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OhioBWC - Basics: (Policy library) - File

 

Policy Name:

Additional Allowance

Policy #:

CP-01-03

Code/Rule Reference:

O. A. C. 4121-3-15 and 4123-3-16

 

Effective Date:

01/01/14

Approved:

Rick Percy, Chief of Operational Policy, Analytics, and Compliance (Signature on file)

Origin:

Claims Policy

Supersedes:

Policy for additional allowance CP-01-03 dated 08/01/12

History:

New 08/01/12; Rev. 01/01/14

Review date:

01/01/19

 

 

I. POLICY PURPOSE

 

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 all other requirements of the Ohio Administrative Code.

 

II. APPLICABILITY

 

This policy applies to BWC claims field staff and managed care organizations.

 

III. DEFINITIONS – N/A

 

IV. POLICY

 

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.  BWC will not address a psychological condition(s) recommended on a Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) subsequent to the initial determination.

 

 

 

 

Procedure Name:

Procedure for Additional Allowance

Procedure #:

CP-01-03.PR1

Policy # Reference:

CP-01-03

Effective Date:

09/14/17

Approved:

Kevin R. Abrams, Chief Operating Officer

Supersedes:

Procedure for additional allowance CP-01-03.PR1 dated 8/01/2012, 01/01/14, 11/20/15, 11/14/16  

History:

New 08/01/12; Rev. 01/01/14, 11/20/15, 11/14/16

Review date:

01/01/19

 

 

I.      BWC staff shall:

A.    Refer to the Standard Claim File Documentation policy and procedure for claim-note requirements and shall follow any other documentation-specific instructions included in this procedure; and

 

B.    Refer to the Jurisdiction policy and procedure to determine if a claim is statutorily open. 

 

II.    Evaluating the Request/Recommendation

A.    When a C-86 or C-9 is filed requesting/recommending an additional condition(s), the application shall be indexed into the claim and then populated to the claims services staff’s tasks.

B.    When a C-86 is filed requesting an additional condition(s), claims services staff shall enter the International Classification of Diseases (ICD) code(s) into the claims management system upon receipt of the application. 

C.   When a C-9 is filed recommending an additional condition(s):

1.    The Medical Claims Specialist (MCS) shall enter the ICD code(s) into the claims management system upon receipt of the recommendation.

2.    The Claims Service Specialist (CSS) shall enter the ICD code(s) into the claims management system upon receipt of the recommendation or when the “C-9 IW Acknowledgement Letter” is sent. 

D.   Claims services staff shall create a legal case with an additional allowance issue when one of the following is filed:

1.    A C-86 requesting an additional allowance(s); or

2.    A C-9 recommending an additional allowance(s), including a request for reactivation due to a medical services/treatment request with an additional allowance(s).   

E.    Claims services staff shall review the request/recommendation to answer the following questions:

1.   Has the statute of limitations for the claim expired?

a.    Claims services staff shall review the claim for the statute of limitations date.

b.    If staff would like more information regarding the statute of limitations, then staff may go to the Statutory Life of a Claim Chart on Claims Online Resources (COR) on the Additional Allowance policy page under Tips and Tools. 

c.    If the statute of limitations has expired, claims services staff shall generate the “Out of Statute of Limitations Letter for Lost Time Claims” or the “Out of Statute of Limitations Letter for Medical Only Claims” located on the claims management system.

d.    Once either letter has been sent, claims services staff shall notify the managed care organization (MCO) of the final decision, and the MCO will notify the treating physician of the status of the request/recommendation. 

2.   Has the claim been disallowed or settled?

a.   If the claim has been disallowed or settled, claims services staff shall send the “Additional Allowance Combination Letter” located on COR on the Additional Allowance policy page under Correspondence to notify the parties to the claim that the request/recommendation cannot be addressed.

b.   Once the letter has been sent, claims services staff shall notify the MCO of the final decision, and the MCO will notify the treating physician of the status of the request/recommendation.

 

F.  Claims services staff shall:

1.   Ensure that the condition requested/recommended is not:

a.   A symptom; or

b.   A condition that the MCO may address using explanation of benefits (EOB) code 776.  To make that determination, claims services staff shall consider if the condition:

i.      Will resolve within a relatively short period of time; and

ii.     Is related to an allowed condition in the claim.

