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Policy and Procedure Name:
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Additional Allowance
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Policy #:
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CP-01-03
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Code/Rule Reference:
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OAC 4123-3-15
and 4123-3-16
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Effective Date:
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04/14/2021
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Approved:
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Ann M. Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-01-03, effective 01/01/14 and Procedure # CP-01-03.PR
1, effective 05/06/19
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History:
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Previous versions of this policy are available upon
request
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Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Causal Relationship
Medical Evidence
IV. POLICY
A. Additional Allowance
Recommendations and Requests
B. Additional Allowances
of Psychological or Psychiatric Conditions
V. PROCEDURE: C-86 ADDITIONAL
ALLOWANCE REQUESTS
A. General Claim Note and
Documentation Requirements
B. Initial Actions
C. Assessing the C-86 and
Medical Evidence
D. Requesting a Medical
Review
E. Requests for Multiple
Conditions
F. Contacting the Employer
G. C-86 Allowance, IC Referral,
and Dismissal
H. Updating Conditions in
the Claims Management System
I. Additional Allowance
Request(s) Received Prior to the Final Initial Determination
VI. PROCEDURE: C-9 ADDITIONAL
ALLOWANCE RECOMMENDATIONS
A. General Claim Note and
Documentation Requirements
B. C-9 Receipt: Initial
MCO Actions
C. Assessing the C-9 and
Medical Evidence
D. Contacting the IW or IW
Representative
E. Requesting a Medical
Review
F. Decision
G. Additional Allowance
Recommendation(s) Received Prior to the Final Initial Determination
The purpose of this policy is to ensure that conditions
allowed in a claim subsequent to the initial allowance are supported by medical
evidence and meet other legal requirements.
This policy applies to BWC claims services staff and managed
care organizations (MCOs).
Causal
Relationship: A medical and legal concept used to establish
whether an injury or condition is compensable.
- A medical concept describing a relationship between the
injury or condition and the industrial accident or occupational disease;
and
- A legal concept that establishes a relationship between
the injured worker’s employment and the industrial accident or
occupational disease.
Medical
Evidence: Relevant information that may prove or disprove
whether a requested condition is medically supported in a claim; one criterion
that BWC must consider when determining compensability of a claim or allowance
of a condition.
1. It is the
policy of BWC to additionally allow a condition in a claim following a thorough
investigation to ensure that the condition is supported by medical evidence and
is causally related to the original injury.
2. In
general, additional allowances may be:
a. Recommended
by a provider on a Request for
Medical Service Reimbursement or Recommendation for Additional Conditions for
Industrial Injury or Occupational Disease (C-9) (see exception below in
IV.B.1); or
b. Requested
by the injured worker (IW) or IW representative on a Motion
(C-86).
3. Upon
receipt of a C-9 recommending or a C-86 requesting the additional allowance of
a condition(s) in a claim, BWC may, at its discretion seek independent medical
verification of the conditions being requested by either:
a. Obtaining
a physician file review (PFR); or
b. Requiring
that the IW attend an independent medical examination (IME).
4. An
additional allowance is not required to be added to the claim for purposes of
treatment that could otherwise be paid under the following policies:
a. Miller
Case Criteria;
b. Health Behavioral
Assessment and Intervention (HBAI) (found in BWC’s Billing and
Reimbursement Manual (BRM));
c. Opioid
Use Disorder Treatment Coverage (found in the BRM); or
d. Payment
for Treatment of Services Related to Concussion Injuries (found in the BRM).
1. BWC will
not address a recommendation for the additional allowance of a psychological or
psychiatric condition on a C-9.
2. Prior to
considering the additional allowance of a psychological or psychiatric
condition, BWC requires that a C-86 be filed with a declaration statement
signed and dated by the IW.
3. For
additional information regarding the handling of claims with psychological or
psychiatric conditions, refer to the Psychiatric
Conditions policy and procedure.
1. BWC staff
shall refer to the Standard Claim File Documentation and Altered Documents
policy and procedure for claim note and documentation requirements; and
2. Shall
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. When BWC
receives a C-86 requesting the allowance of an additional condition, the C-86
shall be indexed into the claim and will populate to the list of work items
belonging to the claims services staff member assigned to the claim.
