The managed care organization (MCO) makes the treatment decisions for the work-related injury. If the injured worker, medical provider or employer disagrees with those decisions, there is an Alternative Dispute Resolution (ADR) process where the MCO's decision can be appealed. The ADR process handles disputes about medical treatment ordered by the injured worker's doctor.
If the injured worker, the medical provider or employer disagrees with the MCO's decision on treatment issues, complete the ADR Appeal to the MCO Medical Treatment/Service Decision (C-11), and send it to the MCO to begin the ADR process.
The MCO relies on medical professionals to review the injured worker's conditions and medical reports to:
- Determine if the services are related to the injury.
- See if the treatment is necessary.
- Determine if the cost is medically reasonable.
The MCO may recommend the injured worker be scheduled for an independent medical examination. Upon review of the doctor's report, the MCO will send BWC its recommended decision. BWC will send out the decision to the injured worker in a letter with copies to all the parties involved in the claim.
Disagreeing with an appeal decision
If there is still disagreement with BWC's decision about the injured worker's medical benefits and/or request for payment of compensation, the injured worker or employer has 14 days to appeal to the Ohio Industrial Commission (IC).
The appeal will be an administrative hearing held at an IC location nearest to the injured worker's home address. Upon filing an appeal, the IC will notify the injured worker and other parties to the claim of the date, time and location of the hearing. This notification is usually received about two weeks prior to the hearing date.
There are three possible levels of appeal for workers' compensation disputes at the IC. Injured workers can choose to represent themselves in this process or hire a lawyer at their own expense.
For more information about the levels of the appeals process, call the IC at 1-800-521-2691 or 614-466-6136. You can also log on to the IC's website.