2.  Contact the MCO to determine if the condition can be addressed through bill payment using EOB code 776 when claims services staff reasonably believes, based on the evaluation above, that the request/recommendation for an additional condition is a billing issue.

a.   If the MCO agrees it is a billing issue, claims services staff shall contact the filing party to relay this information and discuss withdrawal of the request/recommendation.

i.   Claims services staff shall take no further action when the filing party withdraws the request/recommendation.

ii.   Claims services staff shall process the request/recommendation according to BWC policy and procedure when the filing party does not withdraw the request/recommendation.

b.   If the MCO does not agree it is a billing issue, claims services staff shall process the request/recommendation according to BWC policy and procedure.  

G.   The MCO shall address any clarification of the documentation of the medical evidence when a C-86 or C-9 is filed.

H.   If additional evidence to support the condition(s) recommended on a C-9 is requested, but not submitted, claims services staff shall send the “C-9 Additional Allowance Closure Letter” located on the claims management system.  

1.    After sending the letter, claims services staff shall notify the MCO of the final decision.

2.    The MCO will notify the treating physician of the status of the request/recommendation.

I.      The MCO shall provide input to BWC on whether the medical evidence on file supports the existence of the additional condition(s) requested/recommended.

J.  The MCO shall assist the employer in understanding the medical information in the claim, when necessary. 

K.    When a request/recommendation is submitted, contact with the filing party may be needed to clarify information related to a condition(s).

1.    A new request/recommendation will not be needed once the information is clarified.

2.    Claims services staff must enter a note in the claim to confirm the clarified information.

Example:  A request/recommendation is filed for allowance of a herniated disc, but the specific level is not listed.  Claims services staff contacts the filing party and is informed that the level is L4-5.  A new request/recommendation stating the appropriate level is not needed, but claims services staff must enter a note in the claim to reflect the clarified information. 

L.    Claims services staff shall suspend the request/recommendation when a C-240 has been filed, but the settlement process is not complete.  The C-86 or C-9 will be processed if the claim is not settled.  

M.   Psychiatric/Psychological Conditions

1.    When a C-9 is filed and a psychiatric/psychological condition(s) only is recommended, claims services staff shall send the “C-9 Additional Allowance Closure Letter” using the appropriate insert and shall notify the MCO of the final decision.  The MCO will notify the treating physician of the status of the recommendation.

2.    When a C-9 is filed and the recommended conditions include a psychiatric/psychological condition(s) and a physical condition(s), claims services staff shall consider the physical condition(s), but will notify the injured worker (IW) that BWC cannot address the psychiatric/psychological condition(s) without a C-86.  Notification to the IW regarding the need for a C-86 may occur while claims services staff is contacting the IW regarding the physical condition.

3.    A C-86 requesting allowance of a psychiatric/psychological condition(s) shall be processed according to the current policy and procedures.

N.   Claims services staff shall address all issues which fall under BWC’s jurisdiction and are submitted on a C-86 or C-9.  Evidence must be gathered or developed to support BWC’s position toward each issue.  Claims services staff shall refer a C-86 or C-9 to the Industrial Commission of Ohio (IC) when the evidence does not fully support the allowance of all issues within BWC’s jurisdiction.

1.    Addressing multiple issues in a consistent manner will avoid additional issues (e.g., dual appeal periods running, etc.).

2.    It will also serve to keep the status of the entire request/recommendation clear for all parties involved.  

Example: BWC receives a C-86 or C-9 requesting/recommending two additional conditions to be added to the claim.  The evidence supports allowance of one condition, but does not support the allowance of the other condition.  Claims services staff shall refer the C-86 or C-9 to the IC clearly stating BWC’s position and indicating the evidence that is being relied upon to support the position.

O. When a C-86 is filed with a signature, it must be signed by the IW, employer, or an attorney representing the IW or employer.

1.   If the signature belongs to someone other than one of those parties, the appropriate party must be contacted to determine if he/she or an authorized representative had intended to file the motion.  If yes, that party should be encouraged to submit a C-86 with the proper signature.

