Self-Insured Employer Workers Comp: Understanding the Claims Process and Management

Estimated reading time: 16 minutes

Meta Title: Self-Insured Employer Workers Comp: Claims & Who Handles

Meta Description: Self-insured employer workers comp explained: who handles your claim, California differences, private workers comp provider, and the difference vs state fund.

Key Takeaways

• In a self-insured employer workers comp program, the employer—not a traditional insurer—funds and often manages claims, sometimes through a third-party administrator or private workers comp provider.

• Verify who handles your claim by checking workplace postings, employer forms, and asking HR in writing; you can also consult the Division of Workers’ Compensation (DWC) and state self-insurance resources.

• California adds specific steps and timelines (DWC-1, UR/IMR, QME/AME), and large self-insured employers may have on-site clinics and dedicated claims teams.

• The difference between self-insured and state fund models affects who pays claims, who manages them, dispute pathways, and how fast care is authorized.

• If care or benefits are denied or delayed, escalate in writing, use UR/IMR and WCAB hearing options where applicable, and consider legal help early.

Table of Contents

• Introduction

• Who This Guide Is For and Search Intent

• What “Self-Insured Employer Workers Comp” Means

• Definition

• Who Qualifies & Why

• Regulatory Requirement Examples

• What Is a Private Workers Comp Provider?

• Who Handles My Workers Comp Claim When My Employer Is Self-Insured?

• Claim Handlers and Responsibilities

• How to Verify Who Handles Your Claim

• Sample Email Template to Confirm Claim Handler

• Step-by-Step Claims Process for a Self-Insured Employer

• Immediate Steps After Injury

• Employer Response Timeline and Statutory Triggers

• Medical Management in Self-Insured Claims

• Documentation and Best Practices

• Large Company Injury Claim in California — What’s Different?

• California-Specific Rules and Forms

• Typical Structure at Large Employers

• Timing, Benefits, and Common Hurdles

• Difference Between Self-Insured and State Fund

• What It Means for Workers

• Pros and Cons for Employees

• Pros of Self-Insured Employers

• Cons of Self-Insured Employers

• Tips to Protect Your Rights

• What to Do If Your Claim Is Denied, Delayed, or Mishandled

• Immediate Actions After a Denial or Delay

• Medical Care Denials: UR → IMR

• Challenging Indemnity or Disability Decisions

• Time-Sensitive Warnings

• When to Get an Attorney

• Sample Appeal and Escalation Templates

• Practical Checklist for an Injured Worker at a Self-Insured Employer

• Real-World Examples / Mini Case Studies

• Example 1 — Large Retail Chain

• Example 2 — Manufacturing Employer

• Example 3 — Paperwork Delay and Escalation

• Glossary of Key Terms

• Conclusion

• FAQ

Introduction

A self-insured employer workers comp arrangement means the employer—not an insurance company—pays workers’ compensation benefits directly to injured employees. This guide explains what it means to work for a self-insured employer, how the claims process differs, and who is responsible when an injury occurs. Key takeaways: who handles claims, how a large company injury claim in California differs, the role of a private workers comp provider, and the difference between self-insured and state fund. For background, see the Berry Insurance guide to self-insured workers’ compensation and this Visionary Law Group overview of self-insured employer workers comp.

Who This Guide Is For and Search Intent

This resource is for injured employees, HR professionals, and worker advocates who need plain-English answers about self-insured programs. The search intent is informational: understand self-insured employer workers comp and how the claims process changes, including who handles my workers comp claim. For a general definition of self-insurance programs, see Washington’s L&I overview of self-insurance.

What “Self-Insured Employer Workers Comp” Means

Definition

A self-insured employer workers comp program is one in which the employer — rather than a traditional insurance carrier — assumes financial responsibility for workers' compensation claims; the employer pays medical costs, lost wages, and benefits from its own funds or security arrangements. In practice, instead of purchasing a standard insurance policy, the employer funds approved treatment and benefits directly or through an administrator. See the Berry Insurance explanation of self-insured workers’ compensation and the Visionary Law Group guide to self-insured employer programs for foundational context.

By contrast, when an employer buys a policy from an insurer, it pays premiums up front and the insurer pays claims. Under self-insurance, the employer pays claims as they arise. This difference affects who makes decisions about medical authorizations, timing of payments, and day-to-day communication with employees.

This section introduces concepts we expand later, including how a private workers comp provider fits in and the difference between self-insured and state fund models.

Who Qualifies & Why

Self-insurance is typically limited to large employers with strong balance sheets and demonstrated operational stability. Common criteria include substantial net worth, multi-year operating history, positive cash flow, and the capability to post a security deposit or letter of credit. Many states also require proof of current coverage and audited financials.

