injured worker with a lost-time claim may choose to receive either salary continuation or living maintenance during vocational rehabilitation. However, if temporary total or living maintenance has been paid in the claim, the injured worker must receive living maintenance when participating in vocational rehabilitation. Whenever the employer pays salary continuation, it must be paid at the injured workers regular (full) salary level. After the plan is completed, an injured worker who has received salary continuation maintains the right to any future benefits, if otherwise eligible, such as living maintenance wage loss compensation. If the injured worker fails, without good cause, to participate in his/her vocational rehabilitation plan, deductions from living maintenance payments equal to one seventh of the weekly payment can be made for each day of noncompliance. In some circumstances, an injured worker could receive wages or other remuneration while participating in a vocational rehabilitation plan and receiving living maintenance. The checks must either be endorsed over to the self-insured employer, or the employer shall deduct the payments from the injured workers living maintenance payments or from future awards of compensation. Termination of living maintenance Occurs when: The injured worker has returned to work other than as part of a gradual return to work plan; or 51

Closure of the injured workers vocational rehabilitation plan as outlined in prior section titled Plan closure procedure a reflection of OAC 4123-18-05 (E).

The termination of living maintenance shall not affect an injured workers right to compensation or benefits under the ORC for which the injured worker otherwise qualifies. Living Maintenance Wage Loss (LMWL) Compensation According to OAC 4123-18-21, an injured worker with a date of injury on or after Aug. 22, 1986, who completes an approved rehabilitation plan, successfully returns to work and experiences a wage loss while employed, is eligible for living maintenance wage loss compensation. The wage loss must be a consequence of the physical and/or psychiatric limitations caused by the impairments resulting from the allowed conditions in the claim as documented by the injured workers physician of record on a MEDCO-14 form or equivalent. An injured worker requesting living maintenance wage loss payments shall be required to complete and submit an Authorization for Living Maintenance Wage Loss (RH18) or equivalent as well as medical documentation of the physical and /or psychiatric limitations as described above. 1. To submit an initial application for living maintenance wage loss payments, the injured worker must have successfully returned to work. 2. Subsequent applications for living maintenance wage loss payments must be submitted by the injured worker before the specified end date of the restrictions provided by the injured workers physician of record or every six months, whichever occurs first. Note: Successfully returned to work as a result of an approved vocational rehabilitation plan means that the injured worker has obtained employment within 60 days of closure of the injured workers approved vocational rehabilitation plan and the employment is within the physical and/or psychiatric limitations caused by the impairments resulting from the allowed conditions in the claim in which the injured worker completed the vocational rehabilitation plan, as documented by the injured workers physician of record; and is reasonable in comparison with the return-to-work goals of the vocational rehabilitation plan completed by the injured worker. Suitable employment and comparably paying work have the same definition as in OAC 4125-1-01 The injured worker cannot voluntarily limit his or her income by choosing to work fewer hours or at wages below reasonable expectations if more appropriate jobs are rea52

sonably available within the local labor market. If the injured worker voluntarily limits his or her income by choosing to work fewer hours or by accepting a job that does not constitute suitable employment which is comparably paying work, the injured workers living maintenance wage loss benefits shall be calculated as 66 2/3 percent of the difference between the greater of the injured workers full weekly wage or average weekly wage on the claim for which the injured worker underwent rehabilitation plan and the weekly wage the injured worker would have earned had the injured worker not voluntarily limited his or her income. Wage statements must be submitted to verify the wage loss on a regular basis. If the injured worker has a substantial variation in income the wage documentation may be submitted on a quarterly basis. If an injured worker accepts employment that is below the reasonable expectations of the return-to-work goals of the vocational rehabilitation, or if the injured worker can reasonably be expected to obtain different employment for which earnings are more comparable to those prior to injury, the injured worker may be required to make a good faith effort to search for suitable employment with comparably paying work. To receive living maintenance wage loss payments after approval of the benefits, the injured worker must provide proof of earnings at least every four weeks in the form of pay stubs, payroll reports from the injured workers current employer or listed on a Wage Statement (C-94-A) or equivalent. An injured worker may receive up to a maximum of 200 weeks of living maintenance wage loss, provided in accordance with ORC 4121.67(B), less any weeks of wage loss, provided in accordance with ORC 4123.56(B), that have been previously paid. Appeals Any decision that affects an injured workers benefits or compensation may be appealed. OAC 4123-6-69 delineates the dispute resolution process for self-insuring employers who have a Qualified Health Plan (QHP) to deliver medical services to their employees, including vocational rehabilitation. All self-insuring employers with a QHP are required to have an alternative dispute resolution (ADR) process. This ADR process includes vocational rehabilitation issues and affords due process regarding conflicts. When there are disputed issues between the self-insuring employer and parties to the claim, the issues must be decided by the IC as outlined in OAC 4121-3-13. The employee (or dependents) or the employer may file a motion with BWC describing the issue in dispute. BWC will prepare the claim and forward the claim to the IC within sev-

en days. BWC will also notify the opposing party when a motion is filed. Injuries sustained while participating in a vocational rehabilitation plan If an injured worker sustains a new injury or occupational disease while participating in an approved vocational rehabilitation plan, he or she can file a claim. These claims should be filed only for new injuries or occupational diseases. Claims filed as a result of an injury sustained while participating in a rehabilitation plan should follow the normal claims processing procedures.

depression and related return-to-work concerns; Career counseling to assist injured workers who require a substantial change in vocation due to post-injury physical and emotional issues.

Dispute resolution Procedures developed to resolve medical disputes prior to filing an appeal. Ergonomic study An ergonomic study is an analysis of how the worker responds when performing the job in relation to the work environment. It examines the fit between the worker and the job requirements. An ergonomic study takes into account the workers size, strength and ability to handle the tasks, tools and work environment. It is generally used to evaluate the risks of the job and to recommend job modifications. Exercise equipment Exercise equipment is for the sole purpose of maintaining the injured workers physical conditioning for rehabilitation plan participation when access to an exercise facility isnt available. The physician of record should recommend the equipment. Gradual return to work This program allows an injured worker to return to work on a graduated basis building up to a full-time work status, usually within 13 weeks total per vocational rehabilitation referral date. The physician of record must review the plan to make sure the process is within the injured workers restrictions and provide a release. The physician of record must then prescribe that the injured worker can return to work on a part-time basis of at least 20 hours a week and gradually increase to a full-time schedule within 13 weeks total. A gradual return to work vocational rehabilitation plan should include documentation of the scheduled work hours. The scheduled hours to be reimbursed must be agreed upon. Both the employer and the injured worker should sign the plan to indicate agreement. Payments to the injured worker can be either through continuing the living maintenance or paying the injured worker a salary. If the living maintenance method is chosen, payments shall not exceed the injured workers initial living maintenance rate. Job analysis A job analysis is the process of examining a job and collecting measurements while the job is being performed. It explains what the worker does, how he or she performs the work and the outcomes of the work. It identifies the essential functions of the job and describes the physical 53

Terms and service descriptions

The following section provides a listing of vocational rehabilitation terms and services. Although not all inclusive, these services provide the case manager with a guide to best practices in vocational rehabilitation service provision and increase the likelihood of an injured workers successful return to work. Case managers may find a need to provide further services which may not be listed in order to meet the individual needs of an injured worker. Automobile repairs Services for necessary repairs on an injured workers automobile for the sole purpose of allowing participation in a rehabilitation program. Body mechanics education A body mechanics education program instructs the injured worker on topics such as spinal anatomy, the use of proper body mechanics, pacing techniques, injury prevention, methods for managing pain and how lifestyles contribute to pain. Biofeedback training Biofeedback training develops the injured workers ability to control the autonomic (involuntary) nervous system and aids in pain management. Child/dependent care Child/dependent care is for the sole purpose of allowing the injured worker to participate in a rehabilitation program. Counseling Counseling assists injured workers in managing personal/emotional issues that interfere with vocational rehabilitation progress and present barriers to return to work. Professional counseling services that may be used in the course of rehabilitation plans include: * Adjustment counseling to assist injured workers in overcoming disability related life changes, situational

demands of the required tasks, working conditions, and the knowledge, skills and experience generally required to safely perform the job. A job analysis includes information about the tools and equipment used in performing the job. Job club Job clubs are highly structured group meetings composed of job seekers and a facilitator. Participants cultivate skills through actively conducting their job search with training and guidance from the job club facilitator. This program aids a group of injured workers in obtaining job leads and teaches good job search performance. Job coach A job coach is a vocational specialist who provides on-site guidance, training and assistance to the injured worker, focusing on job performance in the actual work situation. This behaviorally based program concentrates on teaching specific instructions to assist in completing the jobs required tasks and maintaining appropriate work behaviors. Note: This service is customarily used with individuals who have traumatic brain injuries, psycho-behavioral conditions, catastrophic injuries or developmental disabilities. Employment should be secured first in order to use this service. Job modification Job modification is the removal or alteration of physical barriers that may prohibit an injured worker from performing essential job functions. These barriers may also prevent the worker from obtaining or maintaining employment. It is generally used for return-to-work positions that are considered permanent. An actual on-site job analysis is usually necessary to begin the process of job modification. The case manager usually works with the employer, injured worker, physician of record and other professionals as appropriate to ensure the suitability of the modification. Job placement and development A professional job-seeking service that assists injured workers in locating jobs. Often, job placement specialists acquire and maintain ongoing relationships with employer contacts in the business community. Job placement specialists use their contacts within the business community to assist injured workers in matching their skills with jobs that may be modified. Job placement professionals direct the injured worker in their job search by providing job leads, setting job search procedures and goals, and closely following their clients progress, correcting/redirecting the performance of the activities of the client along the way. Documentation should be provided detailing all job placement contacts. Job retention services 54

