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OhioBWC - Basics: (Policy library) - File

ADR

Policy and Procedure Name:

ALTERNATIVE DISPUTE RESOLUTION EXAMS

Policy #:

CP-01-02

Code/Rule Reference:

O.A.C. 4123-6-16, R.C. 4121.411, R.C. 4123.53

Effective Date:

11/14/2016

Approved:

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

Origin:

Claims Policy

Supersedes:

Policy and Procedure # CP-01-02, effective 04/24/2014

History:

New 04/24/2014

 

 

I.        POLICY PURPOSE

 

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.

 

II.        APPLICABILITY

 

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).

 

III.        DEFINITIONS

 

Alternative 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.

 

IV.        POLICY

 

A.    It is the policy of BWC to process an MCO request for an ADR independent medical examination (IME) when:

1.    Medical treatment is disputed; and,

2.    The exam is necessary or appropriate.

B.    If the MCO recommends that the IW be scheduled for an ADR IME:

1.    The MCO’s time frame for completing the ADR process is tolled while the ADR IME and the report are pending.

2.    The MCO shall submit its recommended ADR decision to BWC electronically within seven (7) days after the receipt of the IME report.

 

V.        PROCEDURES

 

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

a.    The evaluating physician is expected to ensure that the MCO receives the ADR report within five  (5)  calendar days of the evaluation.

b.    In 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 follows:

                                      i.        IW information is correctly identified [i.e., name, claim number, DOI and claim allowance(s)].

                                     ii.        Report is not altered in any substantive way.

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.

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.

8.    The MCO shall process travel reimbursement requests for ADR exams according to the IW Travel Reimbursement policy.

 

B.    Failure 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 circumstances.

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.

                                      i.        If the exam is rescheduled and the IW attends, the MCO shall QA the report, as outlined in section V.C.6 above.

                                     ii.        The 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.

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 good cause.

                                      i.        Field staff shall notify the MCO to reschedule the exam if field staff determines the IW failed to appear with good cause.

                                     ii.        Field staff shall staff all FTAs without good cause with the supervisor.

                                    iii.        Field staff shall suspend medical benefits only with supervisor approval.

                                   iv.        The supervisor may contact the IW or the IW’s authorized representative to discuss the reason for the FTA.

                                    v.        Field staff shall document all the facts, actions and reasons in claims management notes.

                                   vi.        Field staff shall update and close the exam scheduling case and shall send suspension letters to the IW with copies to all parties.

                                  vii.        Field 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 management system.

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.

                                 viii.        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.

                                   ix.        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.”  

                                    x.        Field 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 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.

b.    Notify the treating provider(s) that the authorization of treatment suspension is lifted and C-9 authorization requests shall be considered and processed.

c.    Process 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.

 

VI.        Billing ADR Exams

A.     ADR IMEs are to be billed:

1.    Through an EDI 837 transaction using procedure code Z1600.

2.    For an out-of-state ADR IME, staff shall use procedure code Z9600.

 

B.    An “administrative time and letter” fee may be billed for non-compliant IWs using:

1.    Procedure code Z1601;

2.    For out-of-state scheduled IMEs, staff shall use Z9601.

 

C.   Field staff shall coordinate with the MCO in providing the IW an Injured Worker Statement for Reimbursement of Travel Expense (C-60) form, when appropriate.


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