2. Upon
receipt of the C-86, claims services staff shall:
a. Immediately
create a legal case in the claims management system with an additional
allowance issue (including when a request for reactivation is filed with an
additional allowance).
b. Review the
claim to determine if:
i. The
statute of limitations for the claim has expired.
a) If it has
expired, generate the appropriate “Out of Statute of Limitations Letter,”
depending on whether the claim is lost time or medical only.
b) For more
information regarding the statute of limitations, refer to the:
i)
“Statutory Life of a Claim Chart” under Tips and Tools on the Additional
Allowance policy page on Claims Online Resources (COR); and
ii)
Jurisdiction (Statute of Limitations, Statutory Life of a
Claim) policy and procedure.
ii. The
request is a moot issue (e.g., claim is disallowed, settled, or the condition
is already allowed or denied), or the claim has been suspended. If so, notify
the parties to the claim that the request cannot be addressed by sending the
“Additional Allowance Combination Letter.”
iii. A Settlement
Agreement and Application for Approval of Settlement Agreement (C-240) or
an Application for Compensation for Permanent Total Disability (IC-2) has
been filed in the claim.
a) If a C-240
or IC-2 is on file, but the respective process is not complete, suspend the
C-86.
b) The C-86
may then be processed if the claim is not settled.
c) Regardless
of the IC’s decision to allow or deny Permanent Total Disability (PTD), claims
services staff shall process the request for additional allowance once the IC
decision regarding PTD becomes final.
C.
Assessing the C-86 and Medical Evidence
1. Upon receipt
of a request for an additional allowance, claims services staff shall verify
that the:
a. Request
includes:
i. A
clear narrative description of each of the requested condition(s), including
location, level, etc. when applicable;
ii. A
causality statement; and
iii. Specific
evidence to support each of the requested condition(s). Claims services staff
shall verify the appropriateness of the submitted medical evidence through:
a) The use of
the “MEDD Coding Reference Guide ICD-10” job aid on COR;
b) Staffing;
c) Applicable
BWC policies and procedures; or
d) Other
medical resources.
b. Requested
condition(s) is not a symptom. If a symptom is requested:
i. Claims
services staff must attempt to clarify with the filing party what condition is
causing the symptom(s) listed on the request.
ii. Claims
services staff may also discuss with the filing party the possibility of
withdrawing the request completely or withdrawing only the requested symptom,
if other conditions are requested.
iii. Claims
services staff may dismiss the request if contact with the filing party is
unsuccessful.
c. C-86
includes the signature of the IW or IW representative.
2. If any of
the abovementioned required information is not available or is unclear, claims
services staff shall make reasonable attempts to obtain the necessary information
from the IW or IW representative.
a. If the
request is missing medical evidence, including a causality statement, claims
services staff shall make reasonable attempts to obtain the specific medical
evidence required for the allowance of the requested conditions (e.g., x-ray to
support the presence of a fracture).
b. If the
C-86 is missing a signature or is signed by someone other than the IW or IW
representative, verbal agreement by the IW or IW representative to the filing
of the C-86 is insufficient. Claims services staff shall make reasonable
attempts to contact the IW or IW representative and obtain a properly signed
C-86.
c. For
all other missing or unclear information, a new C-86 is not needed if claims
services staff obtains verbal clarification. For example:
i. A
request is filed for allowance of a herniated disc, but the specific level is
not listed.
ii. Claims
services staff contacts the filing party and is informed that the level is
L4-5.
iii. A new
request stating the appropriate level is not needed but claims services staff
must enter a note in the claim to reflect the clarified information.
d. When
attempting to obtain missing information, claims services staff shall:
i. Detail
all contacts and contact attempts in claim notes; and
ii. Contact
the IW representative only, unless:
a) The IW has
expressed that they would like to be included;
b) The
representative is not responding to the contact attempts; or
c) The IW does
not have a representative.
3. Upon
receipt of sufficient medical evidence, or after reasonable attempts to obtain
it, claims services staff shall continue considering the allowance of the
requested condition(s). Claims services staff shall:
a. Enter the
ICD code of each condition to be considered into the claims management system;
b. Evaluate
the requested condition(s) using the “MEDD Coding Reference Guide ICD-10”; and
c. If a
medical review is warranted, request one (see the Requesting a Medical Review
section of this procedure immediately below for guidance on when a medical
review is appropriate and how to request one).
4. If none of
the information detailed above is received following reasonable attempts to
obtain it, a medical review is not necessary. Claims services staff shall
dismiss the C-86 via “BWC Miscellaneous Order”, as detailed in the C-86
Allowance, IC Referral, and Dismissal section of this procedure.
D.
Requesting a Medical Review
1. Claims
services staff shall request a medical review if:
a. The
condition is not included in the “MEDD Coding Reference Guide ICD-10” job aid;
or
b. Claims
services staff:
i. Needs
assistance determining causality; or
ii. Feels
that a medical review is necessary.
