Chapter 4123-5 Miscellaneous Provisions

4123-5-01 Assignment of duties to the bureau's operational units.

The administrator may reorganize the work of the bureau to the extent necessary to achieve the most efficient performance of its the functions. The duties of the operational units of the bureau include, but are not limited to the following:

(A) A division responsible for the fiscal and planning function will assist the administrator in maintaining the solvency of the insurance fund, establishing policies and procedures for fiscal management, receiving and disbursing funds from the state insurance fund, and preparing the bureau's budget.

(B) A division responsible for the medical services function will assist the administrator in establishing and maintaining a quality pool of medical and vocational service providers, developing and maintaining quality medical , vocational rehabilitation, and pharmaceutical benefits plans, overseeing managed care services, and ensuring the proper and timely payment of medical bills.

(C) A department responsible for the special investigations function will conduct investigations of alleged workers' compensation fraud and alleged violations of specific safety requirements pursuant to workers' compensation claims.

(D) A division responsible for the customer service function will assist the administrator in:

(1) Identifying employers subject to the Ohio Workers' Compensation Act;

(2) Conducting periodic reviews of the manual classifications and payroll reports of state fund employers to ensure that employer premium payments have been properly computed and paid

(3) Developing and making available alternative premium plans to state fund employers;

(4) Managing the claims of injured workers in accordance with applicable statutes, rules and policies;

(E) A division responsible for the actuarial function will assist the administrator in ensuring that rates for all employers are calculated based on actuarial principles and standards of practice, ensuring that financial liabilities for compensation and compensation adjustment are calculated based on actuarial principles and standards of practice, and developing and supporting alternative rating options for employers.

(F) A division responsible for the investment function will assist the administrator in the investment and monitoring of assets of the state insurance fund and other funds administrated by the bureau, and in the implementation and monitoring of the bureau investment policy approved by the board of directors.

(G) A division responsible for the internal audit function will conduct reviews of divisions and control systems within the bureau, at appropriate intervals, to determine whether they are effectively carrying out their functions of administration, accounting, safeguarding of bureau assets, and control in accordance with management's instructions, policies, and procedures, and in a manner that is in agreement with both agency objectives and high standards of administrative practice; conduct special examinations at the request of management or the bureau of workers' compensation board of directors audit committee; submit an annual audit plan to the administrator and the audit committee for their review and approval.

Replaces: 4123-9-01

Effective: 12/01/2009
R.C. 119.032 review dates: 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.121 , 4121.13 , 4121.30
Rule Amplifies: 4123.05
Prior Effective Dates: 1/1/78, 9/1/96

4123-5-02 Armed services claims. [Rescinded].

Rescinded eff 11-5-09

4123-5-11 Employer's reports must be signed by officer or person in employ of employer.

The bureau of workers' compensation will not accept an employer's report on application for payment of compensation and/or benefits, payroll reports, settlement sheets, and other instruments, which employers are required to submit to the bureau of workers' compensation unless the document is signed by an officer in the organization of the employer, or a person in the employ of the employer, who is duly authorized to sign such instruments. The person signing such instruments for the employer shall indicate in what capacity the person is employed (title). No instruments purporting to authorize any service organization or any other person to sign such instruments for an employer shall be recognized as granting such authority.

Effective: 11/05/2009
R.C. 119.032 review dates: 07/10/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 4121.121 , 4121.30 , 4121.31
Rule Amplifies: 4123.05
Prior Effective Dates: 1/9/67, 1/16/78

4123-5-13 Funeral expenses, what constitutes, amount to be paid.

(A) The date of death shall govern the amount of funeral benefits to be paid in death claims, and that funeral expenses shall constitute all services rendered in connection with the dead bodies of killed employees, or of employees who have died as a result of injury or occupational disease. In such cases no disbursements shall be made in excess of the amount allowed by law for funeral expenses.

(B) In cases where an attempt was made by the ambulance service, by a physician or at a hospital emergency room to revive the employee and such attempt was in the nature of treatment (e.g. use of oxygen, artificial respiration, injection, medication, electro-shock, etc.), payment for such services and for the use of equipment shall be made in addition to the payment for funeral expenses. The bureau may make payment for exceptional transportation costs in addition to the payment of funeral expenses. (e.g. returning the body when the death occurred outside the area where the deceased lived.)

Effective: 11/05/2009
R.C. 119.032 review dates: 07/10/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 4121.121 , 4121.30 , 4121.31
Rule Amplifies: 4123.66
Prior Effective Dates: 1/9/67, 1/16/78

4123-5-18 Medical proof required for payment of compensation.

(A) Except as provided in paragraph (B)(1)(b) of rule 4123-3-09 of the Administrative Code, no payment of compensation shall be approved by the bureau in a claim unless supported by a report of a physician duly licensed to render the treatment.

(B) In evaluation of sufficiency of medical proof the following criteria shall be considered:

(1) The nature and type of injury or occupational disease;

(2) Is the diagnosis consistent with the description of events resulting in the injury or occupational disease, as shown by proof of record;

(3) Is the disability rating based solely on condition or conditions for which the claim is recognized;

(4) Is the disability rating based on objective symptoms of disability as a direct result of the injury or occupational disease in the respective claim; "objective symptoms" means those signs and indications which a physician discovers from an examination of the patient, as distinguished from subjective symptoms which the physician learns from the patient;

(5) Did the physician state reason or reasons for his opinion?