Requirements vary state by state. For example, New York’s Workers’ Compensation Board outlines strict self-insured employer requirements, including years in business, current coverage, and a substantial net worth. In New York, applicants must show years in business, current insurance coverage, and substantial net worth; New York’s minimum security deposit was reported at over $1.9 million as of July 1, 2025. These financial safeguards are designed to ensure injured workers’ benefits are secure even if business conditions change.

Employers often choose self-insurance for cost control, direct oversight of care, and the ability to “pay as you go” rather than prepay premiums. Those incentives can translate to focused safety efforts and investments in return-to-work programs.

Regulatory Requirement Examples

State regulators impose guardrails for self-insured employers. Typical rules include:

• Security deposits via cash, surety bonds, or letters of credit to guarantee claim payments even in a default. New York’s program details these options and deposit amounts in its self-insured employer requirements.

• Excess or stop-loss insurance to cover catastrophic claims that exceed a set threshold—an added backstop to protect workers and the company, discussed in the Berry Insurance guide.

• Periodic financial and compliance reporting, audits, and on-site reviews by oversight agencies, with revocation possible for noncompliance, as noted by both New York’s WCB and Washington’s L&I self-insurance program.

These controls help ensure that a self-insured employer maintains the resources to fund medical care and wage benefits when workers are hurt.

What Is a Private Workers Comp Provider?

Many self-insured employers hire outside partners to administer claims. A private workers comp provider is a specialized firm—often functioning like a Third-Party Administrator (TPA)—that handles intake, claims adjusting, nurse case management, utilization review coordination, bill payment, and sometimes on-site clinic operations. See descriptions in the Berry Insurance article on self-insurance and the Visionary Law Group overview.

These providers streamline processes, but employees should still know who is legally responsible for benefits (the employer) and how to verify the correct claims contact.

Who Handles My Workers Comp Claim When My Employer Is Self-Insured?

When an employer is self-insured, your claim may be handled internally (HR/claims unit), by a third-party administrator (TPA), or by a private workers comp provider under contract.

Claim Handlers and Responsibilities

• Employer internal claims unit / HR: Receives injury reports, provides forms, posts required notices, initiates first report to the state, and may coordinate early care.

• Third-Party Administrator (TPA): Performs intake, investigates the claim, adjusts benefits, issues payments, manages subrogation, and coordinates documentation.

• Private workers comp provider: May supply nurse case managers, manage utilization review (UR), operate on-site or employer-contracted clinics, and handle payment processing.

• Outside adjusters / vendor network: Can include independent medical exam coordinators, investigators, surveillance vendors, and pharmacy networks; privacy and ethical boundaries still apply under state law.

• Medical providers: Your treating physician, any nurse case manager, and (in California) medical-legal evaluators such as QME/AME when disputes arise.

State programs describe these structures at a high level; for example, Washington’s self-insurance overview explains how employers manage claims with state oversight.

How to Verify Who Handles Your Claim

• Check workplace posters and reporting forms: Injury posters and employer packets often list the TPA or private provider’s name, address, and phone.

• Ask HR in writing: Request the full name, phone, email, and mailing address of your assigned claims handler.

• Use state resources: Look up the employer/TPA relationship through state agencies—for California, consult the Division of Workers’ Compensation (DWC) database; for a general description of self-insurance oversight, see Washington’s L&I self-insurance page.

Keep a record of who you spoke with and when. Written confirmations avoid confusion later.

Sample Email Template to Confirm Claim Handler

Subject: Workers’ Compensation Claim — Request for Claims Handler Contact

“Please confirm in writing who is handling my workers' compensation claim and provide direct contact details (name, phone, email).”

“Also, please share any required forms and instructions for medical authorization and wage benefits. Thank you.”

Step-by-Step Claims Process for a Self-Insured Employer

The flow is similar to insured models, but the decision-makers are your employer’s internal team, a TPA, or a private workers comp provider. Procedures and timelines vary by state—check your state DWC or contact an attorney for specifics.

Immediate Steps After Injury

• Report immediately: Tell your supervisor/HR as soon as possible. Suggested phrasing: “I was injured on [date/time] at [location]. Please provide any forms required to report this injury and confirm who will handle this workers’ compensation claim.” For a general filing roadmap, see our guide on how to file a workers’ comp claim.

• Seek medical care: In emergencies, get immediate care. If non-emergency, follow employer instructions. Some states allow initial treatment in an employer-designated network before you can change doctors.