2. Prior to
referring the claim, claims services staff shall:
a. Ensure
that:
i. They
have utilized all available resources to identify any appropriate medical
documentation that would be needed to determine allowance of the conditions
(e.g., online research for conditions not listed in the “MEDD Coding Reference
Guide”); and
ii. All
necessary medical evidence has been received.
b. Follow the
“SOP Medical Referral Note Guidelines”; and
c. Document
the following information in claim notes:
i. The
type of application the request was submitted on;
ii. Date
the application was received;
iii. The
condition(s) being requested (narrative), including level and location, when
applicable;
iv. Previous claims,
if the IW has any;
v. Suspect
intervening injury and a corresponding Insurance Services Office (ISO) report,
if it exists;
vi. Their rationale
for sending the referral for medical review;
vii. Titles and indexing
dates of supporting medical evidence, including causality statement; and
viii. Any other pertinent information.
3.
Claims services staff shall create a “Nurse-AA” case event, which will
in turn create a work item for a Medical Services Specialist (MSS).
4. Refer to
the Independent
Medical Exams and Physician File Reviews policy and procedure for more
information regarding IMEs and PFRs.
1. If one or
more requested condition(s) is fully supported by sufficient medical evidence,
but there is insufficient medical evidence to support the other condition(s)
(even after reasonable attempts by claims services staff to obtain sufficient
evidence), or an IME or PFR report states that there is insufficient evidence
to support the other condition(s):
a. Claims
services staff shall contact the IW or IW representative to determine if they
prefer that:
i. The
entire request be referred to the Ohio Industrial Commission (IC); or
ii. The
conditions in the request be bifurcated to:
a) Allow the
condition(s) that is supported by sufficient medical evidence; and
b) Dismiss
the condition(s) for which there is insufficient medical evidence.
b. The IW or
IW representative may respond either verbally or in writing.
2. If the IW
or IW representative:
a. Agrees to
bifurcate the request, claims services staff shall move forward with processing
the claim by contacting the employer, as detailed in the Contacting the
Employer section of this procedure below.
b. Disagrees
with bifurcating the request or does not respond, claims services staff shall prepare
a Notice of Referral (NOR) to the IC following the Notice of Referral to the Industrial Commission
policy and procedure.
3. Example:
a. A claim is
allowed for back sprain.
b. BWC
receives a request for allowance of right knee sprain and herniated disc at
L5-S1.
c. A
treatment request for the right knee has been submitted to the MCO.
d. The PFR
supports allowance of the right knee sprain, but does not support allowance of
the herniated disc.
e. Claims
services staff contacts the IW or IW representative to determine if they would
like to dismiss the request for herniated disc (the condition that is not
supported).
f. The
IW or IW representative agrees to dismiss the request for herniated disc, which
allows claims services staff to move forward with allowance of the right knee
sprain and allows the MCO to consider the associated treatment.
g. Claims
services staff issues a “BWC Subsequent Order” that addresses the allowance of
the right knee sprain (the condition that is supported by sufficient medical
evidence), and includes language dismissing the request for the herniated disc.
F. Contacting
the Employer
1. Contact
with the employer regarding the request is not necessary if:
a. BWC’s
decision is to dismiss the request; or
b. BWC
recommends the request be denied. The employer will receive the NOR and will
have an opportunity to submit information at the hearing.
2. If BWC’s
decision is to allow the request (in its entirety or in part), claims services
staff shall contact the employer (or employer representative) to obtain
agreement regarding allowance of the conditions and answer any questions the
employer may have regarding the request:
a. By phone,
unless the employer has requested to be contacted by an alternative method
(e.g., e-mail); and
b. Directly,
unless the employer has indicated that contact should be directed to the
employer’s representative.
3. If, after
reasonable attempts, phone contact is unsuccessful, or if there is no response
to the employer’s preferred method of contact, claims services staff shall send
the “C-86 Additional Allowance Insured Due Process Letter” by fax, e-mail
(encrypted using Zixmail), or mail.
a. The
employer has:
i. Three
full business days to respond, if the letter is sent by fax or e-mail; or
ii. Seven
calendar days to respond, if the letter is sent by mail (plus four additional
days per the Mailbox Rule policy).
b. Claims
services staff shall set a work item for:
i. Four
(3+1) full business days in the future, if the letter is sent by fax or e-mail;
or
ii. Twelve
(7+4+1) calendar days in the future, if the letter is sent by mail.
c. Claims
services staff shall not issue a decision until:
i. The
employer has responded; or
ii. The
response period has ended.
