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Policy and Procedure Name:
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Drug Related Issues
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Policy #:
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CP-04-02
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Code/Rule Reference:
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R.C. 4123.66
O.A.C.4123-6-21, 4123-6-21.3, and 4123-6-26.
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Effective Date:
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12/29/20
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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-04-02, effective 10/21/15
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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
IV. POLICY
A. Handling of Drug
Related Issues
B. Referral of Prescription
Medication Issues
C. Denial of Prescription
Medication
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. General Pharmacy
Information
C. Return of Reimbursement
Check or Correspondence from IW to PBM
D. Cancelling of Check
E. When BWC Receives a PBM
AVR-1 Form
F. Request for IME and
Inpatient Detoxification Program
G. Inpatient Detoxification
Program Indicated in IME Report
H. Requests for Drug
Dependency as a Condition in a Claim
I. Phone Inquiries for
Drug Related Issues
J. Motions (C-86) and
Written Requests for Drug Related Issues
K. Industrial Commission
Hearing Orders for Drug Related Issues
The purpose of this policy is to ensure BWC claims services staff
appropriately updates an injured worker’s address in the claims management
system and processes independent medical examinations in a claim to assist the
multifaceted Pharmacy Benefits program.
This policy applies to BWC’s claims services staff.
Drug Utilization Review (DUR): a medical management
strategy performed by the Managed Care Organization (MCO) and BWC to review
prescription medications in a claim and to evaluate the medical necessity and
appropriateness of the prescription medication treatment. DURs may identify
inappropriate utilization (over-utilization or under utilization) of services.
Pharmacy Benefits Manager (PBM): The PBM is a
single-source for accepting and adjudicating prescription drug information and
is separate from the MCO. The PBM processes outpatient medication bills for
State-Fund, Self-Insured Bankrupt, Black Lung, and Marine Industry Fund
claims. This program does not apply to claims managed by self-insured
employers.
Pharmacy Benefits Program: BWC’s Pharmacy benefits
program streamlines the billing process for pharmacy providers and meets BWC’s
mission of providing a quality, customer-focused program for Ohio’s employers
and injured workers.
It is the policy of BWC that
drug related issues are to be handled through the Pharmacy Department, PBM, and
MCOs, except in the following situations when BWC claims services staff shall:
1.
Address updates made in the claims management system as a result of a PBM
Address verification request.
2.
Schedule independent medical examinations as requested by the Pharmacy
Department or MCO.
It is
the policy of BWC that prescription medication issue(s) shall not be referred
to the Industrial Commission (IC) unless a party to the claim files an appeal
to a BWC Order.
It is
the policy of BWC that when prescription medication(s) is denied as a result of
an inactive claim, that the request is handled in accordance with the Claim
Reactivation policy.
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. Claims
services staff shall send all questions about drug related issues solely
through the BWC Pharmacy
Benefits mailbox. Claims services staff shall not use any other email
mailbox for questions.
2. All claims
management system updates regarding drug related issues including drug
authorizations and denials shall be updated by the pharmacy department.
3. Claims
services staff may identify a claim that needs a DUR based on factors
considered to be red flags. The MCO will investigate the claim to determine if
a DUR is or is not warranted in the claim. When claims services staff identify
a potential DUR, claims services staff shall send:
a. A request
for a DUR in an email to the MCO; and
b. The reason
for the DUR referral.
4. Durable
medical equipment (DME) and disposable medical supplies obtained at a pharmacy
are handled through the MCO and in some cases BWC claims services staff, not
the PBM.
5. In cases
of inactive claims, claims services staff shall refer to the Claim
Reactivation policy and procedure when an outpatient drug(s) is denied as a
result of a claim being inactive.
6. BWC claims
services staff may reference the MCO Policy Reference Guide and/or the Provider
Billing and Reimbursement Manual for additional information regarding Pharmacy
Department, PBM and MCO responsibilities.
1.
If the returned envelope contains a forwarding address, the PBM shall
notify BWC of the new address by faxing the PBM Address Verification Request
(AVR) form (PBM AVR-1) to BWC at fax number 866-336-8352 not more than five
business days from receipt of reimbursement check or correspondence.
2.
If the returned envelope does not contain a forwarding address, the PBM
shall check for an updated address for the IW in the PBM system and:
a. If an
updated address exists, shall resend the reimbursement check or correspondence
to the IW not more than three business days from receipt of reimbursement check
or correspondence.
b. If an
updated address exists, shall resend the reimbursement check or correspondence
to the IW not more than three business days from receipt of reimbursement check
or correspondence.
1. In the
event that a check is not cashed within 60 days of issuance, the PBM shall
check the PBM system to see if an updated IW address was received.
2. In the
event that a check is not cashed within 90 days of issuance, the PBM shall
ensure that the PBM system has been checked for an updated address prior to
cancelling the check.
1. The PBM
AVR-1 form shall be indexed in the claim as document type “PBM AVR – Address
Verification Request Form.”
2. Claims
services staff shall review the PBM AVR-1 form within five business days of
receipt. If this review shows the address is current, claims services staff
shall:
a. Update the IW’s current
address and enter a note in the claims management system.
b. Respond to the PBM AVR-1 form
by sending a cover sheet with no attachment using RightFax to the PBM at the
fax number listed on the form and to BWC Imaging. The fax cover sheet shall
contain:
i. Injured
worker’s name;
ii. Claim
number;
iii. BWC claims
services staff response (example below); and
“The correct address for this
injured worker has been verified and updated in our claims management system.
Thank you, Diane”
iv. In RightFax
under more options tab, complete the “From” section. (Note: Once you have
entered your information in the “From” section it will save the data and self
populate so the user will not have to enter it each time.)