• Complete required forms: In California, fill out the DWC-1 claim form as soon as possible. You can get it from your employer or the DWC website. Include injury details and contact information, sign and date, and keep a copy for your records.

If your employer refuses to provide a form or delays, document the refusal and self-initiate where allowed. For more general step-by-step actions after an injury, see steps to take after a workplace injury.

Employer Response Timeline and Statutory Triggers

Self-insured employers or their administrators should promptly authorize medically necessary care. If indemnity (wage-loss) is owed and the claim is accepted, payments in California typically begin within about 14 days; see the California DWC for current timelines and guidance.

For treatment requests, the administrator may conduct Utilization Review (UR). If UR denies or modifies treatment, California workers can request Independent Medical Review (IMR) via the DWC. Keep all notices; they include crucial deadlines.

Medical Management in Self-Insured Claims

• Employer-selected networks: Some states permit initial care within an employer network. In California, many workers may change their treating physician after an initial period (often referenced as 30 days); confirm the current rule on the DWC site or with counsel.

• Nurse case managers: These professionals coordinate appointments, facilitate communication, and support return-to-work planning.

• TPA/private provider roles: They handle intake, authorization, bill payment, and often vocational and return-to-work program administration. See descriptions of TPA functions in the Visionary Law Group overview and the Berry Insurance summary.

To understand doctor choice rules and exceptions, consult our primer on whether you can choose your own doctor in workers’ comp.

Documentation and Best Practices

• Keep copies of the DWC-1 (if in California), medical records, billing statements, benefit notices, and every form you submit.

• Maintain a running timeline with dates, times, and the names of every person you spoke with and what they said.

• Send follow-ups and important notices by email. Ask for written acknowledgments and keep read receipts when possible.

• Organize digital PDFs for quick access during disputes or hearings. These records are critical if you need to appeal a workers’ comp denial.

Large Company Injury Claim in California — What’s Different?

Large self-insured employers in California commonly operate differently because of scale, dedicated claims teams, and state-specific processes at the DWC.

California-Specific Rules and Forms

• Division of Workers’ Compensation (DWC): The California Division of Workers’ Compensation oversees claims, including those involving self-insured employers.

• DWC-1 claim form: This employee form initiates your claim. Download the DWC-1, complete it promptly, give it to your employer, and keep a copy.

• UR/IMR pathway: Treatment requests go through UR. If denied or modified, you can request IMR—details and forms are found through the DWC.

• QME/AME process: When there’s a dispute over diagnosis, work-relatedness, or permanent disability, you may seek a Qualified Medical Evaluator (QME) panel. AME applies if both sides are represented and agree on an evaluator. To learn more, see our explainer, what is QME in workers’ comp.

Typical Structure at Large Employers

Big companies often have on-site or contracted clinics for initial triage, a dedicated internal claims team, and a TPA or private workers comp provider to manage claims. Pros include speedy intake, coordinated care, and robust return-to-work programming. Cons include potential conflicts of interest when the employer (or its agent) controls authorizations and payments.

Example workflow: On-site clinic triages your injury → TPA intake → UR evaluates non-routine treatment → IMR if UR denies → QME if there’s a dispute over medical-legal issues.

For general self-insurance context and characteristics, see the Berry Insurance overview of self-insured programs and the Washington L&I self-insurance page.

Timing, Benefits, and Common Hurdles

Temporary disability (TD) and permanent disability (PD) benefits are calculated under state formulas. In California, check the DWC resources for calculation specifics and current rates. Delays in authorizing treatment, surveillance disputes, and disagreements about QME reports are common friction points.

Proactively document everything and escalate in writing if issues persist. If disputes continue, consider consulting counsel or the DWC’s Information & Assistance resources. For a broader overview of California rules, see our California workers’ comp laws guide.

Difference Between Self-Insured and State Fund

Side-by-Side Comparison

• Who pays claims: Employer directly (self-insured) vs. state-managed pool (state fund).

• Who manages claims: Employer/TPA/private provider vs. state fund administrators.

• Oversight/guarantee: State oversight plus security deposits and stop-loss vs. state guarantee through a fund.

• Funding model: Pay-as-you-go plus security requirements vs. premiums paid to the state fund.

• Predictability and incentives: Variable cost and strong safety incentives (employer bears risk) vs. pooled risk and more predictable premiums.

• Employee experience: Potentially faster, tailored care but possible conflicts vs. standardized processes with less employer direction.

The difference between self-insured and state fund is that in a self-insured model the employer pays and often manages claims directly, while in a state fund the state manages and pays claims from employer-paid premiums. For context on security requirements, see New York’s self-insured rules. For a general explainer of self-insurance characteristics, this Berry Insurance article is helpful.