4. If the
employer:
a. Agrees
with the request or does not respond within the allotted time frames described above,
claims services staff shall issue an order, following the applicable sections
of the C-86 Allowance, IC Referral, and Dismissal section of this procedure.
b. Disagrees
with the request, claims services staff shall prepare a NOR to the IC following
the Notice of Referral to the Industrial Commission
policy and procedure.
5.
Out of Business Employers
a. Claims
services staff shall not contact employers who are out of business or no longer
doing business in Ohio.
b. The
exception to this is if the employer has retained an authorized representative
to oversee their claims. In such cases, claims services staff shall contact the
employer representative.
G. C-86 Allowance,
IC Referral, and Dismissal
1. Allowance
a. Claims
services staff shall issue a “BWC Subsequent Order” to allow the requested condition(s).
b. Allowance
of the requested condition(s) is appropriate when:
i. BWC
agrees with the allowance of the condition(s); and
ii. The
employer:
a) Agreed
with allowance of the condition(s); or
b) Did not
provide a response when contacted regarding allowance of the condition(s).
2. Addressing
Multiple Conditions
a. If the
decision is to allow all requested conditions, claims services staff shall
follow the directions detailed in Section V.G.1(a-b) immediately above.
b. If one or
more requested conditions are supported by sufficient medical evidence, but
there is no medical evidence to support the other condition(s) and the IW or IW
representative has chosen to bifurcate the request, claims services staff shall
issue a BWC Order:
i. Allowing
the condition(s) that is supported by sufficient medical evidence; and
ii. Dismissing
the other(s), using the following language: “IW/IW representative
<<verbally dismissed, dismissed in writing>> the following
condition(s) <<dismissed conditions>> on <<date of
dismissal>> without prejudice.”
3. Waivers
a. If BWC is
allowing the condition(s) and both the employer or employer representative and
the IW or IW representative submit a signed waiver, claims services staff shall
immediately update the claims management system.
b. For more
information about waivers, refer to the Orders, Waivers, Appeals and Hearings policy
and procedure.
4. IC
Referral
a. Claims
services staff shall complete a NOR to the IC when:
i. The
employer disagrees with allowance of the condition(s); or
ii. BWC
recommends denial of any requested condition(s).
b. Before
referring the condition(s) to the IC, claims services staff shall obtain
evidence (e.g. file review or exam) to support BWC’s position on the issue
unless no file review or exam is recommended during staffing with a BWC
attorney.
5.
Dismissal
a. Claims
services staff shall dismiss the C-86 via “BWC Miscellaneous Order” when:
i. The
IW or IW’s authorized representative wishes to withdraw or dismiss the request;
ii. The
C-86 is not signed, following reasonable attempts to obtain a signature;
iii. There is
no evidence to support the request, following reasonable attempts to obtain evidence;
or
iv. The requested
action is not clear, following reasonable attempts to clarify the request.
b. For more
information regarding the dismissal of a C-86, refer to the Motions policy and procedure.
H. Updating
Conditions in the Claims Management System
1. Claims
services staff shall ensure the condition(s) is updated in the claims
management system after making a decision on the request.
2. Specifically,
claims services staff shall update the condition(s) in the claims management
system when any of the following occur:
a. A BWC
Order to allow or dismiss the condition(s) is issued;
b. Upon
completion of a NOR to the IC;
c. An
appeal is filed to a BWC or IC order;
d. All
parties to the claim have waived the appeal period; or
e. The appeal
period expires.
1.
If BWC has not yet published an initial claim decision, the newly requested
condition(s) shall be included in the initial decision, even though the
condition(s) is not listed on the First Report of Injury, Occupational
Disease or Death (FROI). The condition(s) is treated as a condition(s)
found in the medical evidence (e.g., the condition(s) can be allowed, but
cannot be denied because it was not requested by the IW).
2. When a request
is filed prior to the initial determination of the claim becoming final (during
the appeal period with an appeal filed), the request shall be suspended until
the claim is fully adjudicated.
a. Claims
services staff may call the filing party to notify them that the request has
been suspended or send the “Additional Allowance Combination Letter” to notify
parties to the claim that the request has been suspended.
b. If the
claim is allowed, BWC will consider the condition(s) immediately.
c. If
the claim is denied, consideration of the condition(s) is a moot issue. Claims
services staff shall send the “Additional Allowance Combination Letter” to
notify the parties.