These services allow an injured worker (with a previously allowed claim in which compensation was paid) who experiences a significant impediment to maintaining employment to be involved in a vocational rehabilitation program. This problem must be a direct result of the allowed conditions in the claim. A significant impediment to maintaining employment means that the functional problems would cause the worker to lose the current job without receipt of services. Job search An individualized program for an injured worker who cant return to the original employer and has the transferable skills and physical capacities to return to an appropriate job in the labor force. Generally, the case manager coordinates the program and writes the number of job contacts required per week on the rehabilitation plan. The injured worker conducts a job search monitored by the rehabilitation case manager and or the job placement specialist. Job seeking skills training (JSST) Specialized training includes activities that focus on developing skills to obtain employment. It is a group program that helps injured workers to develop job-seeking techniques such as interviewing skills and resume development. This service is usually used in conjunction with job search, job club, or job placement. JSST may be provided individually if waiting for a group program to begin would hinder case progress. Nutritional consultation/weight control These services are offered for weight reduction and weight maintenance when the condition presents a barrier to participation in vocational rehabilitation plan services and return to work. These services must focus on behaviorally oriented nutritional counseling and not on quick weight-loss techniques primarily based on dieting supplements or packaged foods. Occupational Rehabilitation (Comprehensive Occupational Rehabilitation) also known as Work Hardening A comprehensive occupational rehabilitation program is focused on assisting the injured worker to return to the job while minimizing the risk of re-injury. It is interdisciplinary and individualized with a sound vocational direction and measurable outcomes. The program addresses, when appropriate, the reasonable accommodations or adaptations for the injured worker and the work environment. When possible, a specific job goal should be identified prior to services. This program must have CARF accreditation. Occupational therapy Occupational therapy services focus on improving the injured workers job performance level, level of daily activities and physical activities for return to work. Although

services should not be provided in the home, occupational therapy services may be provided at the injured workers work site. On-the-job training On-the-job training allows an injured worker to obtain or upgrade vocational skills through actual work experience. This training should be provided under the close supervision of an experienced person skilled in the targeted job. The vocational rehabilitation plan narrative should be very specific as to the responsibilities of each participant and should include: * An explanation of the targeted job and skills necessary to perform it; * The physician of records release; * The training outline, a schedule of training costs and equipment; * Signatures of the injured worker, case manager and the employer/trainer. As a guideline, the on-the-job training program should not exceed the Specific Vocational Preparation time frames identified in the Classification of Jobs. Pain management program (interdisciplinary pain rehabilitation program) An interdisciplinary pain-management program increases an injured workers pain-management skills and physical activity to allow a return to work. The program must have a strong, well-integrated vocational component. Multidisciplinary services should include: medical services, physical/occupational therapies, nutritional counseling, pharmacological counseling, psychological services and vocational counseling. Physical reconditioning (unsupervised) Unsupervised physical reconditioning is provided at a health club, YMCA/YWCA, spa or nautilus facility and doesnt include supervision by a licensed physical therapist. Physical therapy Active physical therapy within a vocational rehabilitation plan is provided after the receipt of acute treatment modalities. It is provided when the injured worker needs to increase overall physical capacities and attain maximum strength, endurance and range of motion for return to work. This service focuses on the total body and not just a specific injured body part. Although services should not be provided in the home, physical therapy services may be provided at the injured workers work site through transitional work on-site therapy services. Qualified Health Plan (QHP) A QHP is a self-insuring employers managed care plan that must be approved by BWC prior to implementation. Employers plans must be implemented according to the

QHP rules and the QHP standards agreement. Relocation expenses (formerly known as mobility grants) Reimbursement for relocation expenses provides financial assistance to injured workers who have obtained employment and must relocate because the job location is beyond the reasonable expectation of daily commuting. Situational work assessment An evaluation of an injured workers ability to perform specific job tasks using vocationally focused skills assessments to simulate a targeted job (or job family). Successfully returned to work means that the injured worker is on the job, plan services have been completed and the rehabilitation plan is closed. Tools and equipment This service provides for the purchase of tools and/or equipment (e.g., chairs, etc.) necessary for employment or participation in an approved vocational rehabilitation plan. Training remedial (such as GED); short term (less than one year); long term (maximum of two years) An organized form of instruction from an accredited academic, business and/or trade school. A comprehensive vocational evaluation, including a transferable skills assessment is helpful before submission of a plan for longterm training. All long-term training programs should be provided at schools with effective employment placement programs. Training plans should include a labor market analysis for the targeted job goal to show feasibility of return to work following the program. The vocational rehabilitation case manager usually submits a copy of the injured workers official grade report at the end of each grade period to verify full-time attendance and successful completion of course work. GED training should not be the only plan service in any rehabilitation plan. Whenever possible, training plans may be coordinated with the Rehabilitation Services Commission. Transitional work on-site therapy services Transitional work is a work-site program that provides an individualized interim step in the recovery of an injured worker with job restrictions resulting from the allowed conditions in the claim. The overall program is developed in conjunction with the employer, the collective bargaining agent (where applicable), the physician of record and rehabilitation professionals. Transitional work programs have been shown to be one of the most effective ways to help injured workers progressively perform real work tasks and thus maintain employment. The programs have been well received by workers who want to protect their employability, or ability to work, 55

and by employers who wish to maintain their skilled work force and reduce disability-related costs. An occupational therapist or physical therapist provides on-site transitional work therapy to the injured worker at the work site. This therapy assists the injured worker in progressively performing the duties of a targeted job. Reimbursable services may include such activities as administering treatment modalities and other duties aimed at improving physical function, work task analysis, evaluating the injured workers progress and participating in staffings, as appropriate. Unallowed conditions Unallowed conditions may be treated within a vocational rehabilitation plan, if they are clearly aggravating the injury, preventing healing, impeding rehabilitation or are barriers to return to work. This treatment should be concurrent with plan services but not be the primary focus of the plan. Vocational evaluation A vocational evaluation is a process that gathers vocational information about an injured worker, usually through the use of real or simulated work, to assist in determining vocational direction. A transferable skills analysis is a necessary component of reimbursable vocational evaluations. The overall results are based on integrating the injured workers physical capacities, medical, psychological and vocational data with realistic vocational options which exist in the labor market. Two Types of Vocational Evaluation: * Vocational screening Uses simple paper and pencil tests and transferable skills analysis. Relies primarily on vocational interview and clients self-reports of interests and job history. * Comprehensive vocational evaluation Uses extensive client interview and vocational exploration. Uses psychometric testing which may include aptitude, dexterity, achievement and vocational interest testing. Uses transferable skills analysis and the use of commercial work samples or real work tasks. Note: The administration of a comprehensive vocational evaluation must be within the scope of practice of the service provider as authorized by his or her professional certification commission or licensure board. It is the responsibility of each professional to be aware of services that may or may not be within that scope of practice. Vocational exploration and guidance Vocational exploration and guidance assists the injured worker in formulating a new vocational direction when it is determined that he or she cannot attain the physical re-

quirements necessary for the previously identified vocational goal. It is provided as a vocational rehabilitation case management professional service. Vocational rehabilitation The process of restoring the vocational functioning of workers who experience an industrial injury or occupational disease. Vocational rehabilitation case management The development and coordination of a variety of vocationally restorative services designed to restore the injured workers functional capacities and employability. Case management involvement maximizes the injured workers ability to return to work in a safe and cost-effective manner. Since some injured workers have difficulty making this transition back to work, the specialized services of a vocational rehabilitation case manager may be needed to organize and plan this important goal. The case manager works with the injured worker, employer, supervisors, treating physician etc. to ensure timely and appropriate services. The provider shall hold and maintain one of the following credentials through a nationally recognized accreditation committee: * Certified rehabilitation counselor; * Certified disability management specialist; * Certified rehabilitation registered nurse; * Certified vocational evaluator; * Certified occupational health nurse; * Certified case manager. Work adjustment (facility based or employer based A specialized structured program that improves an individuals work behaviors both job performance and social skills needed for successful functioning prior to the injured workers return to work. This program is designed to help the injured worker reach objective measurable goals, and it is usually facility based. Specific behavioral objectives and progress should be documented and reviewed. Work conditioning A work conditioning program involves an individualized treatment program focused on regaining optimal function, prevention and return-to-work goals. The program goals should address improvements in cardiopulmonary, neuromuscular, and musculoskeletal functions. The program incorporates job simulation tasks and is usually used when there is a vocational goal (job title) although the injured worker is not returning to a specific job. When appropriate, the program addresses reasonable accommodations for the worker and adaptations to the work environment. Work Hardening (See Occupational Rehab)

56

Work trial A work trial program permits an injured worker to attempt a return to work in the original job or at a new job with either the same employer or a new employer. It allows an employer to test, evaluate and observe the worker at the actual job prior to hiring. The case manager usually will monitor and document the injured workers progress based on reports from the injured workers direct supervisor at the workplace.