What It Means for Workers

With a self-insured employer, decision-making may be closer to the workplace and potentially faster, but disputes can feel more personal because your employer funds the claim. In state-fund situations, decisions come from a government-run program, which can be more standardized, with predictable processes and appeals within the state system.

Regardless of model, you retain rights to medical care, disability benefits, and the ability to challenge denials. Familiarize yourself with your state’s forms, deadlines, and the exact agency that will receive appeals.

Pros and Cons for Employees

Pros of Self-Insured Employers

• Faster initial care/on-site clinics: Large employers may offer immediate triage or same-day appointments, reducing delays.

• Tailored return-to-work (RTW) programs: Because employers bear costs directly, they often invest in transitional duties and RTW planning.

• Dedicated resources: Internal teams, TPAs, and private workers comp providers can streamline communication and case management.

Cons of Self-Insured Employers

• Potential conflicts of interest: The entity paying benefits may influence medical authorizations or timing.

• Risk of denial or underpayment: Stop-loss policies protect against catastrophic losses, not routine disputes, so some claims may be closely scrutinized or challenged.

• Administrative complexity: Multiple vendors (TPA, UR, pharmacy, case managers) can make navigation confusing.

Tips to Protect Your Rights

• Document everything: keep copies of the DWC-1 (if California), medical records, and benefit notices.

• Request independent medical opinions (QME/AME) when disputes arise, following state rules. See our primer on QME and IMR.

• Contact your state DWC’s Information & Assistance resources or consult a workers’ compensation attorney early if benefits are delayed or denied.

For background on self-insured programs and administrator roles, review the Visionary Law Group resource and Berry Insurance’s overview.

What to Do If Your Claim Is Denied, Delayed, or Mishandled

Denials and delays can be stressful. A clear plan can get your case moving. Procedures and deadlines vary by state—check your state’s guidance and act fast.

Immediate Actions After a Denial or Delay

• Gather your records: medical reports, bills, imaging, claim forms, benefit notices, and emails/texts.

• After any phone call, write a brief summary and email it to your claims handler to confirm what was said.

• Send key documents by email or certified mail and request a written acknowledgment.

Medical Care Denials: UR → IMR

In California, if UR denies or modifies care, you can request IMR. Instructions and forms are available through the California DWC. Follow the timeline on your UR denial notice—missing the window can end the appeal.

Challenging Indemnity or Disability Decisions

For wage-loss denials, delays, or disputes over permanent disability, you can file for a hearing before the Workers’ Compensation Appeals Board (WCAB) via the DWC. Many workers also seek a QME evaluation to resolve medical-legal disputes. If your claim involves complex permanent disability or settlement questions, consult counsel or study your state’s resources. For general appeal guidance, see our article on how to appeal a workers’ comp denial.

Time-Sensitive Warnings

Strict filing windows apply to IMR requests, petitions for hearings, and other appeals. Always read dates on your notices. When in doubt, file early and verify receipt. The DWC posts current procedures and deadlines; check the DWC site for exact timelines.

When to Get an Attorney

• Repeated denials of medical treatment or wage benefits.

• Complex permanent disability ratings or settlement negotiations.

• Surveillance disputes, retaliation concerns, or conflicting medical opinions.

You can also review our overview of return-to-work after injury to understand how benefits, restrictions, and job offers interact while you pursue appeals.

Sample Appeal and Escalation Templates

Short appeal/reconsideration to employer/TPA:

“I respectfully request reconsideration of the [denied/modified] [treatment/benefit] dated [date]. Enclosed are [medical notes, physician requests, pay stubs]. Please provide a written decision and the specific basis for any continued denial, including how to appeal.”

UR/IMR escalation (California):

“I am requesting IMR of the UR decision dated [date] regarding [treatment]. Please confirm the IMR submission requirements and deadlines and provide any forms required. I will submit all supporting medical records and the treating physician’s request per the DWC process.”

Practical Checklist for an Injured Worker at a Self-Insured Employer

• Report the injury immediately to your supervisor and HR—get the name and time of the person you reported to. Mention it is a self-insured employer workers comp claim if applicable.

• Ask for and complete any employer forms (keep copies).

• Request in writing: “Please confirm who is handling my workers' compensation claim and provide contact details.” Use the phrase who handles my workers comp claim so it is clear.

• Get copies of all medical records, bills, and the DWC-1 (if California).

• Request the name and contact for the claims adjuster, TPA, or private workers comp provider.

• Document every conversation—name, date, time, and summary; follow up by email.

• If treatment is denied, request UR and be prepared to request IMR (California).