3. If an
initial claim decision has been issued and a request is filed during the appeal
period, but no appeal is filed, the previous order may be vacated with a new
decision issued to include the new request. However, it may be appropriate to
let the appeal period expire and issue a subsequent decision to facilitate
timely payment of compensation and benefits to the IW.
1. BWC staff
shall refer to the Standard Claim File Documentation and Altered Documents
policy and procedure for claim note and documentation requirements; and
2. Shall
follow any other specific instructions for claim notes and documentation
included in this procedure.
B.
C-9 Receipt: Initial MCO Actions
1. Upon
receipt of a C-9 recommending the allowance of an additional condition, the MCO
will review and assess the recommendation within three business days of receipt
of the C-9 to confirm the following is included:
a. A clear
narrative description of each recommended condition(s), including location,
level, etc. when applicable, and that the recommended condition is not a:
i. Symptom;
or
ii. Generalized
condition (e.g., diabetes, obesity, hypertension) that requires treatment,
which may be:
a) Addressed
through bill payment using explanation of benefits (EOB) 776 instead of
considering the condition for additional allowance in the claim; or
b) Considered
for payment under the Miller Case Criteria policy.
b. Evidence
to support the existence of each recommended condition; and
c. A
causality statement.
2. If any of the
information listed immediately above is not available, or information on the
C-9 needs clarified, the MCO will contact the physician who submitted the C-9.
a. If the C-9
is missing a signature, the MCO must obtain a signed C-9; but
b. In all
other cases, a new C-9 is not needed; however,
c. Evidence
to support the existence of each recommended condition(s) and a causality
statement shall not be obtained verbally.
3. Following
completion of the review and any actions taken as a result, the MCO will:
a. Enter a
summary note, which details:
i. Their
evaluation of the C-9, as detailed above; and
ii. If
necessary, all actions taken to secure the missing information from the
physician making the recommendation.
b. Send the
C-9 to BWC, which will trigger a “BWC Action Required” work item.
4. The MCO
should also assist the employer in understanding the medical information in the
claim, when necessary.
C.
Assessing the C-9 and Medical Evidence
1. Following
review of the C-9 by the MCO and upon receipt of a “BWC Action Required” work
item, the claims services staff shall:
a. Immediately
create a legal case in the claims management system with an additional
allowance issue.
b. Review the
claim to determine if:
i. The
statute of limitations for the claim has expired.
a) If it has
expired, generate the appropriate “Out of Statute of Limitations Letter”,
depending on whether the claim is lost time or medical only.
b) For more
information regarding the statute of limitations, refer to the:
i) “Statutory
Life of a Claim Chart” under Tips and Tools on the Jurisdiction (Statute of
Limitations, Statutory Life of a Claim) or Additional Allowance COR policy
pages; and
ii) Jurisdiction (Statute of Limitations, Statutory Life of a
Claim) policy and procedure.
ii. The
recommendation is a moot issue (e.g., claim is disallowed, settled, or the
condition is already allowed or denied), or the claim has been suspended. If
so, notify the parties to the claim that the recommendation cannot be addressed
by sending the “Additional Allowance Combination Letter”.
iii. A Settlement
Agreement and Application for Approval of Settlement Agreement (C-240) or
an Application for Compensation for Permanent Total Disability (IC-2) has
been filed in the claim.
a) If a C-240
or IC-2 is on file, but the respective process is not complete, suspend the
C-9.
b) The C-9
may then be processed if the claim is not settled.
c) Regardless
of the IC’s decision to allow or deny PTD, claims services staff shall process
the request for additional allowance once the IC decision regarding PTD becomes
final.
c. If
the claim has expired, the recommendation is moot, the claim has been
suspended, or a C-240 or IC-2 is pending:
i. Notify
the MCO of the final decision.
ii. The
MCO will then notify the treating physician of the status of the C-9.
2. Assessing
the Medical Evidence
a. Claims
services staff shall determine whether the C-9 is recommending the additional
allowance of:
i. A
single or multiple physical condition(s);
ii. Both
physical and psychological or psychiatric conditions; or
iii. A single
or multiple psychological or psychiatric condition(s).
b. If any
condition(s) recommended on the C-9 are physical:
i. Claims
services staff shall review:
a) Claim
notes entered by the MCO regarding their review and assessment; and
b) Medical
documentation in the claim and “MEDD and Coding Reference Guide ICD-10” to
determine if additional evidence is needed for any of the recommended physical
conditions.
ii. If
additional evidence is needed and an MCO note has been entered, claims services
staff shall review MCO notes to determine the MCO’s progress on obtaining the
missing evidence.