(PTD). Eligibility for DWRF benefits depends on the PTD rate and Social Security disability information. 2. Obtaining information

H. Subrogation ORC 4123.931

This is the right to recover costs from a third party or person for workers compensation benefits you paid to, or on behalf of, an injured worker. You must prove that the third partys negligence contributed to causing the accident. Example An employee of a trucking company has an injury while working. It happened when another motorist cut him off in traffic and caused an accident. The self-insuring employer must pay compensation and benefits to its employee, the truck driver. However, the employer should also contact the other motorist and his insurance company. This will help the employer to recover costs up to the amount it paid for the truck drivers claim. 1. Legislation

BWCs DWRF section receives notification when an injured worker receives a declaration of PTD. BWC then requests information from the injured worker, the employer and the Social Security Administration. BWC reviews all this information to determine if the injured worker is entitled to DWRF benefits. 3. Benefit payment

BWC determines DWRF eligibility, calculations and payments. BWC makes payments directly to injured workers who are eligible for DWRF benefits. Then, BWC bills you for the full amount of payments made. DWRF benefits are payable only to the injured worker. So, surviving dependents will not receive DWRF as part of their death benefits should the injured worker die. Settling a claim does not automatically stop DWRF payments. Therefore, you must include DWRF when settling a PTD claim. 4. Stopping or amending payments

Senate Bill 227 established these rights when it passed in late 2002. You may subrogate valid third-party claims with dates of injury on or after April 9, 2003. 2. Recovery

You must inform the BWCs DWRF section if: a. The injured worker dies; b. You settle the claim; c. The injured worker turns 65 years old (as the rate changes at that age). Direct any questions to BWCs DWRF section.

As a self-insuring employer, you are responsible for recovering your subrogation costs. You must follow BWCs formula for establishing and dispersing subrogation settlements. 3. Check list

J. Self-insured complaint procedures

BWCs self-insured department investigates and attempts to resolve all allegations of improper claims administration against self-insuring employers. ORC 4123.35(G) establishes the jurisdiction for this process and OAC 412319-09 sets the procedures. 1. a. Filing a complaint The injured worker or his or her representative may file a complaint directly with BWCs self-insured department. Only parties to the claim will receive notification of the complaint (i.e., the injured worker, the self-insuring employer and their representatives). BWC accepts inquiries and complaints by telephone or e-mail at siinq@bwc.state.oh.us. Injured workers or their representatives may also file a complaint by 57

You can use BWCs subrogation information gathering check list as a guide (subrogation check list). While not all-inclusive, it provides guidelines as to when and how to gather information needed to recover benefits paid.

I. Disabled Workers Relief Fund (DWRF) (See BWC Web site)

1. Eligibility b.

DWRF benefits provide a cost-of-living adjustment for injured workers who are permanently and totally disabled

completing the Filing of a Complaint Against a Self-Insured Employer (SI-28). However, BWC accepts any complaint or allegation made in writing. c. Medical providers may file complaints or inquires with BWC by calling 1-800-644-6292. The Ombuds Office conducts an initial investigation. If the initial review indicates a probable violation, the unit will refer the issue to BWCs self-insured department as a formal complaint. There is a two-year statue of limitation on complaints. BWC will not investigate events that occur prior to this time frame. Processing the complaint Incoming complaints go to the self-insured complaint unit, where the staff assigns it an internal number. An auditor reviews the complaint summary to determine if there is enough evidence to move forward. He or she will request additional information as needed.

a.

Employers, injured workers and their representatives receive a letter dismissing the complaint when BWC finds the allegations are not valid. The letter clearly indicates the process for appealing this decision. BWC mails a letter to the employer when the findings indicate a violation of a law, rule or resolution and the matter is considered resolved. BWC also sends copies to the injured worker and to representatives. The letters clearly indicate the process appealing this decision, within 14 days. BWC retains a copy of the valid violations as part of the employers risk file. The agency reviews such violations at the time of the employers annual renewal of the self-insurance privilege. When a violation of a law, rule or resolution is found and remains unresolved, a letter confirming the unresolved violation is mailed to the employer. Copies are also mailed to the injured worker and authorized representative(s). The employer has seven days to respond. If the employer does not respond to the finding of a valid violation within seven days, BWC will refer the case to the Self-Insuring Employers Evaluation Board. Appeals/reconsiderations Parties must file an appeal within 14 days of receiving BWCs decision. All parties to the complaint may file a request for reconsideration. In order to consider this request, BWC must receive evidence of new or changed information that bears on the initial decision. BWCs Legal Division reviews all reconsideration summaries. The administrators designee then reviews the reconsideration and issues a decision. BWC will then issue a decision in writing. Any party who is still not satisfied with the decision must file an appeal within 14 days of receiving the new decision. The Self-Insuring Employers Evaluation Board hears such appeals. Self-Insuring Employers Evaluation Board ORC 4123.352 and 4123-19-13 The board consists of three members. A member of the IC representing the public serves ex officio, as chairman. A member of the Ohio Self-Insurers Association also serves. The governor appoints him or her with the advice and consent of the Ohio Senate.

b.

d.

2. a.

c.

d. b. BWC faxes a letter and any supporting material to notify the employer of the complaint. BWC also mails a hard copy of the complaint. 5. Note: The employer must respond to the complaint. BWC will distribute the complaint according to the most recent information the employer provided the bureau. So, you should always inform BWC of relevant changes within your company. c. BWC requires employers to respond in writing within 14 days of receiving the notification letter. Employers with good cause may contact the assigned BWC representative to request an extension. Investigating the complaint The assigned auditor will gather information on the complaint. He or she will use the information to evaluate the allegations and uncover pertinent facts. The timetable for this evaluation depends on the quality of the supporting material the injured worker and employer supply. But, in most cases, the auditor completes a determination within 45 days of notifying the employer by fax. BWC notifies the employer, the injured worker and their representatives when the investigation is complete. The notification letter lists all findings and conclusions. Resolution of the complaint d. e. a.

b.

c.

3. a.

6. a. 1) 2)

b.

4.

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3)

A member of labor also serves on the board. The governor appoints him or her with the advice and consent of the Ohio Senate. No more than two members may be of the same political party. The board meets monthly to review any complaints (and accompanying investigation documents). It renders decisions at an informal conference. The board does not need to make its determinations by formal hearing. However, it must put its decisions in writing and signed by at least two members. The board will notify all parties if it needs to hold a formal conference before rendering a decision. During the conference, each party gets a chance to present a statement. Once both parties present their positions, the board makes a final determination. There is no appeal to the boards decision within BWC. Penalties The Self-Insuring Employers Evaluation Board may fine a company a maximum of $10,000.00 for each violation. BWC maintains inquiries for two years in an employers complaint file. It maintains valid complaints of a confirmed violation of a law, rule or resolution in the employers risk file for two years.

a.

b. c.

You must have a company office located within the state of Ohio, along with a knowledgeable person to administer your workers compensation claims program. This persons responsibilities must include, but may not be limited to: processing and allowing or rejecting claims; providing forms to injured workers; paying (or overseeing) compensation and benefits; maintaining claim files, and making them available for inspection by injured workers, their representatives and BWC. The injured workers claim file must be available for review within 72 hours of notification (written) from the employee or his or her representative. Claim files maintained out-of-state, or at a thirdparty administrator You must house your claim files in Ohio. BWCs selfinsured department must give you permission in writing to house the files out of state or at a third-party administrators office. When BWC grants such permission, it is contingent on the companys ability to maintain a workers compensation program that complies with Ohio laws and rules. The company must furnish a toll-free telephone number to all injured workers. It must also allow employees to review their claim files within 72 hours after making a request. The company workers compensation administrator is required to attend and participate in all BWC audits. If the audit occurs outside Ohio you are responsible for the prepayment of the BWC auditors travel expenses. Availability of claims files for audit OAC 4123-19-10 You must make your records and facilities available to BWC employees to conduct an audit during office hours.

b.

d.