(C) Whenever payment of compensation cannot be made due to lack of medical proof, the claimant shall be immediately advised of the necessity to submit appropriate medical proof, as specified in paragraph (A) of this rule.

(D) In cases of continued temporary disability as a result of the allowed injury or occupational disease it shall be the duty of the claimant to submit periodic medical reports and the signed request for temporary total disability compensation (form C-84) or an equivalent form or document containing the information on the C-84 form to support disability to assure regular payment of compensation. The frequency of filing such reports depends on the type and nature of the injury or occupational disease and the degree of disability.

Effective: 11/05/2009
R.C. 119.032 review dates: 07/10/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 4121.121 , 4121.30 , 4121.31
Rule Amplifies: 4123.05
Prior Effective Dates: 1/9/67, 1/16/78

4123-5-20 Payment of compensation when advancements are made during period of disability.

(A) Except for payments made to claimants under a contract of hire or under a collective bargaining agreement by an employer that is a professional sports franchise domiciled in Ohio, whenever a claimant and the employer advise the bureau in writing that the wages were paid or the advancements were made solely for the purpose of assisting the claimants in obtaining necessary maintenance and care during a period not to exceed twelve weeks following an injury sustained or occupational disease contracted by the claimant in the course of and arising out of employment, particularly while a claim for compensation is being acted upon by the bureau, and the claimant and employer had mutually agreed that the employer is to be reimbursed, at least to the extent of any compensation paid to the claimant over the same period in which the wages were paid or the advancements made, the bureau shall issue warrants in payment of compensation awarded for a period not to exceed twelve weeks commencing from the date of such an injury or beginning of disability, which warrants are to be mailed to the claimant in care of the employer with instructions that the warrants are to be endorsed personally by the claimant. The bureau will not honor the agreement unless the written notice of the agreement is signed by the employer and claimant and filed with the bureau within thirty days of the beginning date the period in the agreement covers. The warrants to be sent in care of the employer are not to be in payment of compensation for disability in excess of a period of twelve weeks closely following the date of injury or beginning of disability, unless under special circumstances the bureau authorizes the sending of warrants in payment of compensation for disability beyond the twelve weeks in care of the employer.

The warrants to be sent in care of the employer are not to be in payment of compensation for disability in excess of a period of twelve weeks closely following the date of injury or beginning of disability, unless under special circumstances the bureau authorizes the sending of warrants in payment of compensation for disability beyond the twelve weeks in care of the employer.

(B) Whenever an employer that is a professional sports franchise domiciled in Ohio makes payment pursuant to the terms of a contract of hire or a collective bargaining agreement during a period of disability resulting from the injury or occupational disease, the aggregate amount of such payments shall be deemed an advanced payment. Upon the filing of proof of such payments, compensation payments under sections 4123.56 to 4123.58 of the Revised Code shall be reimbursed by the bureau directly to the employer if it is a state fund employer unless payment has been made to the claimant prior to the bureau's receipt of the employer's proof of an advanced payment. Self-insured employers shall apply the aggregate amount of advanced payments to a claimant to offset that claimant's future payments of compensation under section 4123.56 to 4123.58 of the Revised Code. Employer reimbursements and offsets shall apply only where the employee's application for compensation is pending on or after August 22, 1986.

(C) Where a claimant is entitled to vacation with pay, payment of wages for a vacation period during the period of temporary disability resulting from injury or occupational disease shall not be deemed an advancement nor shall such payment be applied to offset any compensation that is payable for that period of time.

Where claimants are paid a regular salary during the period of disability on any other basis, for example, sick leave, payment of compensation for temporary disability, compensation cannot be paid so long as such regular salary or wages are paid, unless the claimant and the employer notify the bureau in writing that such salary or sick leave was paid as an advancement.

Effective: 11/05/2009
R.C. 119.032 review dates: 07/10/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.121 , 4121.30 , 4121.31
Rule Amplifies: 4123.05
Prior Effective Dates: 1/9/67; 1/16/78; 8/22/86 (Emer.); 11/8/86, 8/15/07

4123-5-21 Abatement of claims.

(A) When a claimant dies, action on any application filed by the claimant, and pending before the bureau or the industrial commission at the time of his death, is abated by claimant's death.

(B) Abatement of action, as described in paragraph (A) of this rule, does not apply to payment for medical and hospital treatment, for medicine, nursing, and other health care services rendered as a result of the injury or occupational disease for which the claim was allowed during the deceased claimant's lifetime, provided that the respective bills were filed within the time as required by law and by the rules of the industrial commission and the bureau.

R.C. 119.032 review dates: 07/10/2009 and 07/01/2014

Promulgated Under: 119.03

Statutory Authority: 4121.121 , 4121.30 , 4121.31

Rule Amplifies: 4123.66

Prior Effective Dates: 1/16/78