Agency Schedule Detail

Authorization Number : 855-0762

Agency Series No. : PE-01

Status : Active

Agency Web Link :

Agency : BWC

Confidential Description : Provider Files have Social Security Numbers and Tax Identification Numbers imbedded into the number, therefore are kept confidential for Senate Bill 7 and identity theft.

Division : BWCIACS

Vital Description :

Section : BWCIACSMSPA

Record Title : Provider Folders

Revision : 4

Record Description : Providers applying to be enrolled and/or certified to treat injured workers have an electronic provider file containing documents relative to that provider. These include all various historical and miscellaneous documents related to that provider’s enrollment/certification and qualifications. Examples of file contents may include: enrollment application form, license/credential/requirement information, Liability Insurance, BWC provider agreement, Form W9 (lists the Tax Identification Numbers (Tax ID) and the legal name of the party receiving payment from BWC), curriculum Vitae (schooling), internal emails regarding the provider, decertification information, compliance information, returned mail, record updates, or other related information. The Provider Files information is scanned into the provider Universal Document Service (UDS) imaging repository system for electronic storage. There is an enrollment department intake box where email/faxed and mailed applications are sent, and those records are assigned to a worklist where, when processed, a new UDS file is created, or the information is placed into an existing provider UDS file

Retention Period	Retention Justification	Media Code	Method of Disposal
• Hardcopy/mailed applications/updates – destroyed after faxing into the enrollment intake box • The intake fax box serves as the main intake and scanned received images are held in case they need to be referenced for a period of 6 months, then deleted • The UDS provider file is the BWC history of our provider network. The UDS file provides all enrollment and certification history and is linked with the PEACH system record for the provider. It is essential to know a provider history for network eligibility.		Electronic	Delete
• Hardcopy (mailed in) applications/updates are destroyed after faxed to the intake enrollment box via the confidential trash bin on the floor that is shredded. • The information in the intake enrollment fax box is retained for a 6-month period, then delete. • Retain the electronic provider files indefinitely in UDS.		Paper	Shred

Approvals

Status	Name	Title	Date
Approved	JEFF Hitch	Records Coordinator	10/21/2021 1:22:57 PM
Approved	TOM Sico	Records Officer	1/4/2022 3:01:12 PM
Approved	Terri Dittmar	Record Administrator	1/6/2022 11:07:44 AM
Approved	Fred Previts	State Archivist	1/6/2022 2:41:36 PM
Approved	Martin Meeks	State Auditor	1/10/2022 9:42:25 AM

Notes

Date	Reason	User