2. a.

7.

b.

K. Interpreter services OAC 4123-19-03

Ohio law states you must provide assistance and information to injured workers in relation to their workers compensation claims. See Interpreter services. You must provide assistance if a language barrier impedes the injured workers understanding of his or her rights. This also applies to any barriers to their understanding of claims forms and medical documentation. In state-fund claims, BWC determines whether an interpreter is reasonable, necessary and appropriate. The agency generally approves use of an interpreter for medical specialist consultations. As a self-insuring employer, you are responsible for these costs. The IC also provides interpreter services to injured workers and employers. This applies to the hearing impaired or those who require foreign language interpretation for hearings and medical exams. Complete and submit a Request for Interpretive Services (IC-INT) prior to the hearing date to request this service.

3.

M. Handicap reimbursement
1. Definition

Handicap reimbursement is a cost-relief program. The state of Ohio uses it as an incentive to encourage employers to hire and retain employees with disabilities or military service handicaps (see OAC 4123-3-35). The handicaps may be physical or mental, and can be congenital or due to injury or disease. The law states that such impair-

L. Availability of claim files OAC4123-19-03

(I)(J)(K) 1. Ohio administrative requirements 59

ment must be an impediment to obtaining employment or re-employment. 2. Eligibility and application

1.

Schedule of occupational diseases

n. Carbon dioxide poisoning o. Brass or zinc poisoning p. Manganese dioxide poisoning q. Radium poisoning r. Tenosynovitis and prepatellar bursitis s. Chrome ulceration of skin or nose t. Potassium cyanide poisoning u. Sulphur dioxide poisoning v. Berylliosis w.Cardiovascular, pulmonary diseases x. Silicosis y. Coal miners pneumoconiosis z. Radiation illness aa.Asbestosis

This is contingent upon an employers participation in the program and the amount of money it contributes to the handicap fund. If you pay into the fund, you may qualify for reimbursement of some of the costs of these workers compensation claims. It depends on the amount or percentage attributable to the employees handicap. You must file an Application for Handicap Reimbursement (CHP-4A) for BWC to consider you for reimbursement.

N. Occupational disease
ORC 4123.85

ORC 4123.01(F) and

a. Anthrax b. Glanders c. Lead poisoning d. Mercury poisoning f. Arsenic poisoning g. Poisoning by benzol h. Poisoning by petroleum products i. Poisoning by carbon bisulfide j. Poisoning by wood alcohol k. Infection/inflammation of the skin l. Eithelion cancer m.Compressed air illness

An occupational disease is one: An employee contracts in the course of employment; Where its causes and characteristics result in a hazard for the employee; Where the condition of employment itself results in a hazard for the employee; Where the character of the employment itself is distinguishable from other employment; Where the employment itself creates a greater risk of contracting the disease than for the general public. For a description of occupational diseases, see ORC 4123.68. 2. Eligibility An employee disabled by an occupational disease is entitled to compensation. If he or she dies because of an occupational disease, his or her dependents are entitled to compensation. 3. Incident report You must complete an accident report for all claims. Please refer to the Medical-only section of this guide.

bb.All other occupational diseases

4.

Medical report These conditions require medical documentation. Please refer to the Medical-only section of this guide.

5. a.

Application for payment of occupational disease benefits You must ensure there is a completed First Report of an Injury, Occupational Disease or Death (FROI-1) when an injured worker is disabled and out of work for eight or more calendar days after contracting an occupational disease. Retain a copy of the completed FROI-1 in the employees claim file. You must either certify or reject the application, or seek clarification. You must file a completed FROI-1 with BWC. The statute of limitations for filing an occupational disease claim is two years from the date of disability or six months from date of diagnosis, whichever is the latest. Establishing the date of disability Payment of benefits for an occupational disease claim depends on the laws in effect on the established date of disability. Establish the date of disability using the latest of three dates: The date the injured worker received the medical diagnosis informing him or her of the condition(s); The date the injured worker first received medical treatment for the condition(s);

b. c.

6.

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The date the injured worker first quit work because of the condition(s).

O. Self-Insured Review Panel (SIRP)

ORC 4121 and 4123 OAC 4123-19-14 BWCs administrator appoints members to this panel. Members advise the administrator and BWCs self-insured department on many matters. They also provide hearings on matters referred to the panel, or as requested by an employer. BWC refers all unresolved issues involving the financial strength or administrative ability of an employer to operate a selfinsured workers compensation program to the panel for a hearing. 1. 2. The panel has three members with expertise or experience in matters relating to self-insuring employers. The panel holds meetings and hearings to determine matters referred to it by BWCs administrator or selfinsured department. The administrator may authorize the review panel to consider: a. b. c. d. Granting or denying an application for the privilege of self insurance; Non-renewals of self-insured status; Revocation of self-insuring employer status; Issues of a companys adequacy of contribution to the Self-Insuring Employers Guaranty Fund or need for additional security (ORC 4123.351).

Examples 1) An employee reports a rash and inflammation on his hands, arms and feet to his supervisor on May 21, 2006. The injured worker seeks medical treatment on May 21, 2006, and gets a diagnosis indicating an occupational disease of contact dermatitis. The attending physician certifies the employee as disabled on June 30, 2006. The date of disability is June 30, 2006. An employee experiences pain and tingling in his right hand. He reports it to the employer on Oct. 25, 2006. He seeks medical attention and gets a diagnosis of carpal tunnel syndrome on Nov. 5, 2006. At that time, he starts wearing a brace to alleviate the condition. When his condition does not improve, the injured worker elects to have surgery on July 12, 2007 , and thus becomes disabled from his job. So, July 12, 2007 is the disability date used to calculate the full , weekly wage and average weekly wage. Computing compensation Use the same formula discussed in the section on lost-time claims. Paying compensation/stopping payments Pay compensation using the same guidelines as those for lost-time claims, except use wages for the year prior to the date of disability. You may stop payments in the same manner used to terminate compensation in lost-time claims. 9. Medical fee bills Process bills for occupational diseases as you would for injury claims. 10. Payment verification/proof of payment The payment verification requirements are the same as those for injury claims. 11. Required claim file content is the same as that for injury claims. 12. Paperless workers compensation claim files Injured workers must have access to all the same information as required for injury claims.

2)

3.

7. 8.

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VI. Suggestions for an effective self-insured program

1. 2. 3. 4. 5. 6. Involve senior management in support of safety and health programs. Educate entry-level management (supervisors, team leaders, etc.) about safety and health programs. Develop and post written safety and health policies. Educate and train employees on safe-work practices and proper use of equipment. Involve employees in identifying potential problems and suggesting solutions. Follow up with corrective measures (cost/benefit). Develop and post written accident and injury reporting procedures. Timely notification (when, where, to whom) Make required forms available Investigate injuries File claims timely Develop and post medical treatment and return-towork practices. Medical assessment (first aid, urgent care, hospital emergency room) Notify injured worker of requirements: routine care, requests for treatment (C9s), return-to-work options Relationship with physician of record: provide job description, return-to-work policies, billing information Light duty, transitional duty, gradual return-to-work programs: availability, duration Develop and post compensation and benefits policies. Notify injured worker on status of claim: Completed FROI-1 form, claim certification or rejection, allowed conditions Provide company contacts and a toll-free number for questions. Give information about compensation payments. Who issues payments: the company or a thirdparty administrator? (If a third party does, provide a contact name and toll-free number.) Do you pay weekly or biweekly and for what period time? Whats the rate, and what type of compensation is available? Required information to receive benefits (i.e. C-84, MEDCO 14, etc.) Provide required forms. Give info about notification to renew disability. Bill processing: date stamping, scanning, denial/request for information Make assessments. Accident and injury Analysis: Where are problems, and why?, trends, resolution Claims reviews: duration of disability, appropriate and cost-effective care, return-to-work options, litigation, settlement. Medical reviews: cost and type of care, assessing need for: case managers, IMEs, formal rehabilitation, pharmacy programs, future needs Customer service: i.e., surveys, injured worker inquiries/complaints

8. Use state resources. BWC: ohiobwc.com, Self-Insured Reorientation classes, Procedural Guide to Self-Insured Claims Administration Safety & Hygiene: training, library, videos, publications

Self-insured compliance audit process

Claims audit ORC 4123.35 and Rule 4123-19-3 (K) BWC has the authority to audit all self-insuring employers. This helps BWC monitor your compliance with Ohios workers compensation laws and rules. The self-insured department conducts these periodic audits. It also provides training to the self-insured community. This departments headquarters is in Columbus. It consists of auditors, a supervisor and clerical support. The staff conduct audits are routinely at all locations where you may house claim files. This includes TPA sites or corporate offices outside of Ohio (if BWC grants you special permission).A knowledgeable employee of your company must be present if BWC conducts an audit at a TPA office. The agency may also make random visits to your Ohio locations to verify required certificate postings. BWC may conduct more frequent audits if: 1. 2. 3. 4. 5. It found your program was not-in-compliance during a routine audit; It found your program to be Satisfactory Level 3 during a routine audit; You have had several valid complaints filed against you; The Self-Insured Employers Evaluation Board requests it; The Self-Insured Review Panel requests it.