iii. If additional
evidence is needed and the MCO has been unsuccessful at obtaining the necessary
evidence, claims services staff shall make an additional request for the
evidence to the physician who submitted the C-9.
a) If insufficient
evidence is on file and no additional evidence is received when requested,
claims services staff shall:
i) Document
the evidence requested and that it was not received; and
ii) Continue
considering the recommendation.
b) If no
evidence is on file and none is received when requested,
i) Claims
services staff shall:
a. Dismiss
the C-9 recommendation by sending the “Additional Allowance Combination Letter”;
and
b. Notify the
MCO of the dismissal.
ii) The
MCO will then notify the treating physician that the recommendation has been
dismissed due to lack of evidence.
iv. If additional
evidence is needed but no MCO note has been entered:
a) Claims
services staff shall contact the MCO and attempt to obtain details about MCO
actions taken.
b) If this
contact is unsuccessful, claims services staff shall discuss with their supervisor
whether:
i) Additional
contact with the MCO is necessary; or
ii) If
the matter should be referred to the BWC MCO
Business Unit, documenting the MCO’s non-response to BWC’s attempts
to obtain required information.
c. If
the condition(s) recommended on the C-9 include psychological or psychiatric
conditions only:
i. Claims
services staff shall:
a) Send the
“C-9 Additional Allowance Closure Letter,” which notifies the IW that they need
to file a C-86 for BWC to consider allowance of the psychiatric or
psychological condition(s); and
b) Notify the
MCO.
ii. The
MCO will then notify the treating physician the status of the recommendation.
d. If the
conditions recommended on the C-9 include psychological or psychiatric and
physical conditions, claims services staff shall:
i. Complete
the actions detailed above in C.2.b. for a physical condition(s) and C.2.c. for
a psychological or psychiatric condition(s); and
ii. Notify
the IW by phone that:
a) BWC will
address the physical conditions recommended on the C-9; but
b) The IW
must submit a C-86 for the recommended psychological or psychiatric conditions,
as outlined in the “C-9 Additional Allowance Closure Letter.”
e. If a C-9
has been received that recommends an additional condition that has previously
been addressed:
i. Claims
services staff shall determine if new and changed circumstances exist by
reviewing:
a) Claim
notes; and
b) The
medical evidence that supports the recommendation.
ii. If
new and changed circumstances exist, claims services staff shall continue
consideration of the allowance of the recommended condition(s).
iii. If new and
changed circumstances do not exist, claims services staff shall
send the “C-9 Additional Allowance Closure Letter.”
f. Once
claims services staff has completed review of all the recommended conditions as
detailed above, they shall enter the International Classification of Diseases
(ICD) code of each condition to be considered into the claims management
system.
D.
Contacting the IW or IW Representative
1.
Following their assessment of the C-9 and medical evidence, claims
services staff shall contact the IW or IW representative by phone to discuss
the physician’s recommendation.
a. Claims
services staff shall contact the IW representative only, unless:
i. The
IW has expressed that they would like to be included;
ii. The
representative is not responding to the contact attempts; or
iii. The IW
does not have a representative.
b. If claims
services staff must leave a voicemail, the IW or IW representative has three
full business days to return the call. Claims services staff shall not make a
decision regarding the additional allowance until:
i. A
response is received; or
ii. The
response period has ended.
c. If
phone contact is successful, or the IW or IW representative responds to a
previous contact attempt, claims services staff shall:
i. Verify
that the IW or IW representative agrees with BWC evaluating the condition(s)
recommended by the treating physician for allowance in the claim; and
ii. For
lost time claims only:
a) Discuss
the possibility of an Independent Medical Examination (IME) to determine
allowance of the recommended condition(s); and
b) Obtain and
enter the IW’s exam availability in a claim note titled “IW Availability.”
iii. If the IW
or IW representative:
a) Agrees
with the treating physician’s recommendation(s), send the “C-9 IW
Acknowledgement Letter” to the IW and copy all other parties to the claim. This
letter serves as confirmation of the IW or IW representative’s verbal request
to evaluate the condition(s).
b) Does not
agree with the treating physician’s recommendation(s), or the IW or IW
representative does not respond to a previous contact attempt within three full
business days:
i)
Claims services staff shall:
a. Send the
“C-9 Additional Allowance Closure Letter” to the IW and copy all other parties
to the claim;
b. Delete the
recommended condition(s) from the claims management system; and
c. Notify
the MCO of the final decision.
ii)
The MCO will then notify the treating physician of the status of the
recommendation.
