Medical-Only Program Employer Ad-Hoc Letter

Instruction note:

  • Copy and paste this letter into a V3 Adhoc letterand use either Insert 1 or Insert 2. Choose the employer as the addressee and copy all parties to the claim.
  • Print A-31b (found under Forms in COR) and complete the A-31b and attach it to the letter. The Customer Care Team (CCT) needs to enter the Employer’s name and the injured worker’s claim number in “BWC Customer Number.” In the address line under the employer name enter “RE: IW’s Name, $5 or $15K Program.” In the Payment Type section, Check box for Recollected Compensation and Mark MIIS and/or CARE (both should be marked if monies are being recollected from both systems) and the Amount Paid should have the total due from the Employer.
  • Send two copies of the letter andtwo copies of the data warehouse report(s) to the employer andone copy of the letter to the injured worker, injured worker’s representative, and the employer’s representative.
  • Print correspondence locally so that data warehouse report(s) and A-31b can be attached to the employer’s copies.

This letter is in response to your recent inquiry, Motion (C-86), or letter on the claim listed above. You requested wecredit your policy for payments made for this claim and to place the claim in the Select $15,000, $5,000, or $1,000Medical-Only Program.

Insert 1

Our researchconfirms this claim qualifies forenrollment in the Medical-Only Program.

I haveenclosed a Health Partnership Programand/orMedical Invoice Information System report. The report(s) details billing history for the claim andshows all medical bills paid to date. For us to place this claim in the Medical-Only Program, we must receive full payment of $ <insert amount>,the reimbursed amount shown in the report(s). To ensure proper credit, please include a provided copy of this letter and data warehouse report(s) along with your payment and the Accounting General Deposit Slip (A-31-b).

The reimbursed amount(s) represents the amount we paid, whichwe willremove from your experience. Employers participating in the Medical-Only Program must pay the billed amount or an amount according to a prior agreement with the provider. Therefore, you should pay the provider the difference between the billed amount and our reimbursement amount.

We must receive payment along with copies of this letter and data warehouse report(s) within 14 days of the date of this correspondence. Please make your payment to the Ohio Bureau of Workers’ Compensation and mail it to:

BWC Medical Payment Recovery

30 W. Spring St., 20th Floor

Columbus, OH 43215

Once we receive payment,we will credit that amount to the claim and place the claim in the Medical-Only Program.If we do not receive payment,we cannotcredit the claim, remove the claim costs from your experienceand place the claim in the Medical-Only Program.

Please call me at the number listed below if you have any questions about the information in this letter.

Thank you, >

Rep’s name

Insert 2

Our research confirms the medical payments in question were appropriate. Therefore, we will charge the payments to your policyper Ohio Administrative Code 4123-17-59.

We will not place this claim in the Select $15,000, $5,000, or $1,000Medical-Only Programbecause:

  • You have not complied with the rules of the program; and/or
  • We have already made payment according to the program rules.

We based this decision on Enter reason.

Please contact me at the number listed below if you have any questions about the information in this letter or if you disagree with this decision.

Thank you,