7 .

Your BWC auditor will contact the workers compensation administrator at the company to set a mutually convenient date for an audit. The audit period usually covers a twoyear span of time. The auditor will ask you to provide a listing of the claims, as well as copies of the OSHA 300 logs for the years covered in the review period. The auditor will confirm the date and time ofthe audit in writing, and indicate what documentation will be required. The audit itself has three basic parts.

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1.

Brief interview with your workers compensation administrator This helps the auditor to determine how your company processes claims and if your administrator is knowledgeable. It also gives the auditor a chance to view the required postings. These include the current Employers Right to Pay Compensation Directly (with the claims administrators name, location and telephone number), the Notice to Employees poster and rebuttable presumption.

claim. A cover letter will accompany the report. It will identify the overall status of your companys workers compensation program based on these ratings. Excellent: There were no recommendations and you had no violations. Satisfactory Level 1: There were no recommendations, but you had one to five violations. Level 2: There was a maximum of one recommendation, and you had six to nine violations. Level 3: There were two to three recommendations (only one of which had to do with payment of compensation), and ten or more violations. Not in compliance: You had two or more recommendations related to payment of compensation and more than three recommendations in other areas.

2.

Random sampling of claim files The auditor selects a random sample of claims from the review period. She or he then reviews the losttime and medical-only claims in detail and records pertinent information. The auditor will contact your administrator if information is missing from your files or if he or she has questions. Your files should include these items*. Incident or accident report FROI-1 Documentation accepting or rejecting the claim Wage information from the 52-week period prior to the injury FWW/AWW calculation sheets Medical proof of disability (i.e., C-84 forms, medical slips, medical notes, MEDCO-14 forms, emergency room reports, etc.) Medical bills, EOBs, requests for additional info, payments Medical reports Compensation payments BWC/IC correspondence Requests for medical treatment, tests, change of physician, etc. and responses to all All information pertaining to the injury Written job offers for light, modified or restricted duty

You should direct any questions about the report to the auditor who conducted it. She or he can amend reports if warranted. If there are still unresolved issues, please contact Jenny Johnson, audit supervisor, at 614-644-9937 . BWC may ask your claims administrator to complete a customer service survey. She or he will receive it by email after the audit. Please provide feedback on the audit processes and suggest improvements BWC can make.

Administrative program review

In addition to compliance audits, the audit team conducts administrative program reviews (APRs). These are claims reviews are for companies that have only been self-insured for about six months. An auditor will visit the employers site, review some claims files and walk through the audit process with the workers comp administrator. The auditor will also suggest ways to run an efficient program and let the employer know if there appears to be any early problems. So APRs are unofficial audit. The auditor will not produce an official report following an APR. However, she or he will document any problems, issues, suggestions or concerns in a memo and file it accordingly. This review is not mandatory for employers. If you understand Ohios requirements and believe your program runs properly, you may waive this visit. However, it is a service BWC makes available to you. The first compliance audit usually occurs one year after the APR if you are newly self-insured. APRs are also available to if you want BWCs feedback on how well youre administering claims. You do not have to be a new employer. 63

* List not all inclusive 3. Exit Interview/closeout conference The auditor will summarize the findings and review the claims in detail if your administrator desires. The auditor will leave behind a Request for Information sheet if there are any unresolved issues (i.e., underpayment of an injured worker, dates of disability are in question, etc. Your company must provide BWC with documentation within seven days after the audit. The auditor may complete a report and leave it at the audit site. This is possible if time allows and your claims files are complete. If not, the auditor will send you a report within 30 days. The report will summarize the audit findings and show any violations in each

Paid compensation/SI-40 audits

BWC conducts audits to verify the accuracy of information you report on the Report of Paid Compensation and Statistical Information (SI-40). You must file this report online at BWCs Web site. Log on to ohiobwc.com and click on: Ohio Employers; Self-Insured; Policy Information; and then Paid Compensation Report (SI-40). You will need your policy number or federal tax ID number to complete the report online. You must file the form by the end of February to provide figures for the previous calendar year. You should only complete one form even if you have multiple locations. However, it must show figures for your entire operation in Ohio. History BWC bases the premium assessment for self-insured employers on the amount of compensation you pay rather than on your payroll dollars (as is the case for state-fund employers). BWC will bill you for this assessment twice a year. BWC will assess a penalty to any employer who misrepresents payroll or compensation paid (ORC 4123.25). If you violate this law, you will be liable for 10 times the amount of the difference in premium you paid versus the amount you should have paid. For example, say a company paid $5,000 in compensation but should have paid $12,000. BWC would assess it a penalty of 10 times the $7 ,000 difference or $70,000. Enforcement of this rule deters underpayment of premiums and ensures equitable distribution of workers compensation system costs. BWC enforces this action via civil action in the name of the state. Funds collected under this action go to the state insurance fund. BWC analyzes the paid compensation data to determine premium rates for the next fiscal year. BWC may also charge you a late fee if you do not pay your assessment when due. This fee can be up to $500 plus an additional penalty based on how late you pay the assessment. (See ORC 4123.35 (L) for details on the assessments.) 1. a. b. 2. Purpose of paid compensation audits To ensure companies report the correct figures to BWC. Inaccurate reporting may lead to higher premium rates and the need for a letter of credit. Numbers from the paid compensation reports help to identify high risk industries. Information needed for a paid compensation audit

a. b. c. d. e. f.

Information about the type and total amount of compensation paid in each workers compensation claim, and where the claim file is housed (loss runs) Verification of reimbursements from subrogation or from BWC for compensation paid in overturned claims Verification of sick and accident disbursements to injured workers Files for all claims that had compensation paid during the specified audit year, regardless of injury dates Check register OSHA logs Example: SI-40 audit for 2009 Claims with dates of injury in 2009; and all compensation payments made in 2009

3. a.

Paid compensation (SI-40) audit procedure The auditor will review the employers information, including files for any claims that had compensation paid during the audit period. He or she verifies if the company paid the correct amount and period of compensation. The auditor may review 100 percent of the employers claims at all its Ohio locations if he or she finds any unresolved variances. This will determine if there are any further inaccuracies. The auditor will review the findings with the employer and request payment verification for any underpayments found. The auditor will complete a report and leave it onsite with the employer if there is complete information in all the claims files and enough time. If not, the auditor will generate a report within 30 days. The report will summarize the audit findings and show which claims had incorrect amounts reported on the SI-40 form. A company representative must sign and return a portion of the report to acknowledge that he or she understands the proper reporting procedures. If there is a variance, BWC will either bill or credit the company based on its premium rate for the reporting year.

b. c.

d.

e.

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VII. Ohio case law

This section includes these cases. Ashcraft v. Industrial Commission Bos case Carrick v. Riser Foods, Inc. Coolidge v. Riverdale Local School District Crim v. BWC Daimler Chrysler v. Self-Insuring Employers Evaluation Board Hall China Co. v. Industrial Commission Kabealo v. Industrial Commission Miller v. Industrial Commission MTD Products Inc. v. Robatin machine a procedure for recovering lost money since the machine often malfunctioned. But, the employee did not comply with this procedure. The court called the employees behavior horseplay and denied coverage. Coolidge v. Riverdale Local School District (2003) Discharging or penalizing injured workers The Ohio Supreme Court upheld ORC 4123.90, which prohibits employers from discharging or otherwise penalizing employees for work-related injuries. Thus, the court held that an employer cannot discharge an employee from work solely on the basis of absenteeism or inability to work if he or she is receiving temporary total disability compensation and the absence or inability to work directly relates to an allowed condition in the claim. The court stated that employees who are temporarily and totally disabled have a right to whatever period of absence from work is deemed medically necessary to complete their recovery or stabilize their injuries. And the court quoted with approval a Kansas Supreme Court decision. It says an employer cannot count the absences caused by an employees work-related injuries against him or her regardless of the companys attendance policy. The decision also addressed information an employee must provide his or her employer while on temporary total disability. The Coolidge case held that the employee may not ignore the employers reasonable inquiries about the cause or length of an absence. Nor can he or she refuse to answer the employers requests for relevant information regarding the employees condition or work status. But the court warned that an employee may not be discharged for failing to complete forms required for a leave of absence, or for failing to notify his or her employer as to the length of the absence, where the employer is otherwise on notice of the employees condition and status. ORC 4123.90 specifies that relief includes reinstatement, back pay, lost wages and attorney fees. Reinstatement means restoring all rights, privileges and benefits lost as a result of the punitive action. However, you may subtract earnings, temporary total disability compensation and unemployment compensation received after the punitive action from any award for relief. Crim v. BWC School employees The Ohio Supreme Court held a teacher is not entitled to temporary total compensation over the summer unless he or she can show intent to work during those months. According to this case, payment of temporary total compensation during this period would be a windfall for the in65

