Ohio Admin. Code 4123-3-15 - Claim procedures subsequent to allowance
(A) Requests for subsequent actions when a
state fund claim has not had activity or a request for further action within a
period of time in excess of twenty-four months.
(1) The bureau shall consider a request for
subsequent action in a claim in the following situations:
(a) Where the employee requests that the
bureau or commission modify or alter an award of compensation or benefits that
has been previously granted; or
(b)
Where the employee request
requests that the bureau or commission grant a
new award of compensation or to settle the claim; or
(c) Where the claimant
request
requests that the allowance of a disability or
condition not previously considered; or
(d) Where the claimant dies and there is
potential entitlement for accrued benefits or payment of medical bills, or the
decedent's dependent is requesting death benefits due to relatedness between
the recognized injury and death.
(e) Except for a medical issue relating to a
prosthetic device or durable medical equipment as designated by the
administrator, the bureau, in consultation with the MCO assigned to the claim,
shall issue an order on a medical treatment reimbursement request in a claim
which has not had activity or a request for further action within a period of
time in excess of twenty-four months as follows:
(i) The MCO shall refer a medical treatment
reimbursement request in a claim which has not had activity or a request for
further action within a period of time in excess of twenty-four months to the
bureau for an order when the request is accompanied by supporting medical
evidence dated not more than sixty days prior to the date of the request, or
when such evidence is subsequently provided to the MCO upon request (via "Form
C-9A" or equivalent). The bureau's order shall address both the causal
relationship between the original injury and the current incident precipitating
the medical treatment reimbursement request in a claim and the necessity and
appropriateness of the requested treatment. The employer or the employee or the
representative may appeal the bureau's order to the industrial commission
pursuant to section 4123.511 of the Revised
Code.
(ii) The MCO may dismiss
without prejudice, and without referral to the bureau for an order, a medical
treatment reimbursement request in a claim which has not had activity or a
request for further action within a period of time in excess of twenty-four
months when the request is not accompanied by supporting medical evidence dated
not more than sixty days prior to the date of the request and such evidence is
not provided to the MCO upon request (via "Form C-9A" or equivalent).
(2) Requests which
require proof shall conform to the standards required by paragraph (C) of rule
4123-3-09
of the Administrative Code and rules
4123-5-18
and
4123-6-20
of the Administrative Code.
(a) Medical
evidence is required to substantiate a request for temporary total
disability.
(b) Medical evidence is
required to substantiate the allowance of a disability or condition not
previously considered.
(3) In state fund cases, upon a request for
subsequent action under paragraph (A)(1) of this rule, the bureau shall, upon
notification, inform the parties to the claim of the pending action prior to
issuing a decision. Upon request, the bureau shall provide a copy of the
request and proof to the employer and the claimant, and their representatives,
where applicable. Requests in self-insuring employers' cases shall be submitted
to the self-insuring employer which shall accept or refuse the matters
sought.
(4) The bureau or
commission may require the filing of additional proof or legal citations by
either party or may make such investigation or inquiry as the circumstances may
require.
(5) A state fund employer
shall, upon receipt of notification of the request, notify the bureau of any
objection to the granting of the relief requested. Such notification must be
filed within the time as required by the rules of the bureau and industrial
commission.
(6) Such requests shall
be determined with or without formal (public) hearing as the circumstances
presented require. If the request is within the jurisdiction of the bureau and
the matter is not contested or disputed, the bureau shall adjudicate the
request in the usual manner. In all other cases, the request shall be acted
upon by the industrial commission's hearing officer or as otherwise required by
the rules of the commission, depending on the subject matter.
(7) Failure by the employee to furnish
information as specifically requested by the bureau or commission shall be
considered sufficient reason for the dismissal of the request. If the employer
fails to furnish any information requested by the bureau or commission, the
request may be adjudicated upon the proof filed.
(B) "Application for Determination of
Percentage of Permanent Partial Disability or Increase of Permanent Partial
Disability" pursuant to division (A) of section
4123.57 of the Revised Code in
state fund and self-insured claims.
(1) An
"Application for Determination of Percentage of Permanent Partial Disability or
Increase of Permanent Partial Disability" shall be completed and signed by the
applicant or applicant's representative and shall be filed with the bureau of
workers' compensation. An application for an increase in permanent partial
disability must be accompanied by substantial evidence of new and changed
circumstances which have developed since the time of the hearing on the
original or last determination. The bureau shall dismiss an unsigned
application. Except where an additional condition has been allowed in the claim
and the request is for an increase in permanent partial disability based solely
on that additional condition, the bureau shall dismiss a request for an
increase in permanent partial disability filed without medical documentation.
Whenever the applicant or applicant's representative leaves a question or
questions in the application form unanswered, the bureau shall contact the
applicant and applicant's representative to obtain the information necessary to
process the application. Should the applicant or applicant's representative
inform the bureau that the failure to provide the information necessary to
process the application is beyond the applicant's control, the bureau shall
take appropriate action to obtain such information.
(2) Upon the filing of the application for
either of these requests, the application shall be referred to the bureau for
review and processing. The bureau shall send notice of the application to the
employer and the employer's representative, unless the employer is out of
business. The employer shall submit any proof within its possession bearing
upon the issue to the bureau within thirty days of the receipt of the
claimant's application.