b. When phone
contact with the IW or IW representative is not successful and leaving a
message via voicemail or other means is not an option, claims services staff
shall send the “C-9 Additional Allowance Due Process Letter” to all parties to
the claim.
i. The
letter may be sent by:
a) Mail;
b) E-mail
(encrypted using Zixmail); or
c) Fax.
ii. The
parties have:
a) Three full
business days to respond, if the letter is sent by fax or e-mail; or
b) Seven
calendar days to respond, if the letter is sent by mail (plus four additional
days per the Mailbox Rule policy).
iii. Claims
services staff shall set a work item for:
a)
Four (3+1) full business days in the future, if the letter is sent by
fax or e-mail; or
b) Twelve (7+4+1)
calendar days in the future, if the letter is sent by mail.
iv. Claims services
staff shall not proceed with consideration of the issue until:
a) the
response period has expired; or
b) they have
received a response.
v.
If the IW or IW representative responds to the “C-9 Additional Allowance
Due Process Letter”:
a) And
indicates that they agree with the treating physician’s recommendation, claims
services staff shall:
i) Update
claim notes documenting the IW or IW representative’s agreement and the date it
was obtained; and
ii) If
the IW or IW representative’s response is by phone, send the “C-9 IW
Acknowledgement Letter” to the IW and copy all other parties to the claim.
b) And
indicates they disagree with the treating physician’s recommendation, or if the
IW or IW representative does not respond within the specified response period:
i) Claims
services staff shall:
a. Send the
“C-9 Additional Allowance Closure Letter” to the IW and copy all other parties
to the claim;
b. Delete the
recommended conditions from the claims management system; and
c. Notify
the MCO of the final decision.
ii) The
MCO will then notify the treating physician of the status of the
recommendation.
2. Upon
receipt of the IW or IW representative’s agreement to continue evaluating the
condition(s) recommended on the C-9, claims services staff may request a
medical review by a medical service specialist.
1. Claims
services staff shall request a medical review if:
a. The
condition is not included in the “MEDD Coding Reference Guide ICD-10” job aid;
or
b. Claims
services staff:
i. Needs
assistance determining causality; or
ii. Feels
that a medical review is necessary.
2. Prior to
referring the claim, claims services staff shall:
a. Ensure
that they have:
i. Utilized
all available resources to identify any appropriate medical documentation that
would be needed to determine allowance of the conditions (e.g., online research
for conditions not listed in the “MEDD Coding Reference Guide”); and
ii. Received
all necessary medical information.
b. Follow the
“SOP Medical Referral Note Guidelines”; and
c. Document
the following information in claim notes:
i. The
type of application the recommendation was submitted on;
ii. Date
the application was received;
iii. The
condition(s) being recommended (narrative), including level and location, when
applicable;
iv. Previous claims,
if the IW has any;
v. Suspect
intervening injury and a corresponding Insurance Services Office (ISO) report,
if it exists;
vi. Their rationale
for sending the referral for medical review;
vii. Titles and indexing
dates of supporting medical evidence, including causality statement; and
viii. Any other pertinent information.
3. Claims
services staff shall create a “Nurse-AA” case event, which will in turn create
a work item for a Medical Services Specialist (MSS).
4. Refer to
the Independent
Medical Exams and Physician File Reviews (PFR) policy and procedure for
more information regarding IMEs and PFRs.
F.
Decision
1. Prior to
making a decision on the C-9, claims services staff shall await the employer’s
response to the “IW Acknowledgement Letter.”
a. If the
employer or employer representative responds to the letter and indicates they
agree with the treating physician’s recommendation, or if they do not respond
within three full business days for letters sent by fax or e-mail or seven calendar
days (plus four additional days per the Mailbox
Rule policy) for letters sent by mail, claims services staff shall:
i. Enter
a claim note documenting either the agreement and the date it was obtained, or
the employer’s non-response; and
ii. Continue
considering allowance of the condition(s).
b. If the employer
or employer representative responds to the letter and indicates they disagree
with the treating physician’s recommendation, claims services staff shall:
i. Enter
a claim note documenting the employer or employer representative’s disagreement
and the date it was obtained; and
ii. Prepare
a NOR to the IC, following the Notice of Referral to the Industrial Commission
policy and procedure.
c. Claims
services staff shall not contact employers who are out of business or no longer
doing business in Ohio. The exception to this is if the employer has retained
an authorized representative to oversee their claims. In such cases, claims
services staff shall contact the employer representative.
2. Addressing
Multiple Physical Conditions
a.