2. Verbal agreement to the filing of the C-86 is insufficient.  Staff must obtain a signature.

P. When a C-86 is filed requesting an additional allowance, but the C-86 is not signed, claims services staff shall dismiss the C-86 using the appropriate insert for the “Additional Allowance Combination Letter.”

1.  Claims services staff shall notify the MCO of the final decision, and the MCO will notify the treating physician of the status of the request.

2.  Claims services staff may verbally clarify the request or verbally obtain missing information other than a signature.  The clarification of the request or missing information must be documented in notes in the claim. 

Q. If a C-9 has been received that recommends an additional condition(s) and the “C-9 Additional Allowance Closure Letter” has been sent previously for the same condition(s), claims services staff will review claim notes and the evidence that supports the recommendation to determine if new and changed circumstances exist.

1.    If new and changed circumstances exist, consideration of allowance of the recommended condition(s) will continue.

2.    If new and changed circumstances do not exist, the “C-9 Additional Allowance Closure Letter” will be sent. 

R.   If BWC has not published an initial claim decision yet, the newly requested/recommended condition(s) shall be included in the initial decision, even though it is not listed on the First Report of Injury (FROI).   

S.    When a request/recommendation is filed prior to the initial determination of the claim becoming final (during the appeal period with an appeal filed), the request/recommendation shall be suspended until the claim is fully adjudicated. 

1.     Claims services staff may call the filing party to notify him/her that the request/recommendation has been suspended, or send the “Additional Allowance Combination Letter” to notify the parties to the claim that the request/recommendation has been suspended.

2.     Claims services staff must notify the MCO that the request/recommendation has been suspended, and the MCO will notify the treating physician of the status of the request/recommendation.

3.     If the claim is allowed, BWC will consider the condition(s) immediately.

4.     If the claim is denied, consideration of the condition is a moot issue. 

T.    If an initial claim decision has been issued and a request or recommendation is filed during the appeal period, but no appeal has been filed, the previous order may be vacated with a new decision issued to include the new request or 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.

U.  Claims services staff shall complete a review of the request/recommendation to determine if any additional information is needed to continue managing the request or recommendation.  If no additional information is needed, the requested/recommended condition(s) shall be entered into the claims management system in alleged status.

 

III.   Providing Due Process

A.    Contact with the filing party of a C-86 is not necessary unless claims services staff needs to inquire about a specific issue or information is missing.

B.    All forms of due process must be documented in claim notes.  The note will state whether the party contacted agreed or disagreed with the additional allowance(s), as well as any other pertinent information pertaining to the issue.

C.   Claims services staff shall contact the IW representative only, unless the IW would like to be included in the decision or the representative is not responding to the contact(s).  When necessary, staff shall document in claim notes the reason for contacting the IW.

D.   Claims services staff shall contact the employer, except when the employer has requested that all contact be directed to the employer’s authorized representative. Staff shall document the employer’s request in claim notes.

E.    Due process shall be provided by one of the following methods:

1.    Calling the parties on the phone (recommended method of contact);

2.    Sending the appropriate letter by fax;

3.    Sending the appropriate letter by email (encrypt using ZixMail); or

4.    Sending the appropriate letter by U.S. mail.

 

F.    If claims services staff reaches an agreement with the employer regarding the preferred method of contact for due process, the agreement must be documented in claim notes.

      Example:  BWC policy states that due process contact shall be made by phone; however, the city of Warren has stated that they prefer due process contact by email.  The agreement between the city and BWC shall be documented in claim notes and due process with the city of Warren shall be provided by email.

 

G.   When due process is provided by phone or the letter is sent by fax or email, the party has three (3) full business days to respond.

Example:  Phone contact is made on Thursday.  The party contacted has Friday, Monday, and Tuesday to respond, if necessary.  Claims services staff shall act on the request/recommendation on Wednesday.

H.   When the letter is sent by mail, the party has seven (7) full business days (three days for due process and four additional days per the mailbox rule policy) to respond. Example:  The “C-9 Additional Allowance Due Process Letter” is sent by U.S. mail on Tuesday.  The party has Wednesday, Thursday, Friday, Monday, Tuesday, Wednesday, and Thursday to respond.  Claims services staff shall act on the request/recommendation on Friday.