3. If the PBM
did not provide an updated address on the PBM AVR-1 form or the address
provided by the PBM is not current, the claims services staff shall:
a. Review existing documents in
imaging and claim notes contained in the claims management system; if an
updated address is located, claims services staff shall update the address.
b. If an updated address is not
located, claims services staff shall:
i. Attempt
to contact IW by phone (if IW number is invalid or there is no number for IW,
contact the IW representative, employer, employer representative, MCO, and/or
provider).
ii. If a
corrected address is located, claims services staff shall update the address.
iii. Enter note
in the claims management system with action taken.
iv. After two
unsuccessful attempts to obtain IW’s current address, claims services staff
shall:
a) Enter PBM
AVR note in the claims management system; and
b) Respond to
the PBM AVR-1 form by sending a cover sheet with no attachment using RightFax
to the PBM at the fax number listed on the form and to BWC Imaging. The fax
cover sheet shall contain:
i) IW’s
name;
ii) Claim
number;
iii) BWC claims
services staff response (example below); and
“I have made two unsuccessful
attempts to obtain a current address for this injured worker. Thank you, Diane.”
iv) In RightFax
under the more options tab, complete the “From” section (Note: Once you have
entered your information in the “From” section it will save the data and self
populate so the user will not have to enter it each time.)
1. Claims
services staff will receive a request for an IME on drug related issues in the
following manner:
a. An email
from the MCO; or
b. A referral
work item from the Pharmacy Department.
2. When claims
services staff receive a request via email from the MCO or a work item from the
Pharmacy Department for an IME on drug related issues including the specific
IME questions to be addressed, claims services staff shall:
a. Create an
Exam Scheduling case in the claims management system using the “Miscellaneous”
category; and
b. Schedule
the IME exam.
3. Schedule
the IME based on the request and include the specific questions to the DEP
Physician, and MSS will perform quality assurance.
4. Notify the
MCO/Pharmacy department in the appropriate manner when IME exam is complete and
report is received.
5. Close the
Exam Scheduling case in the claims management system.
1. Claims
services staff shall notify the prescribing physician that it is his/her
responsibility to coordinate the authorization of the inpatient detox program
with the MCO.
2. Claims
services staff shall notify and coordinate with the MCO to facilitate the
outcome with the prescribing physician.
1. When in
receipt of a request for an additional allowance of drug dependency as a
condition in the claim, claims services staff shall:
a. Contact
the IW and request they dismiss the Motion (C-86); and
b. Contact
the MCO and request they speak with the doctor about filing a Completing the
Request for Medical Service Reimbursement or Recommendation for Additional
Conditions for Industrial Injury or Occupational Disease (C-9) for
detoxification (in dependency cases) and/or counseling (only warranted in cases
of addicition).
2. Claims
services staff shall process a request for drug dependency in the same manner
as a psychiatric condition request when the contact with the IW results in a
refusal to dismiss the C-86. Refer to the Psychiatric Conditions policy
and procedure.
3. When the
additional allowance of drug dependency as a condition in the claim is
requested on a C-9, claims services staff shall follow the instructions
provided in the Additional Allowance policy and procedure.
1. Claims
services staff shall send an email to the BWC Pharmacy Benefits mailbox
for all phone inquiries regarding outpatient drug benefits or other drug
related issues not more than 48 hours from receipt of the call. Claims services
staff shall include in the email:
a. Name of IW,
b. Claim
number,
c. Name
of person calling,
d. Description
of the issue, and
e. Phone
number to return call.
2. The
pharmacy department shall handle all phone inquiries and enter notes in the claims
management system not more than 48 hours from receipt of the claims services
staff email.
1. C-86
Motions and written requests: Claims services staff shall enter a note in the
claims management system and send a work item to the BWC Pharmacy Benefits mailbox
notifying them of all C-86 Motions and written requests for drug related issues
not more than five business days from the imaged date of the document in the
claim. Claims services staff shall include in the work item:
a. Name of IW;
b. Claim
number;
c. Issue
to be addressed:
i. C-86
Motion or written request, and
ii. Date
of image.
2. Claims
services staff shall update the C-86 motion status in the claims management
system as follows:
a. Create a
Legal Case Management case;
b. Set a
30-day work item to follow-up on the outcome of the C-86 Motion;
c. Close
the Legal Case Management case once the decision is final on the C-86 Motion.
3. The
pharmacy department shall:
a. Address
C-86 Motions which shall result in one of the following:
i. Dismissal,
or
ii. Suspension,
or
iii. BWC Order
to allow and/or deny.
b. C-86
Motions for drug related issues shall be suspended when another request is
filed and in process that will have a significant and demonstrable bearing on
the drug related issue thereby making the information necessary in order to
properly administer the requested action. (e.g., Additional Allowance request)
c. Enter
a note in the claims management system with the action taken and outcome as a
result of a C-86 Motion or written request.
1. Claims
services staff shall set a Pharmacy Tech work item not more than three business
days from receipt of the imaged date of all IC hearing orders regarding drug
related issues. Claims services staff shall include in the work item:
a. Issue to
be addressed;
b. Date of
imaged document; and
c. Type
of hearing order (District Hearing Officer (DHO) or Staff Hearing Officer
(SHO).
2. The
pharmacy department shall create (if case does not exist) or update the Medical
Management case in the claims management system and enter a new row for each
drug or authorization on all IC hearing order decisions concerning drugs on DHO
hearing orders after the appeal period has expired (if no appeal has been
filed), and upon request of an IC SHO order.
3. The
pharmacy department shall contact the appropriate BWC attorney for appeals or
staffing as the situation warrants by creating a Case Event work item – Notice
to BWC Legal in the claims management system.