OhioBWC - Basics: (Policy library) - File

Catastrophic Claims

Policy and Procedure Name:

Catastrophic Claims Initial Determination

Policy #:

CP-03-14

Code/Rule Reference:

N/A

Effective Date:

04/01/21

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

None

History:

N/A


 

Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

Catastrophic (CAT) Claim

IV. POLICY

A.          Claim Review and Referral

B.          Claim Determination

C.         Claim Notification

D.         General Statement

V. PROCEDURE

A.          General Claim Note and Documentation Requirements

B.          Claim Review and Referral

C.         CAT Claim Determination Process

D.         Non-CAT Claim

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that the claims services specialist (CSS) and catastrophic nurse advocate (CAT nurse) identify and manage catastrophic claims appropriately during initial claim determination.

 

II. APPLICABILITY

 

This policy applies to the CSS and CAT nurse.

 

III. DEFINITIONS

 

Catastrophic (CAT) Claim: A claim in which there is a serious injury or occupational disease resulting in limited mobility and/or cognition related to the allowed conditions in the claim that severely limit the ability of the injured worker (IW) to perform activities of daily living and has a high probability of resulting in permanent disability.

 

IV. POLICY

 

A.     Claim Review and Referral

1.     It is BWC’s policy that CAT claims, as defined in this policy, may include, but are not limited to, the following indicators:

a.     Brain injuries, moderate to severe;

b.     Amputations, fractures, or crush injuries of a major extremity, or loss of use of one or more limbs;

c.      Spinal cord injuries such as paraplegia, quadriplegia, hemiplegia or diplegia;

d.     Total occupational blindness;

e.     Severe burns, including second-or third-degree burns on more than 25 percent of the body;

f.       Actual and anticipated hospitalization in excess of four weeks, (i.e., ventilators, intensive care unit, psychiatric hospitalization);

g.     Severe occupational diseases and bloodborne pathogens (not end stage);

h.     Toxic exposure with long term complications; and

i.       Any other medical diagnoses identified by the managed care organization (MCO) and CAT nurse.

2.     It is the policy of BWC that CSSs refer claims with the indicators outlined above to the CAT nurse for determination of catastrophic claim status.

 

B.     Claim Determination

 - It is the policy of BWC that a CAT nurse determines whether a claim meets the criteria of being deemed a CAT claim.

 

C.    Claim Notification

 - It is BWC’s policy that the CAT nurse provide notification to both the CSS and MCO regarding the CAT nurse’s determination as to whether or not a claim has been deemed a CAT claim or not.

 

D.  General Statement

1.     The MCO, not the CAT nurse, is responsible for providing case management for all CAT claims including but not limited to on-site visits.

2.     For additional details on MCO management of CAT claims, please refer to Chapter 3, Section G, Catastrophic Claims portion of the MCO Policy Reference Guide.

 

V. PROCEDURE

 

A.     General Claim Note and Documentation Requirements

1.     BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note requirements; and

2.     Shall follow any other specific instructions for claim notes included in this procedure.

 

B.     Claim Review and Referral

1.     The CSS shall review a claim to decide if the claim meets the criteria listed in Section IV. A. of the policy, prior to referring the claim to a CAT nurse.

a.     The CSS shall refer a claim meeting the criteria listed in this policy to the CAT nurse within three business days from the receipt of that claim. 

b.     If the CSS is unsure whether a claim should be referred to the CAT nurse for CAT claim determination, the CSS may contact a medical service specialist or an injury management supervisor for assistance in determining whether to refer the claim to a CAT nurse.

2.     The CSS shall collaborate with the MCO to:

a.     Obtain the IW’s medical records. The medical records may include the following information:

i.       Type of injury;

ii.      Date of injury;

iii.     Emergency room report;

iv.    Physician statement;

v.      Diagnoses;

vi.    Clinical findings (extent of injury);

vii.   Comorbidities;

viii. Treating provider(s);

ix.    Physician report;

x.      Operative reports;

xi.    X-ray, MRI, CT Scan;

xii.   Accident report;

xiii. Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9);

xiv. Physician's Return to Work Report (MEDCO-14);

xv.   Physician’s office progress notes;

xvi. Medical and prescription bills.

b.     Establish communication with the IW. If the IW is unable to be reached or is unable to provide information, attempts shall be made to the following individuals to obtain necessary information:

i.       The IW’s family member(s) or other individuals that have knowledge of the IW.

ii.      The employer of record (EOR). The following information shall be obtained from the EOR:

a)     The IW’s contact information;

b)     The IW’s job description;

c)     Wage information shall be obtained so that compensation may begin as soon as possible; and

d)     Facts surrounding the incident and certification from the employer.

iii.     The IW’s attorney of record, if applicable.