I.      No decision will be made regarding the additional allowance(s) until a response is received or the response period has ended.

J.    IW Due Process – C-9

1.    When a C-9 is filed, claims services staff shall attempt to contact the IW/IW representative by phone to discuss the physician’s recommendation and verify that the IW/IW representative agrees with evaluation of the condition(s) recommended by the treating physician.  Attempted phone contact must be documented in claim notes.

2.    While claims services staff is speaking with the IW, he/she shall discuss the possibility of an examination of the IW to determine allowance of the condition(s) recommended.

a.    Claims services staff shall ask for the IW’s exam availability.

b.    When the IW’s availability is obtained, claims services staff shall enter the information in a note in the claim and title the note “IW Availability.”

c.    Exam availability is not necessary on a medical only claim.

3.    If phone contact with the IW/IW representative is successful and he/she agrees with the treating physician’s recommendation, claim notes are updated documenting the IW/IW representative’s agreement and the date it was obtained.

4.    Claims services staff shall send the “C-9 IW Acknowledgement Letter” to the IW and copy all other parties to the claim. The letter serves as due process to the employer and the employer’s representative, confirms the IW/IW representative’s verbal request that the condition(s) be evaluated, and is on COR on the Additional Allowance policy page under Correspondence. 

5.    When the IW/IW representative cannot be contacted by phone, but claims services staff leaves a voicemail message for the party, he/she has three (3) business days to return the call. 

a.    If he/she does return the call and agrees with the request, claims services staff shall document, in claim notes, the IW/IW representative’s agreement, and the date it was obtained.

b.    If the IW/IW representative returns the call, but does not agree with the treating physician’s recommended condition(s), the “C-9 Additional Allowance Closure Letter” is sent to the IW. 

i.      All other parties to the claim shall receive a copy of the letter.

ii.     Once the letter is sent, claims services staff shall delete the recommended condition(s) from the claims management system and notify the MCO of the final decision.

iii.    The MCO shall notify the treating physician of the status of the recommendation. 

c.    If the IW/IW representative does not return the call, claims services staff shall send the “C-9 Additional Allowance Closure Letter” to the IW.

i.      All other parties to the claim shall receive a copy of the letter.

ii.     Once the letter is sent, claims services staff shall delete the recommended condition(s) from the claims management system and notify the MCO of the final decision.

iii.    The MCO shall notify the treating physician of the status of the recommendation. 

6. When phone contact with the IW/IW representative is not successful and voicemail/leaving a message is not an option, claims services staff shall send the “C-9 Additional Allowance Due Process Letter” to all parties to the claim.  This letter can be found on COR on the Additional Allowance policy page under Correspondence. 

a.    Claims services staff shall set a task for the appropriate number of days, depending on the method used to send the letter.

b.    If the IW/IW representative does not respond within the specified response period, the “C-9 Additional Allowance Closure Letter” will be sent to the IW and all other parties to the claim will receive a copy of the letter.

i.      After sending the letter, claims services staff shall delete the recommended condition(s) from the claims management system and notify the MCO of the final decision.

ii.     The MCO shall notify the treating physician of the status of the recommendation.

c.    If the IW/IW representative responds to the letter by U.S. mail, fax, or email and indicates that he/she agrees with the treating physician’s recommendation, claims services staff shall update claim notes documenting the IW/IW representative’s agreement and the date it was obtained.

d.    If the IW/IW representative responds to the letter by phone and indicates he/she agrees with the treating physician’s recommendation, staff shall send the “C-9 IW Acknowledgement Letter.”

e.    If the IW/IW representative responds to the letter and indicates that he/she disagrees with the treating physician’s recommendation, staff shall send the “C-9 Additional Allowance Closure Letter” to the IW and all other parties to the claim will receive a copy of the letter. 

i.      After sending the letter, claims services staff shall delete the recommended condition(s) from the claims management system and notify the MCO of the final decision.

ii.     The MCO shall notify the treating physician of the status of the recommendation.