If one or more recommended conditions are supported by sufficient
medical evidence, but there is no medical evidence to support the other condition(s):
i. Claims
services staff shall contact the IW or IW representative by phone, fax, or
e-mail to determine if they prefer that:
a) The entire
recommendation be referred to the IC; or
b) The
condition(s) in the recommendation be bifurcated to:
i) Allow
the conditions that are supported by sufficient medical evidence; and
ii) Dismiss
the conditions for which there is insufficient medical evidence.
ii. The
IW or IW representative may respond either verbally or in writing.
iii. If the IW
or IW representative:
a) Chooses to
bifurcate the recommendation, claims services staff shall issue a BWC Order:
i) Allowing
the conditions that are supported by sufficient medical evidence; and
ii) Dismissing
the others, using the following language: “IW/IW representative
<<verbally dismissed, dismissed in writing>> the following
condition(s) <<dismissed conditions>> on <<date of
dismissal>> without prejudice.”
b) Does not
want to bifurcate the issues, or does not respond within three full business
days, claims services staff shall complete their investigation and prepare a
NOR to the IC following the Notice of Referral to the Industrial Commission
policy and procedure.
iv. Example:
a) A claim is
allowed for back sprain.
b) BWC
receives a C-9 for allowance of right knee sprain and herniated disc at L5-S1.
c) A
treatment request for the right knee has been submitted to the MCO.
d) The PFR
supports allowance of the right knee sprain, but does not support allowance of
the herniated disc.
e) Claims
services staff contacts the IW or IW representative to determine if they would
like to dismiss the recommendation for herniated disc (the condition that is
not supported).
f) The
IW or IW representative agrees to dismiss the recommendation for herniated
disc, which allows claims services staff to move forward with allowance of the
right knee sprain and allows the MCO to consider the associated treatment.
g) Claims
services staff issues a “BWC Subsequent Order” that addresses the allowance of
the right knee sprain (the condition that is supported by sufficient medical
evidence), and includes language dismissing the recommendation for the
herniated disc.
b. If the
decision is to allow all recommended conditions, claims services staff shall
follow the directions detailed immediately below.
3. Allowance
a. Claims
services staff shall issue a “BWC Subsequent Order” to allow the conditions
when:
i. The
IW agrees to consider the recommended condition(s);
ii. BWC
agrees with the allowance of the condition(s); and
iii. The
employer:
a) Agreed
with allowance of the condition(s); or
b) Did not
provide a response when contacted regarding allowance of the condition(s).
b. Claims
services staff shall notify the MCO when:
i. Claims
services staff refers the recommendation to the IC via NOR; or
ii. Claims
services staff issues a BWC Order to allow the condition(s);
iii. BWC
receives an appeal to the BWC Order; and
iv. The order is
final.
v. The
MCO will notify the treating physician of the status of the recommendation.
4. Waivers
a. If BWC is
allowing the condition(s) and both the employer or employer representative and
the IW or IW representative submit a signed waiver, claims services staff shall
immediately update the claims management system.
b. For more
information about waivers, refer to the Orders, Waivers, Appeals and Hearings policy
and procedure.
5. Claims
services staff shall update the conditions in the claims management system:
a. When a BWC
Order to allow or dismiss the condition(s) is issued;
b. Upon
completion of a NOR to the IC;
c. When
an appeal is filed to a BWC or IC order;
d. When all
parties to the claim have waived the appeal period; and
e. When the
appeal period expires.
G.
Additional Allowance Recommendation(s) Received Prior to the Final
Initial Determination
1. If BWC has
not yet published an initial claim decision, the newly recommended conditions
shall be included in the initial decision, even though the conditions are not
listed on the First Report of Injury, Occupational Disease or Death
(FROI).
2. When a
recommendation is filed prior to the initial determination of the claim
becoming final (during the appeal period with an appeal filed), the
recommendation shall be suspended until the claim is fully adjudicated.
a. Claims
services staff may call the filing party to notify them that the recommendation
has been suspended or send the “Additional Allowance Combination Letter” to
notify parties to the claim that the recommendation has been suspended.
b. Claims
services staff must notify the MCO that the recommendation has been suspended,
and the MCO will notify the treating physician of the status of the
recommendation.
c. If
the claim is allowed, BWC will consider the conditions immediately.
d. If the
claim is denied, consideration of the conditions is a moot issue.
3. If an
initial claim decision has been issued and a recommendation is filed during the
appeal period, but no appeal is filed, the previous order may be vacated with a
new decision issued to include the new recommendation. However, it may be
appropriate to let the appeal period expire and issue a subsequent decision to
facilitate timely payment of compensation and benefits to the IW.