and Procedure Name:
DISPUTE RESOLUTION EXAMS
4123-6-16, R.C. 4121.411, R.C. 4123.53
Percy, Chief of Operational Policy, Analytics and Compliance (Signature on
and 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 decisions.
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).
Dispute 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 (IME) when:
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.
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
evaluating physician is expected to ensure that the MCO receives the ADR report
within five (5) calendar days of the evaluation.
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
information is correctly identified [i.e., name, claim number, DOI and claim
is not altered in any substantive way.
c. If the MCO
determines that an addendum is necessary based on the QA requirements above:
MCO may make, and document in notes, any request for clarification or
additional information by telephone, but the MCO shall follow-up in writing.
amended report must be received by the MCO two (2) calendar of the request.
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.
original report shall not be withheld from imaging while waiting on the
6. 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 Hearings policy.
7. 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.
MCO shall process travel reimbursement requests for ADR exams according to the IW
Travel Reimbursement policy.
to Appear (FTA) for an ADR Exam
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
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.
the exam is rescheduled and the IW attends, the MCO shall QA the report, as
outlined in section V.C.6 above.
MCO shall write notes and shall update the “Medical” case with the appropriate
ADR exam outcome status.
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.
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 good cause.
staff shall notify the MCO to reschedule the exam if field staff determines the
IW failed to appear with good cause.
staff shall staff all FTAs without good cause with the supervisor.
staff shall suspend medical benefits only with supervisor approval.
supervisor may contact the IW or the IW’s authorized representative to discuss
the reason for the FTA.
staff shall document all the facts, actions and reasons in claims management
staff shall update and close the exam scheduling case and shall send suspension
letters to the IW with copies to all parties.
staff 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
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.
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.
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
staff 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
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.
Billing ADR Exams
IMEs are to be billed:
an EDI 837 transaction using procedure code Z1600.
an out-of-state ADR IME, staff shall use
procedure code Z9600.
“administrative time and letter” fee may be billed for non-compliant IWs using:
2. 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.