 

K.  Employer Due Process – C-9

1.  If the employer/employer representative responds to the “C-9 Additional Allowance Due Process Letter” and indicates he/she agrees with the treating physician’s recommendation, claim notes are updated documenting the agreement and the date it was obtained.  Consideration of the recommended condition(s) shall continue based on the IW/IW representative’s response. 

2.  If the employer/employer representative responds to the “C-9 Additional Allowance Due Process Letter” and indicates he/she disagrees with the treating physician’s recommendation:

a.    Claim notes are updated documenting the employer/employer representative’s disagreement and the date it was obtained;

b.    Consideration of the recommended condition(s) shall continue; and 

c.    The issue shall be referred to the IC via Notice of Referral (NOR) after BWC has had an opportunity to obtain evidence to support a position on the issue.  The NOR shall include the following:

i.      BWC’s recommendation for the condition(s);

ii.     Reference to the medical evidence submitted by the filing party to support the allowance of the condition(s), if claims services staff is recommending allowance of the condition(s).

3.    If the employer/employer representative does not respond to the “C-9 Additional Allowance Due Process Letter,” claim notes are updated and consideration of allowance of the condition(s) shall continue based on the IW/IW representative’s response. 

 

IV.  Reviewing Medical Evidence

A.    When a request/recommendation for an additional condition(s) is submitted on a C-86 or a C-9, claims services staff must determine if the condition(s) is included in the Medical Evidence for Diagnosis Determination (MEDD) guidelines.

B.    If the condition(s) is included in the MEDD guidelines, claims services staff shall review the request/recommendation to determine the following:

1.    Is a medical review necessary?

2.    Does a causal relationship exist?

3.    Is the medical evidence submitted sufficient to support the requested/recommended condition(s)?

 

C. Claims services staff shall create an event to the virtual medical services group in the following situations:

1.  Claims services staff feels that a medical review is necessary;

2.  The condition is not included in the MEDD guidelines; or

3.  Claims services staff needs assistance determining causality.

D.  Claims services staff shall document the following information in claim notes:

1.  The type of application the request/recommendation was submitted on;

2.  Date application was received;

3.  The condition(s) being requested/recommended (level and location);

4.  Prior claims;

5.  Suspect intervening injury;

6.  Claims services staff’s rationale for sending the referral for medical review; and

7.  Any other pertinent information.

E.  Upon receipt of the task, the Medical Services Specialist (MSS) shall review the medical evidence on file and determine if an examination or physician file review is necessary.

1.  If neither a physician file review nor an exam is necessary, the MSS shall enter a note in the claim regarding his/her decision.

2.   The note shall include the following:

a.    A summary of the medical evidence reviewed to support the MSS decision;

b.    The ICD code; and

c.    The ICD description.

3.  If a physician file review is necessary, the MSS shall send the Medco-21 to the physician and follow up in 1-7 days.

a.    Once the reviewing physician’s report is received, the MSS shall review the findings for quality assurance (QA) and to determine if an addendum is needed. 

b.    If an addendum is not necessary, the MSS shall enter a note in the claim and complete the task.  The note shall include the following:

i.      A summary of the medical evidence reviewed to support the MSS decision;

ii.     The ICD code; and

iii.    The ICD description. 

c.    If an addendum is necessary, the MSS shall send the addendum request to the reviewing physician and follow up in 1-3 days.

4.    If the MSS determines an exam is necessary, he/she shall create the exam packet via “create a doc” and select the appropriate exam case issue.

5.    The MSS shall enter a note in the claim that documents the following information that is to be referenced by the exam scheduler prior to scheduling the exam: 

a.    Type of exam requested;

i.      Additional allowance – physical;

ii.     Additional allowance DOI on/after 8/25/06;

iii.    Loss of use;

iv.   Loss of use by amputation;

v.    Loss of hearing; or

vi.   Loss of vision.

b.    Specialty of physician needed;

c.    First and second choice of physician; and

d.    Any additional questions or notes to the physician.

6.  When the MSS has received the examination report, he/she shall review the findings for QA and to determine if an addendum is needed.

a.    If an addendum is not necessary, the MSS shall enter a note in the claim and complete the task.  The note shall include the following:

i.      A summary of the medical evidence reviewed to support the MSS decision;

ii.     The ICD code; and

iii.    The ICD description.

b.   If an addendum is necessary, the MSS shall send the addendum request to the reviewing physician and follow up in 1-3 days.