Ashcraft v. Industrial Commission (1988) No temporary total benefits if incarcerated The Supreme Court held that a workers incarceration, independent of his previously recognized work-related injury, precludes him from receiving temporary total disability compensation since he was not in a position to return to work. Bos case (2000) Wage loss calculated weekly Following an injury, Bos returned to light-duty work to accommodate his medical restrictions. Several years later, he sought wage-loss compensation. The self-insuring employer denied the request and the IC agreed with that decision. The Court of Appeals issued a writ of mandamus finding that the IC had overlooked prima facie evidence suggesting at least one two-week wage-loss period. Relying on a payroll record showing that Bos earned $781.39 per week for one two-week pay period, the court found an actual wage loss after comparing that post injury figure with Bos average weekly pre injury earnings of $920.18. The employer contended that the IC should compare Bos pre-injury average weekly wage, or $ 920.18, with his post injury average weekly wage of $959.90. The Supreme Court disagreed with this method, finding that the wage-loss formula mandated a week-by-week analysis to determine a claimants actual wage loss. Carrick v. Riser Foods, Inc. (1996) Horseplay The court held that an employee who broke his leg when a soda machine fell on top of him as he shook it in order to dislodge a drink did not sustain the injury during the course of employment. The employer had put in place

jured worker. This reasoning also applies to other school employees, such as cafeteria workers or custodians working a nine-month schedule. An injured worker may prove his or her intent to work during the summer break by showing a job offer for that period or a history of working at another job during those months. The worker may also show proof that he or she had previously performed a job search. If the injured worker indicates an intention to work during the summer but has no evidence to support it, refer the case to the IC. Generally, an injured worker is not entitled to receive both wages in lieu of temporary total and temporary total compensation for the same period of time. However, this case also holds that you cannot offset temporary total compensation if a teacher is receiving wages in the summer that he or she earned during earlier periods. If a teacher is entitled to temporary total compensation, he or she should get payments as long as he or she is unable to return to work at any former place of employment. This applies regardless of how the teacher is paid. Daimler Chrysler Corp. v. Self-Insuring Employers Evaluation Board (2006) Recouping overpayments Self-insured employers cannot unilaterally recoup from an injured worker any overpayment of benefits due to a clerical error. This was the unanimous opinion of the 10th Ohio District Court of Appeals in which DaimlerChrysler Corp. tried to recover a $3,036 overpayment. The company wanted the injured worker to send a personal check, money order, or authorize a payroll deduction for the entire amount. The court found that this was not a proper way to recoup the overpayment. State law spells out the method employers should use. It calls for employers to recoup overpayments by withholding a portion of present and future benefits until the worker satisfies the full amount. Hall China Co. v. Industrial Commission (1962) Injurious exposure This case defines injurious exposure as related to silicosis (and other pulmonary-related diseases) as: an exposure in the injured workers last place of employment which proximately caused silicosis, or an exposure in such last place of employment which augmented (increased) or aggravated a pre-existing silicosis caused by constant exposure to free silica during many years in 66

prior places of employment. Thus, an injurious exposure is one that proximately causes a disease or augments or aggravates a pre-existing disease (ORC 4123.68 (W). This case also set the standard working definition of last injurious exposure. It holds that though the workers ex posure to a substance during the last years of employment may not, of itself, been sufficient to cause silicosis (or any pulmonary disease), it could have aggravated a pre-existing condition enough to cause disability. As a result, the last employer must bear the entire financial burden of compensating the worker. In essence, this IC ruling indicates the word injurious signifies the cumulative effect of any exposure. The ruling determined the exposure was injurious to the individual and did occur during the period of time required by law to allow a claim for silicosis (and in this case, other pulmonary occupational diseases). Kabealo v. Industrial Commission (1990) Scheduled loss awards The Court of Appeals found that to qualify for a loss of the third or distal phalange (top of finger) award under ORC 4123.57 the loss must be at or near the joint. , Miller v. Industrial Commission (1994) Additional medical condition The claimant sought a mandamus review of the ICs decision to deny further temporary total disability compensation and deny authorization to enroll in a supervised weight-loss program. The Court of Appeals, Franklin County, upheld the denial of weight-loss treatment. But, it ordered the IC to vacate the order and re-determine entitlement to temporary total disability compensation. The Supreme Court held that: (1) an additional allowance of obesity was not a prerequisite for considering payment for a weight-reduction program; and (2) the IC needed to do more fact finding to determine the permanency of the claimants condition. From this decision is derived the Miller Criteria, which must be applied to authorization of medical services: 1. Are the medical services reasonably related to the allowed injury? 2. Are the services necessary for the treatment of the allowed injury? 3. Is the cost of the service medically reasonable?

VIII. BWC and IC offices

BWC offices
For the most up-to-date information, please visit ohiobwc. com and ohioic.com. BWC headquarters Stephen Buehrer, Administrator/CEO 30 W. Spring St. Columbus, OH 43215-2256 Phone: 1-800-OHIOBWC For the hearing impaired: 1-800-BWC-4-TDD Fax: 1-877-520-OHIO Customer service offices Cambridge 61501 Southgate Parkway Cambridge, OH 43725-9114 Claims: 800-644-6292 Employer Services: 740-435-4210 Fax: 866-281-9351 Canton 400 Third St., S.E. Canton, OH 44702 Claims: Employer Services: Fax: Toll free Governors Hill 8650 Governors Hill Dr.ive, Suite 400 Cincinnati, OH 45249-1386 Claims: 800-644-6292 Employer Services: 513-583-4403 Fax: 866-281-9357 Hamilton One Renaissance Center 345 High St. Hamilton, OH 45011-6055 Claims: 800-644-6292 Employer Services: 513-785-4510 Fax: 866-336-8343 Lima 2025 E. Fourth St. Lima, OH 45804-4101 Claims: Employer Services: Fax:

800-644-6292 419-227-5656 866-336-8346

330-438-0638 330-471-0937 866-281-9352 800-713-0991

Cleveland 615 W. Superior Ave., Sixth floor Cleveland, OH 44113-1889 Claims: 216-787-3050 Employer Services: 216-787-3060 Fax: 866-336-8345 Toll free 800-821-7075 Columbus 30 W. Spring St., 11th floor Columbus, OH 43215-2256 Claims: 614-728-5550 Employer Services: 614-752-4538 Fax: 866-336-8352 Dayton 3401 Park Center Drive, Suite 100 Dayton, OH 45413-0910 Claims: 800-644-6292 Employer Services: 937-264-5217 Fax: 866-281-9356 Garfield Heights 4800 East 131 St., Suite A Garfield Heights, OH 44105 Claims: 216-584-0100 Employer Services: 216-584-0115 Fax: 66-457-0590 Toll free 800-224-6446

Logan 1225 W. Hunter St., P Box 630 .O. Logan, OH 43138-0630 Claims: 740-385-5607 Employer Services: 740-385-1331-9848 Fax: 866-336-8348 Toll free 800-385-560 Mansfield 240 Tappan Drive N., Suite A Mansfield, OH 44906-8051 Claims: 419-747-4090 Employer Services: 419-529-4528 Fax: 866-336-8350 Portsmouth 1005 Fourth St. Portsmouth, OH 45662-1307 Claims: 800-644-6292 Employer Services: 740-353-3419 Fax: 866-336-8353 Toledo P Box 794 .O. 1 Government Center, Suite 1136 Toledo, OH 43604-0794 Claims: 800-644-6292 Employer Services: 419-245-2474 Fax: 866-457-0594 Youngstown 242 Federal Plaza W., Suite 200 Youngstown, OH 44503-1877 Claims: 330-797-5500 Employer Services: 330-797-5010 Fax: 866-457-0596 Toll free 800-551-6446

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IC hearing administration offices

Each of the five regional hearing administrator offices serves specific local offices. If you need to contact your hearing administrator, use the information below.