(3) The
bureau shall contact each applicant for a determination of the percentage of
permanent partial disability to schedule an examination by a physician
designated by the bureau. If the applicant fails to respond to the bureau's
attempt to schedule the examination or fails to appear for the examination, the
bureau may dismiss the application as provided in rule 4123-3-15.1 of the
Administrative Code. The examining physician shall file a report of such
examination, together with an evaluation of the degree of impairment as a part
of the claim file. The bureau shall send a copy of the report of the medical
examination to the employee, the employer, and their representatives.
(4) Upon receipt of the examining physician's
report, the bureau shall review the medical evidence in the employee's claim
file and shall make a tentative order as the evidence at the time of the making
of the order warrants. If the bureau determines that there is a conflict of
evidence, the bureau shall forward the application, along with the claimant's
file, to the industrial commission to set the application for hearing before a
district hearing officer.
(5) Where
there is no conflict of evidence, the bureau shall enter a tentative order on
the request for percentage of permanent partial disability and shall notify the
employee, the employer, and their representatives, in writing, of the tentative
order and of the parties' right to request a hearing. Unless the employee, the
employer, or their representative notifies the bureau, in writing, of an
objection to the tentative order within twenty days after receipt of the notice
thereof, the tentative order shall go into effect and the employee shall
receive the compensation provided in the order. In no event shall there be a
reconsideration of a tentative order issued under this division.
(6) If the employee, the employer, or their
representatives timely notify the bureau of an objection to the tentative
order, the bureau shall refer the matter to a district hearing officer who
shall set the application for hearing in accordance with the rules of the
industrial commission. Upon referral to a district hearing officer, the
employer may obtain a medical examination of the employee, pursuant to the
rules of the industrial commission.
(7) Where the application is for an increase
in the percentage of permanent partial disability, no sooner than sixty days
from the date of mailing of the application to the employer and the employer's
representative, the applicant shall either be examined, or the claim referred
for review by a physician designated by the bureau. Such period may be extended
or the processing of the application suspended by the bureau for good cause
shown. If the bureau has determined that the employer is out of business the
bureau will not mail the application and may process the application without
waiting the sixty day period. The bureau physician shall file a report of such
examination or review of the record, together with an evaluation of the degree
of impairment, as part of the claim file. Either the employee or the employer
may submit additional medical evidence following the examination by the bureau
medical section as long as copies of the evidence are submitted to all
parties.
(8) After completion of
the review or examination by a physician designated by the bureau, the bureau
may issue a tentative order based upon the evidence in file. If the bureau
determines that there is a conflict in the medical evidence, the bureau shall
adopt the recommendation of the medical report of the bureau medical
examination or medical review.
(9)
The bureau shall enter a tentative order on the request for an increase of
permanent partial disability and shall notify the employee, the employer, and
their representatives, in writing, of the nature and amount of any tentative
order issued on the application requesting an increase in the percentage of the
employee's permanent disability. The employee, the employer, or their
representatives may object to the tentative order within twenty days after the
receipt of the notice thereof. If no timely objection is made, the tentative
order shall go into effect. In no event shall there be a reconsideration of a
tentative order issued under this division. If an objection is timely made, the
bureau shall refer the matter to a district hearing officer who shall set the
application for a hearing in accordance with the rules of the industrial
commission. The employer may obtain a medical examination of the employee and
submit a defense medical report at any stage of the proceedings up to a hearing
before a district officer.
(10)
Where an award under division (A) of section
4123.57 of the Revised Code has
been made prior to the death of an employee, the bureau shall pay all unpaid
installments accrued or to accrue to the surviving spouse, or if there is no
surviving spouse, to the dependent children of the employee, and if there are
no such children surviving, then to such other dependents as the bureau may
determine.
(C) Payment
of permanent partial disability pursuant to division (B) of section
4123.57 of the Revised Code
(scheduled loss) in state fund and self-insured employer claims.
(1) The bureau or self-insuring employer will
determine the payment of scheduled loss for a loss by amputation or for a loss
of use upon the motion of a party for such award. To determine the payment of
the award, the bureau or self-insuring employer may review the medical evidence
in the file, may request additional medical information from the parties, or
may refer the injured worker
claimant for an examination by a physician
designated by the bureau or self-insuring employer.
(2) The bureau shall enter an order on or the
self-insuring employer shall make a decision on the payment of scheduled loss
for a loss by amputation or for a loss of
use and shall notify the employee, the employer, and their
representatives, in writing, of the order or decision. The parties have a right
to appeal the order or contest the decision pursuant to section
4123.511 of the Revised
Code.
(3) Upon an order for the
payment of scheduled loss for a loss by amputation
or for a loss of use, the bureau or self-insuring employer shall
calculate such award pursuant to the statutory schedule of division (B) of
section 4123.57 of the Revised Code. The
bureau or self-insuring employer shall pay the award to the
injured worker
claimant in weekly payments as provided in division
(B) of section 4123.57 of the Revised
Code.
(4) Where a scheduled loss
has been ordered but not paid prior to the death of an employee, upon
application, the award is payable to the surviving spouse, or if there is no
surviving spouse, to the dependent children of the employee, and if there are
no such children surviving, then to such other dependents as the bureau may
determine.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05
Rule Amplifies: 4121.121, 4123.57, 4123.65
Prior Effective Dates: 10/09/1976, 01/16/1978, 08/22/1986 (Emer.), 11/08/1986, 07/16/1990, 11/01/2004, 02/10/2009, 10/12/2010, 07/11/2013, 04/01/2014, 06/18/2018
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