 

V.   Scheduling an Exam

A.    The exam scheduler must schedule the exam immediately.

B.    The exam scheduler shall:

1.    Review the note entered by the MSS for specific information pertaining to the exam, and

 

2.    Request the appropriate Cognos report and image it into the claim, if received directly.

C.   Prior to scheduling the exam, the scheduler shall review the claim notes regarding the IW’s exam availability (see note titled “IW Availability”).  If no such notes exist, the exam scheduler shall contact the IW directly to obtain availability.

                1.    If the scheduler was unable to speak with the IW, he/she shall give the IW 48 hours to return the call.

                2.    If the IW does not return the call within 48 hours, follow the usual exam scheduling process.

D.   Once the exam scheduler has determined the IW’s availability, he/she shall:

1.    Contact the provider from the Disability Evaluator Panel (DEP) database and obtain the first available exam date;

2.    Add the appointment information to the claims management system; and

3.    Send the Physician and IW Notice of Exam.

E.    After the specific exam information has been established, the exam scheduler shall:

                1.    Contact the IW to confirm the appointment date, time, and location; and

                2.    Notify the IW that a follow up letter will be sent, but may arrive after the exam date.

F.    When the exam report is received, the exam scheduler shall:

                3.    Update the case in the claims management system to indicate the exam report has been received; and

                4.    Ensure the exam report is imaged into the claim.

G.   For more information pertaining to exam scheduling, refer to the additional allowance training manual on COR on the Additional Allowance policy page. 

 

VI.  Issuing a Decision

A. When claims services staff recommends allowance of the condition(s), he/she shall contact the employer/employer representative by phone or the preferred method of contact documented in claim notes to obtain agreement or disagreement regarding allowance of the condition(s).

1.  Claims services staff shall not contact the employer/employer representative when the “C-9 IW Acknowledgement Letter” or the “C-9 Additional Allowance Due Process Letter” has already been sent.

2.  Claims services staff shall not contact employers who are out of business or no longer doing business in Ohio.  However, if the employer is out of business or no longer doing business in Ohio and has retained an authorized representative to oversee his or her claims, claims services staff shall contact the employer representative. 

B.     If the employer agrees with allowance of the condition(s), claims services staff shall:

1.    Notify the MCO of BWC’s decision to allow the condition(s) in the claim;

2.    Publish a BWC “Subsequent Decision Order” to allow the condition(s); and

3.    Update the claims management system. 

a.    When speaking with the employer/employer representative, claims services staff may also take advantage of the opportunity to notify the employer/employer representative that he/she can visit BWC’s website at www.bwc.ohio.gov to file a waiver online.

b.    Claims services staff may send a waiver to the employer/employer representative and IW/IW representative via U. S. mail or fax if the employer/employer representative or IW/IW representative cannot access the website.

i.      If the IW/IW representative and employer/employer representative submits a waiver, claims services staff shall allow the condition(s) and update the claims management system immediately.

ii.     Claims services staff shall notify the MCO of the final decision.

iii.    The MCO shall notify the treating physician of the status of the request/recommendation.

 

C.   When the BWC Order is issued and an appeal is filed, claims services staff shall update the condition(s) in the claims management system and notify the MCO that a final decision on allowance of the condition(s) is pending.

1.    Claims services staff shall notify the MCO of the final decision when it is rendered.

2.    The MCO shall notify the treating physician of the status of the request/recommendation.

D.   If the employer disagrees with allowance of the condition(s) or BWC recommends denial of the condition(s), claims services staff shall:

1.    Refer the issue to the IC via NOR;

2.    Enter a note in the claim;

3.    Update the condition(s) to Hearing in the claims management system; and

4.    Notify the MCO that a final decision regarding allowance of the condition(s) is pending.

a.    When a final decision is rendered, claims services staff shall update the claims management system and notify the MCO of the final decision.

b.    The MCO shall notify the treating physician of the status of the request/recommendation. 

 

 

 

 

 


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