Workers' Compensation: Claims Process
Claim Process
- Your agency will forward the completed Accident or Illness Report (ADM 4303) to your Managed Care Organization (MCO).
- Your health care provider will forward all medical information to your MCO; your MCO may contact you to gather information regarding your claim.
- The state's third party administrator (TPA) will review all the information received from your MCO and contact your employing agency regarding approval or denial (certification of rejection) of your claim. Note: Some agencies process their own workers’ compensation claims; you should contact your personnel officer for more information.
- The TPA will be informed of all information and will keep records regarding your claim, and will file the claim with the Bureau of Workers’ Compensation (BWC).
- The BWC will make an initial decision (allow or disallow) regarding your claim.
- The BWC will send you a letter informing you of your claim number. This number is to be retained and referenced when contacting your agency, BWC, the TPA, the MCO and your health care provider regarding your claim.
- Shortly after you receive your claim number, the BWC will notify you of the approval or denial of your claim.
Claim Approval
Medical-Only Claims
- You may be eligible for a medical-only claim if you are unable to work for seven days or less.
- If your medical-only claim is approved, your MCO will pay your health care provider for authorized treatments that are directly related to your claim.
Lost Time Claims
- If your attending physician determines that your injury or illness will prevent you from working for eight or more consecutive days, you may be eligible to receive lost time benefits.
- If your claim is approved for lost time benefits, the BWC will begin paying benefits:
- On the eighth day, if you are off work from eight to 14 days; or
- From the first day, if you are off work for 15 or more consecutive days;
- Note that some bargaining contracts will cover the first seven days of absence due to a work-related injury. Check your contract or with your personnel officer regarding this.
- BWC will pay you directly by electronic deposit to you bank account. If you do not have an account, you will receive a debit card that will permit access to benefits.
- If you are paid by the BWC for the same period you were paid by your agency, you are responsible for reimbursing your agency for the benefit they paid.
Temporary Total Compensation
- If your claim is approved for lost time, you may receive temporary total compensation at 72 percent of your weekly wages for up to 12 weeks (Note that the weekly wage you receive is subject to a maximum established by the BWC).
- If your injury or illness prevents you from working for more than 12 weeks, your temporary total compensation will be reduced to two-thirds of your weekly wages.
- Lost time checks are subject to a weekly maximum amount and are not taxable.
Prescription Medications
- Should you require prescription medications relative to your work injury, the BWC contracts with a pharmacy benefit manager (PBM) to process pharmacy benefits.
- You must provide your BWC claim number, your Social Security Number and your date of injury so that your pharmacist can bill the PBM for the cost of your prescriptions.
- If you require a prescription but have not received your claim number from the BWC, you may be required to pay your pharmacy for the cost of the prescription. Once you receive your claim number, give it to your pharmacy, which will then ask the PBM to reimburse you for your out-of-pocket expenses.
Claim Denial
- If any party (you or your agency) disagrees with the decision of the BWC on your workers’ compensation claim, an appeal may be filed with the Industrial Commission.
- All appeals must be made in writing and must be filed within 14 calendar days of the date of receipt of the order issued by the BWC. The order will inform you of your appeal rights. If you have questions regarding appeal rights, you can contact the BWC at 1-800-OHIO-BWC.
|