IC local offices
Customer service contact information
E-mail: AskIC@ic.state.oh.us Phone: 614-466-6136 (Columbus area) 800-521-2691 (toll-free nationwide) 800-686-1589 (toll-free TDD) (8 a.m. - 4:45 p.m. Monday to Friday) Address: 30 W. Spring St. Columbus, OH 43215-2233 Fax: 614-728-7004

Akron

161 South High St., Suite 301 Akron, OH 44308-1602 Tel: 330-643-3554 Fax: 330-643-3153 Offices served Akron Canton Mansfield

Cincinnati

125 East Court St., Suite 600 Cincinnati, OH 45202-1211 Tel: 513-357-9764 Fax: 513-721-7503 Offices served Cincinnati Dayton Hamilton

Akron

Oliver R. Ocasek Government Office Building 161 South High St., Suite 301 Akron, OH 44308-1602 Debra Lynch Regional Manager Jackie Lawson Claims Manager Tel: 330-643-3550 Fax: 330-643-1468

Cleveland

615 Superior Ave. N.W., Seventh floor Cleveland, OH 44113-1898 Tel: 216-787-3633 Fax: 216-787-5289 Offices served Cleveland Youngstown

Cambridge

2130 E. Wheeling Ave. Cambridge, OH 43725 Lynette Haggins Administrative assistant Tel: 740-435-4000 Fax: 740-435-4010

Columbus

30 W. Spring St., Seventh floor Columbus, OH 43215-2233 Tel: 614-644-8351 Fax: 614-466-7043 Offices served Bridgeport Columbus Logan Portsmouth Springfield Zanesville

Cincinnati

125 E. Court St., Suite 600 Cincinnati, OH 45202-1211 Landi Jackson-Forbes Regional Manager Layle Rogers Manager Tel: 513-357-9750 Fax: 513-723-9811

Toledo

One Government Center Suite 1500 Toledo, OH 43604 Tel: 419-245-2747 Fax: 419-245-2673 Offices served Lima Toledo 68

Cleveland

615 Superior Ave. N.W. Cleveland, OH 44113-1898

Greg Gibbons Regional Manager Cathy Fischer Administrative Assistant (Office Manager) Tel: 216-787-3001 Fax: 216-787-3483

Logan

12898 Grey St. Logan, OH 43138 Charles R. Roberts Administrative assistant (Office manager) Tel: 740-380-9685 Fax: 740-385-2436

Columbus

William Green Building 30 W. Spring Street, Seventh floor Columbus, OH 43215-2233 Jayne Beachler Regional manager David Binkovitz Regional manager Mark Collins Administrative assistant Tel: 614-466-6136 Fax: 614-644-8373

Mansfield

P Box 8051 .O. 240 Tappan Drive. N. Mansfield, OH 44906 April Heckert Administrative assistant (Office manager) Tel: 419-529-1360 Fax: 419-529-3084

Dayton

Portsmouth

3401 Park Center Dr., Third floor Dayton, OH 45414-2580 Lyman Hunnicutt Administrative assistant (Office manager) Tel: 937-264-5116 Fax: 937-264-5130

1005 Fourth St. Portsmouth, OH 45662-4315 Jami Wise Administrative assistant (Office manager) Tel: 740-354-2334 Fax: 740-353-6975

Hamilton

Toledo

One Renaissance Center 345 High St., Fifth floor Hamilton, OH 45011-6016 Cynthia Thornton Administrative assistant (Office manager) Tel: 513-785-4680 Fax: 513- 785-4682

One Government Center, Suite 1500 Toledo, OH 43604 Scott Hines Regional manager BJ Kristufek Administrative assistant Tel: 419-245-2740 Fax: 419-245-2652

Lima

Youngstown

2025 E. Fourth St. Lima, OH 45804-0780

Robin Underwood Administrative assistant (Office manager)

242 Federal Plaza W. Youngstown, OH 44503-1206 Ken Carpenter Office manager Tel: 330-792-1063 Fax: 330-792-2473

Tel: 419-227-7193 Fax: 419-227-7150

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IX. Glossary
Accident -- An accident is an unforeseen incident that occurs in the course of or arising out of employment at an employer sponsored event or on premises the employer controls. Active claim -- A claim is legally active for six years from the date of last payment of compensation or medical benefits. Alternative Dispute Resolution (ADR) All self-insuring employers with QHPs must have an ADR process. This allows employers to handle medical disputes involving quality assurance, utilization review, medical necessity and other treatment and provider issues without IC hearings. Appeal This formal notification indicates a party is dissatisfied with a hearing officers decision. So the party requests a new hearing so a higher level officer can consider the issue and render a decision. Either party the injured worker or employer may file an appeal. Average weekly wage (AWW) and rate This is the injured workers average weekly earnings for the 52 weeks prior to his or her date of injury. Injured workers start getting this payment during the 13th week of disability, at a rate of 66 2/3 percent of the calculated wage. Ohio Bureau of Workers Compensation (BWC) The state agency that administers claims, collects premiums and monitors compliance with the Ohio Revised Code and the Ohio Administrative Code. Certify/certification This indicates the employer considers the injury or occupational disease claim to be valid. It shows the employer accepts the claim and will issue payments for related expenses. Claim file This is a record of all information (notes, forms, medical bills, payments, etc.) pertinent to an injured workers injury or occupational disease. Compensation These are payments an employee receives when he or she is out of work for more than seven days due to a workplace injury or occupational disease. Consecutive The term means following in order without interruption, as in four consecutive days. In the course of employment/Arising out of employment In the course of employment means that the injury must occur while the employee is performing a duty for his o her employer. Arising out of employment means the injury must bear a direct relationship to the employment situation. Deny The employer determines the injury or occupation70 al disease is not work-related and does not wish to accept the claim or pay associated expenses. Disabled Workers Relief Fund (DWRF) This is a fund for permanently and totally disabled employees whose workers compensation benefits have not kept up with inflation. District hearing This is the first level of the ICs hearing process. This hearing is informal in nature. Employee An employee is every person an employer requires or directs to work in exchange for direct or indirect gain or profit. Employer An employer is every person, firm, corporation, agent, manager, representative or other person having control or custody of any employment, place of employment or employee. Employment Any trade, occupation or process of manufacture; or any method of carrying on such trade, occupation or process of manufacture in which any person may be engaged. Fee bill A fee bill is a request by a health-care provider for payment of services rendered. Filing a claim with employer When an employee notifies the employer that he or she has sustained a work related injury or occupational disease and requests compensation for lost wages and other associated expenses. Filing with the bureau Submitting required documents, including the FROI-1 form to BWC. Full weekly wage (FWW) and rate This is a comparison of the injured workers wages for the last full work week prior to the date of the injury (less overtime) and the average of his or her earnings for the last six weeks prior to the date of the injury. The higher of these two figures is the full weekly wage. The injured worker receives compensation at a rate of 72 percent of the full weekly wage for the first 12 weeks of his or her disability. Handicap reimbursement A provision of Ohio law set up as a cost relief program to encourage employers to hire and retain handicapped employees. Hearing A formal meeting before a hearing officer where evidence is presented, testimony is given, and an official decision is made regarding a disputed claim or portion of a claim. Industrial Commission (IC) This is the sister agency

of BWC responsible for adjudicating workers compensation claims. It is also a governing body comprised of three members. Injured worker An employee who has been injured or has contracted an occupational disease in the course of and arising out of employment at an employer sponsored event or on premises the employer controls. Injured worker refund Reimbursement to an injured worker for compensable expenses that he or she initially paid such as pharmacy bills, doctor visits, and mileage to and from specialists. Injuries Any injury caused by external accidental means or that is accidental in character and result, which occurs in the course of and arising out of the injured employees employment. Injury does not include: Psychiatric conditions except where the claimants psychiatric conditions have arisen from an injury or occupational disease sustained by that claimant or where the claimants psychiatric conditions have arisen from sexual conduct in which the claimant was forced by threat of physical harm to engage or participate; Injury or disability caused primarily by the natural deterioration of tissue, an organ, or part of the body; Injury or disability incurred in voluntary participation in an employer sponsored recreation or fitness activity, if the employee signs a waiver of his rights to compensation or benefits under ORC 4123 prior to engaging in the recreation or fitness activity; A condition that pre-existed an injury unless that pre-existing condition is substantially aggravated by the injury. Objective diagnostic findings, clinical findings or test results must document proof of such a substantial aggravation. Subjective complaints may be evidence of such a substantial aggravation. However, subjective complaints without objective diagnostic findings, clinical findings or test results are insufficient to prove a substantial aggravation claim. Lost-time claim Being disabled from work eight or more calendar days due to an injury or occupational disease; these days need not be consecutive. Medical-only claim Being disabled from work seven or fewer calendar days due to an injury or occupational disease. Medical provider Any licensed, qualified health-care provider who provides treatment to an injured worker as a result of work-related injury or occupational disease (i.e., a

