DISPUTE RESOLUTION EXAMS
R.C. 4121.411, R.C. 4123.53
Chief of Operational Policy, Analytics and Compliance (Signature on File)
Procedure # CP-01-02, effective 04/24/2014
The purpose of this policy is
to ensure Alternative Dispute Resolution (ADR) exams are processed in
accordance with O.A.C. 4123-6-16 and that the appropriate entities make timely
This policy applies to the
BWC Field Operations staff, the BWC Medical Services Division, Medical Programs
and Pharmacy Division, the Disability Evaluators Panel (DEP) and to all Managed
Care Organizations (MCO).
Resolution (ADR) exam: an exam conducted as part of processing a medical
dispute between an employer of record (EOR), an injured worker (IW), a provider
and/or an MCO arising from the MCO’s decision regarding a medical treatment
reimbursement request. An IW or EOR shall exhaust the ADR process prior to
filing an appeal pursuant to R.C. 4123.511 regarding an MCO’s decision on a
medical treatment reimbursement request.
is the policy of BWC to process an MCO request for an ADR independent medical examination
treatment is disputed; and,
exam is necessary or appropriate.
the MCO recommends that the IW be scheduled for an ADR IME:
MCO’s time frame for completing the ADR process is tolled while the ADR IME and
the report are pending.
MCO shall submit its recommended ADR decision to BWC electronically within seven
(7) days after the receipt of the IME report.
A. The MCO shall process medical
disputes in accordance with the MCO Policy Reference Guide (MPRG), Chapter 5.
B. BWC and MCO staff shall refer to the Standard
Claim File Documentation policy and procedure for claim-note requirements
and shall follow any other specific instructions included in this procedure.
C. The MCO Process for ADR Exams
1. Exam Scheduling Preparation
– under the authority of BWC, the MCO shall:
a. Contact the IW to ensure that
he/she is aware of the obligation to attend the ADR IME. The MCO shall make
three (3) attempts to contact the IW at different times and on different days
and shall document each attempt in the claim notes.
b. Determine times when the IW
is available to attend the IME and make every reasonable effort to schedule the
ADR IME during those times.
c. Explain to the IW that
benefits may be suspended for failing to appear, cancelling or requesting to
reschedule the exam without good cause.
d. The MCO creates a “Medical”
case for exam scheduling and tracking.
e. The original exam letter is
sent to the injured worker and copies of the letter are sent to the parties to
the claim through “Documents”.
2. The MCOs may enter into agreements with administrative agents
to schedule, coordinate and bill ADR IMEs under the authority of BWC.
3. Exam Packets
a. The MCO shall create the exam
packet and include all relevant information to the dispute.
b. The MCO shall
neither add questions nor combine questions from another scheduled IME for an
ADR exam. An ADR exam is a stand-alone exam.
4. The MCO shall only refer an
IW for an out-of-state exam with a BWC out-of-state vendor when the IW lives
more than 50 miles from the Ohio border.
5. IME Report and Addendum
evaluating physician is expected to ensure that the MCO receives the ADR report
within five (5) calendar days of the
addition to those requirements found in the MPRG, the MCO shall be responsible for
reviewing the report to ensure it meets Quality Assurance (QA) requirements as
i. IW information is correctly
identified [i.e., name, claim number, DOI and claim allowance(s)].
ii. Report is not altered in any
c. If the MCO determines that an addendum is
necessary based on the QA requirements above:
i. The MCO may make, and
document in notes, any request for clarification or additional information by
telephone, but the MCO shall follow-up in writing.
ii. An amended report
must be received by the MCO two (2) calendar of the request.
iii. The MCO shall ensure the original
exam report is sent to BWC Scan Zone to be imaged in the claim and shall note
the request for an addendum in the “Medical”case
and in notes.
iv. The original report shall not
be withheld from imaging while waiting on the addendum.
The MCO shall submit
its recommended ADR decision to BWC electronically within seven (7) days after
receipt of the IME report, and the order shall be published under the authority
of BWC within two (2) days after receipt of the MCO recommendation. Additional
information on BWC Orders may be found in the Orders, Waivers, Appeals and
BWC and MCO staff
shall refer to the Independent Medical Examinations policy and procedure
for additional information and shall follow any other specific instructions
included in this procedure.
shall process travel reimbursement requests for ADR exams according to the IW Travel
to Appear (FTA) for an ADR Exam
1. Pursuant to the Independent
Medical Examinations policy:
a. The MCO shall determine if
the IW failed to appear, cancelled or requested to reschedule an ADR exam with
good cause. An investigation is conducted to establish unforeseen extraordinary
b. If the MCO determines the IW
failed to appear with good cause, the MCO shall reschedule the exam by creating
a new “Medical”case.
If the exam is
rescheduled and the IW attends, the MCO shall QA the report, as outlined in
section V.C.6 above.
The MCO shall
write notes and shall update the “Medical” case with the appropriate ADR exam
c. If the MCO has determined the
IW did not have good cause, the MCO shall update the “Medical” case with the
appropriate ADR exam outcome and shall notify BWC field staff.
d. Before suspending benefits,
BWC field staff shall review the MCO determination regarding good cause, and
field staff shall determine if the IW had unforeseen circumstances that warrant
shall notify the MCO to reschedule the exam if field staff determines the IW
failed to appear with good cause.
shall staff all FTAs without good cause with the supervisor.
shall suspend medical benefits only with supervisor approval.
may contact the IW or the IW’s authorized representative to discuss the reason
for the FTA.
shall document all the facts, actions and reasons in claims management notes.
shall update and close the exam scheduling case and shall send suspension letters
to the IW with copies to all parties.
shall stop bill payment of all medical benefits except for medications and
emergency or life-sustaining treatment and authorization of treatment using the
Stop Payment Dates field in the Claim Dates section of the claims management
a) The information will be
communicated to the MCO the next day via the ADR FTP file.
b) The MCO shall cease
processing of all C-9s and ADR appeals.
If the IW
contacts field staff and commits to attend an exam, field staff shall contact
the MCO to reschedule the exam and create a new “Medical” case, but the medical
benefits remain suspended until the IW appears.
After the IW
appears for the examination and the physician sends the ADR report to the MCO,
the “Medical” case shall be updated with the appropriate exam status. A task
will be generated for the CSS titled “ADR Report Received-Process Reinstatement.”
shall immediately reinstate the IW’s benefits by:
a) Sending the “ADR Reinstatement
Letter” to the IW and copying all parties;
b) Emailing the MCO and HPP
System Support mailbox so bills are no longer denied;
c) Medical Billing and
Adjustment (MB&A) shall take the claim off REVIEW in Cambridge.
2. The MCO shall then:
a. Review all treatment
authorization requests in its possession, as outlined by the C-9 authorization
guidelines, as providers need not re-submit C-9s to the MCO that the provider
submitted during the suspension of benefits.
the treating provider(s) that the authorization of treatment suspension is lifted
and C-9 authorization requests shall be considered and processed.
pended bills as providers need not re-submit bills that the provider submitted to
the MCO during the suspension of benefits.
3. BWC shall send an
“Administrative Time and Letter” fee to DEP physicians when an IW fails to appear
for an ADR exam.
IMEs are to be billed:
an EDI 837 transaction using procedure code Z1600.
an out-of-state ADR IME, staff shall use procedure
“administrative time and letter” fee may be billed for non-compliant IWs using:
For out-of-state scheduled IMEs, staff shall use Z9601.
staff shall coordinate with the MCO in providing the IW an Injured Worker Statement
for Reimbursement of Travel Expense (C-60) form, when appropriate.