When you file a workers’ compensation claim in Ohio, two different entities may become involved at different stages. The Bureau of Workers’ Compensation (BWC) determines whether your claim qualifies for benefits. A Managed Care Organization (MCO) then manages your medical care after the BWC allows the claim. Knowing each entity’s role may help you go through the process with greater confidence.
What does the BWC do?
The BWC operates as Ohio’s state-administered workers’ compensation fund, although qualified large employers may choose to self-insure. Its role focuses on reviewing claims and administering benefits. After you or your employer reports a work injury, a BWC claims specialist may review the paperwork and medical records. The specialist then determines whether the injury arose out of and in the course of employment under Ohio law.
If the BWC allows the claim, it may authorize payment for medical bills and lost wages. The agency may also monitor whether the parties meet their responsibilities and support your return to work when medically appropriate.
What does the MCO do?
Your employer selects an MCO from a BWC-approved list to manage the medical side of allowed claims. The MCO coordinates your treatment, reviews requests for specific services and pays medical providers. It may also track your progress and assist with return-to-work planning.
You can think of the MCO as the medical gatekeeper for your claim. However, it does not determine whether your claim qualifies for benefits. That decision generally rests with the BWC.
What happens when an MCO denies treatment?
An MCO may deny a recommended treatment, test or referral even after the BWC allows your claim. The denial could involve questions about medical necessity, treatment guidelines or whether the requested care relates to an allowed condition.
If this happens, you may have options. You can:
- Request a written explanation for the denial.
- Ask your treating provider to submit additional records or a letter explaining the medical need.
- File an appeal with the MCO through the Alternative Dispute Resolution (ADR) process within 14 days of the denial notice.
If the ADR process does not resolve the dispute, the BWC may issue a formal administrative order. If you disagree with that order, you may appeal and request a hearing before the Industrial Commission of Ohio.
What Ohio laws apply to your claim?
Ohio law establishes the Bureau of Workers’ Compensation (BWC) and defines its administrative role in Ohio’s workers’ compensation system. The statute provides the legal foundation for the BWC’s responsibility to administer workers’ compensation claims and related benefits.
How can an attorney help you?
An experienced workers’ compensation attorney may review denial letters, help gather supporting medical evidence and guide you through the ADR or hearing process. Legal counsel may also help you determine whether your treatment aligns with BWC medical guidelines and the conditions allowed in your claim.
Key takeaways about your claim
The BWC generally determines whether your claim qualifies for benefits, while the MCO manages medical care after approval. If an MCO denies treatment, you may have the option to challenge the decision through the ADR process or request a hearing before the Industrial Commission.