physician, hospital, urgent care center, emergency room, nurse, pharmacist, chiropractor, surgeon and specialist). Modalities Forms of treatment such as heat, electrical stimulation and cold packs used in conjunction with chiropractic adjustment, manipulation or physical therapy. Motion A form (C-86) requesting a workers compensation hearing with BWC. Narrative medical report A detailed report, on a doctors letterhead, stating the diagnosis and prognosis of an injury or occupational disease; not an emergency room or operating room report. Occupational disease Any of a list of diseases detailed in the ORC 4123.68 that an employee contracts in the course of and arising out of employment; often the result of repetitive motion or exposure over a period of time. Order Any decision, rule, regulation, direction, requirement, standard or other determination the IC makes or is empowered to make. Payment verification Claims files must contain verification of all payments. This must include the check number, date of issuance, period of compensation, description of medical services, payee information and the amount of the payment. A copy of a canceled check can serve as proof of payment. Permanent partial An impairment from a work-related injury or occupational disease that is permanent but only partially disabling to the employee. Permanent total An impairment from a work-related injury or occupational disease that is permanent and totally disabling to the employee and which prohibits him or her from returning to employment that is substantially remunerative (profitable). Physician of record (POR) The physician the injured worker has chosen to treat his or her injury or occupational disease. Place of employment Every place, whether indoors, outdoors or underground, and its premises, where either temporarily or permanently, any industry, trade or business is carried on, or where any process or operation directly or indirectly related to any industry, trade or business is carried on, and where any person is directly or indirectly employed by another for direct or indirect gain or profit. Qualified Health Plan (QHP) An individual employers

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unique health-care network that can provide all the necessary medical care and services to injured workers. Rebuttable presumption Effective 10-13-04, ORC allows employers to seek disallowance of a workers compensation claim filed by an injured worker who tests positive for drugs or alcohol (on a qualifying chemical test), or refuses to be tested. This creates a rebuttable presumption that the employees intoxication is the proximate cause of a work-related injury. This puts the burden on the injured worker (versus the employer) to prove that drugs or alcohol was not the proximate cause of the accident. Rehabilitation A service that specifically attempts to rehabilitate injured workers so they may return to their former jobs or other gainful employment. Reimbursement agreement/Set-off agreement An agreement injured workers sign stating that any workers compensation benefits due to them will be used to reimburse any monies they have received from their employers wholly funded non-occupation insurance programs (per ORC 4123.56). Salary continuation When an employer chooses to pay an injured worker his or her full salary or wages, instead of workers compensation payments, for the time he or she is off work due to a work-related injury or occupational disease. Scope of employment The employee is engaged in a duty or action that relates to his or her employment; if not for the employment, the employee would not have been engaged in that activity. Self insurance The privilege BWC grants employers who meet strict criteria to pay workers compensation and benefits directly to their employees in accordance with IC and BWC laws and rules. Sickness and accident insurance Insurance that covers the employee and dependents for non-industrial accidents and illnesses. Statewide maximum weekly wage This is a weekly wage set by the legislature each year that is based on the earnings of every worker in Ohio.

Statute of limitations The legal time limitations set by the legislature for an employee to file a workers compensation claim. If it is an injury claim, the time limitation is two years from the date of injury or death. The time limitations on an occupational disease claim is two years from the date of the diagnosis, disability or death, or six months from date of disability or diagnosis, whichever is later. Temporary total The injured workers state of being temporarily and totally disabled from his or her regular position of employment. Timely payment Payment made within the statutory or required period of time; for medical bills, this is 30 days from the receipt of the medical bill or the order to pay; initial compensation payments must be made within 21 days of the notification of lost time, receipt of medical evidence, or upon receipt of the order to pay Ongoing weekly compensation must be paid at least biweekly with supporting medical. Violation of a Specific Safety Requirement (VSSR) A VSSR is a type of claim payment for certain industries; can only be awarded to the employee by the IC and is in addition to any compensation payable in the claim. Wage loss Compensation awarded in claims filed for injuries occurring on or after Aug. 22, 1986, where an employee suffers a loss in wages due to a work-related injury. This is a fund set up by the state and funded by employers to compensate workers who have been injured or have contracted an occupational disease in the course of, or arising out of, their employment.

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X. Forms
Visit BWC and the ICs Web sites for the most current versions of these forms. BWC forms Log on to ohiobwc.com and click on BWC Library and then Forms (on the left menu). IC forms Log on to ohioic.com and click on Forms (at the top of the home page).

C-60

Injured Worker Statement for Reimbursement of Travel Expense

Injured workers use this form to get reimbursement for expenses associated with attending required examinations (IC exams as well as employer requested exams) or receiving training or other specialized medical care.

C-60-A Injured Worker Reimbursement Rates for Travel Expenses

Most commonly used workers compensation forms

C-9 Physicians Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease C-84

This form provides current rates for reimbursement of injured workers travel expenses (i.e., car mileage, meals, lodging, etc.).

Request for Temporary Total Compensation

Medical providers use this form to supply information to self-insuring employers or managed care organizations (MCOs) and to request authorization for additional testing, consultations or treatment. Information includes: the current diagnosis; additional conditions related to the industrial accident/exposure; causal relationship of conditions to the accident/exposure; pre-existing conditions; disability and treatment plan. If a physician requests additional treatment, he or she must indicate the specific type, frequency and duration of the treatment.

This form serves as medical evidence to support continued temporary total benefits.

C-86

Motion

Parties use this form to request a decision on disputed issues by BWC or the IC.

C-92

Application for Determination of the Percentage of Permanent Partial Disability

C-94-A Wage Statement

This statement lists an employees wages from the year prior to the date of injury.

C-9-A Request for Additional Medical Documentation for C-9

C-101

Authorization for Release of Medical Information

Medical providers use this form to supply additional medical information upon request. This info may include progress notes/office notes, emergency room reports, operative reports, discharge summaries, etc.

C-140 Initial Application for Wage Loss Compensation

Optional form for employers to use when injured workers seek wage loss compensation

C-17 C-l9

Pharmacies use this form to bill for pharmaceuticals. All other medical providers may use this form for billing. The injured worker completes this form when changing from the established physician of record to another.

Pharmacy Invoice Service Invoice

C-141 Wage Loss Statement for Job Search

Optional form for an injured worker to document the contacts he or she makes when seeking another job.

C-23

Change of Physician Notice

C-159 Waiver of Workers Compensation Benefits for a Voluntary Participant in an Employers Sponsored Recreation or Fit ness Program/Activity C-174 Self Insured Semi-Annual Report of Claim Payments

C-59

Self-Insurers Agreement as to Compensation on Account of Death

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C-196 Amputation/Loss of Use Diagram Right Hand & Left Hand Views

SI-1

Use this form to show the exact point of an am- putation.

Certificate of Employers Right to Pay Compensation Direct

FROI-1 First Report of Injury, Occupational Disease or Death

BWC issues this certificate of workers compen sation coverage when it grants an employer selfinsured status. BWC also issues this certificate annually to companies that renew their self-insuring status.

This is the basic application used to file a workers compensation claim. It is now available in Spanish, as well as English.

SI-28

Filing of an Allegation against a Self-Insured Employer

IC-2

Application for Permanent Total Disability SI-40

An injured worker or his or her representative may use this form to file a complaint with BWC against a self-insuring employer.

IC-8/9 Application for Additional Award for Violation of Specific Safety Requirement in a Workers Compensation Claim

Report of Paid Compensation

SI-42

Self Insured Joint Settlement Agreement and Release Acknowledgement of the Self-Insured Joint Settlement and Release Instructions Election to Withdraw from Claims Reimbursement Fund

IC-12

The Industrial Commission of Ohio Notice of Appeal

Any party (employer, employee or their representative) may use this form to appeal a decision to the next IC hearing level.

SI-43

IC-22

Agreement as to Award for Permanent Total Disability Request for Continuance The Industrial Commission Application for Reconsideration

SI-44

IC-51 IC-88

Spanish language forms

Spanish-language versions of these four commonly used BWC forms are available on ohiobwc.com.

Submit this form to the IC for reconsideration of a permanent partial award.

AC-3: C-84: C-86: C230 FROI:

Temporary Authorization to Review Information Request for Temporary Total Compensation Motion Authorization to Receive Workers Compensation Check First Report of an Injury, Occupational Disease or Death

IC-167-T Objection to Tentative Order Awarding Permanent Partial Disability Compensation IC-INT Interpretive Services Request Form
Complete this form to request an interpreter at an IC hearing. This could be for sign language or foreign language interpretation. Providers use this form to indicate work restrictions while the injured worker is on the job, or to show temporary total disability. The form shows if the injured worker has reached maximum medical improvement (MMI) or has a referral for vocational rehabilitation.

MEDCO-14 Physicians Report of Work Ability

These Spanish forms are just beneath the corresponding English versions on the Ohio Employers, Medical Providers and Injured Workers sections of ohiobwc.com.

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