• If you work for a large company in California, follow DWC-specific steps such as completing DWC‑1 and learning about UR/IMR (see DWC links).

• Keep in mind the difference between self-insured and state fund when deciding who to contact for help.

• Consider consulting a workers’ compensation attorney if benefits are delayed or denied.

Real-World Examples / Mini Case Studies

Example 1 — Large Retail Chain

After a lifting injury, a worker at a large self-insured retailer reports to an on-site clinic and receives immediate care. A TPA processes the claim. When a surgeon requests a procedure, UR initially denies it; the employee pursues IMR through the California DWC, and IMR overturns the denial. Lessons for a large company injury claim California scenario: on-site care can be fast, but IMR can be essential. Keep a precise timeline and all notices from UR/IMR. What to do: request IMR promptly, and submit complete medical support.

Example 2 — Manufacturing Employer

A self-insured manufacturing company delays wage payments despite medical disability notes. The worker files for a WCAB hearing via the DWC, obtains a QME evaluation, and wins an award for back wage replacement. Lessons: persistence and use of the medical-legal process matter. If you’re unsure who handles my workers comp claim, confirm in writing and escalate to the state when deadlines loom. For background on oversight of self-insurance and protections, see New York’s WCB self-insurance requirements and Washington’s L&I overview. What to do: request a hearing if benefits stall and obtain a QME when medical disputes arise.

Example 3 — Paperwork Delay and Escalation

The TPA repeatedly asks for the same documents, delaying treatment authorization. The worker emails HR and the TPA: “Please confirm in writing who is handling my claim, required documents, and the status of authorization.” The worker then references the state’s process at the DWC and sets a follow-up date. Within days, the TPA confirms receipt and issues authorization. Takeaway: concise written requests, clear deadlines, and state-agency references can accelerate responses.

Glossary of Key Terms

• Self-insured employer workers comp: An arrangement where the employer funds and often manages workers’ comp claims directly, sometimes through a TPA or private provider.

• TPA: “Third‑Party Administrator — a company contracted by a self‑insured employer to administer claims, including intake, investigations, and payments.”

• Private workers comp provider: “A specialized firm that provides claims management services to self‑insured employers, often functioning like a TPA.”

• Stop‑loss: “Excess insurance that covers catastrophic claims above a specified threshold, protecting a self‑insured employer from devastating claims costs.”

• State fund: “A government‑managed insurance pool that provides workers’ compensation coverage and pays claims from employer‑paid premiums.”

• DWC: “Division of Workers’ Compensation — California’s regulatory body that oversees workers’ comp claims, UR/IMR, QMEs, and hearings.” See the California DWC.

• QME: “Qualified Medical Evaluator — a physician who performs medical‑legal evaluations in California to resolve disputes about injury, extent of disability, or MMI.”

• IMR: “Independent Medical Review — a process used in California to independently review disputes over utilization review denials of medical treatment.”

• UR: “Utilization Review — the process by which a claims administrator reviews and approves or denies requested medical treatment.”

• WCAB: Workers’ Compensation Appeals Board in California, which hears disputes about benefits and medical issues within the workers’ compensation system.

Conclusion

If you work for a self-insured employer, knowing who handles your claim and how to use state processes (UR/IMR, QME/AME, WCAB hearings) is crucial. Confirm the administrator in writing, keep complete records, and use your state’s timelines and forms. If care or checks are delayed, escalate quickly and consider getting legal help. With the right steps—and a clear paper trail—you can move your case forward and protect your benefits.

Need help now? Get a free and instant case evaluation by US Work Accident Lawyers. See if your case qualifies within 30-seconds at https://usworkaccidentlawyer.com.

FAQ

Who handles my workers comp claim at a self-insured company?

It may be your employer’s HR/claims unit, a TPA, or a private workers comp provider under contract. Always request written confirmation and check state resources like Washington’s L&I self-insurance overview for program context.

How is a large company injury claim in California handled differently?

California claims follow DWC rules: file the DWC‑1, expect UR for treatment requests, use IMR if UR denies, and use QME/AME for medical-legal disputes. Large employers may have on-site clinics and dedicated claims teams.

What is a private workers comp provider?

A specialized firm that administers claims for a self-insured employer—similar to a TPA—handling intake, authorization, payments, and nurse case management. See the Berry Insurance summary and Visionary Law Group overview.

What is the difference between self-insured and state fund?

Self-insured employers pay and often manage claims directly; state funds manage and pay claims from employer-paid premiums. For a quick explainer, review Berry Insurance’s guide.

Can a self-insured employer refuse care?

They can deny or modify treatment via UR, but workers can request IMR under California’s DWC process or file other appeals as state rules allow.