3.     All CAT nurse referrals or requests for staffing shall be submitted via the following steps outlined below in the claims management system. The CSS shall:

a.   Enter a note in the claim indicating the reasoning for the need for the referral being made to the CAT nurse.

b.   Create a work item in the claim.

i.    From the task template drop down select “Review for Possible Catastrophic Claim;”

ii.   Select the Assign to team radio button;

iii.   From the Team drop down select ‘Nurse – Catastophic;’ and

iv.  Click the finish button.

4.     When a CSS needs to refer a claim to the CAT Nurse using the Work Item “Review for Possible Catastrophic Claim” in the claims management system, the CSS must enter the name of the MCO in the Description box. The individual CAT Nurse assignment is based on the MCO, not the service office.

5.     When a new claim is referred to the CAT nurse for review, a referral should not also be made to a Medical Service Specialist. The CAT nurse will review the claim and determine whether the claim meets CAT claim criteria listed in Section IV. A. of the policy.

a.     If the claim is catastrophic, the CAT nurse will enter a note with support of the determination and/or send for physician review, if needed. The CAT nurse will identify and code the conditions in the claim.

b.     If the claim is NOT catastrophic, the CAT nurse will enter a note and send an email notification to the referring CSS.

 

C.    CAT Claim Determination Process

1.     Upon receipt of a claim referred for CAT claim determination, the CAT nurse shall use the medical evidence on file to assist with making his/her determination within two business days.

2.     If the CAT nurse receives a claim referral without medical evidence, the CAT nurse will contact the MCO and CSS to request the medical evidence for the claim.

3.     The CAT nurse shall complete the following tasks in the claims management system upon determination that the claim will be handled as a CAT claim:

a.     Enter a note in the claims management system that includes the following data elements:

i.       The date of CSS/MCO referral;

ii.      A summary of the accident and injuries;

iii.     A statement that the medical documentation was reviewed;

iv.    If applicable, the MCO case manager that the claim was staffed with, including the case manager credentials;

v.      The determination of CAT status and clinical justification;

vi.    Place the ICD-10 code recommendations into the claims management system and request modifications; and

vii.   Notify the CSS when the modification is complete.

b.     To update the screen in the claims management system to a CAT claim, the CAT nurse will:

i.       Select Claim Details from the left side Secondary Navigation menu.

ii.      Open the Injury tab. The default for the Injury tab is the Details.

iii.     Select the checkbox Catastrophic Injury tab.

iv.    From the Catastrophic Injury Type drop-down, make the appropriate selection.

v.      Enter any applicable comments in the Catastrophic Injury Type Comment box.

vi.    Click Save tab.

vii.   Select Claim Details from the Secondary Navigation at the left.

viii. Open the Details tab.

ix.    Click the link for Claim Dates.

x.      Use the scroll bar at the right of the screen to scroll down to the Other Dates section.

xi.    At the right of the screen, click the green add icon.

xii.   From the Date Type drop-down, select Catastrophic Dates.

xiii. Effective Date: enter the date claim was determined as catastrophic.

xiv. Click Save tab.

c.   The CAT nurse shall add him or herself as secondary assignment in the claims management system and expire the CAT Nurse Group assignment that is automatically created by the claims management system when the CSS makes the referral.

i.       Please refer to the Adding and Expiring Secondary Claims Assignment job aid on the Claims Online Resource (COR) site for additional information.

ii.      When a new claim has been determined to be catastrophic, the claim assignment must be updated to reflect the CAT nurse as a secondary assignment.

iii.     To add the secondary assignment in the claims management system the CAT nurse will follow the steps outlined below:

a)     Make sure the claim is open.

b)     Click the View Assignments icon.

c)     Select Add Assignment.

d)     The Assignment window will open.

e)     From the Functional Role drop-down, select Nurse Catastrophic.

f)       From the User drop-down, select your name.

g)     The Team field auto populates the team.

h)     From the Status drop-down, select Assignment.

i)       The Effective Date defaults to the system’s current date.

j)       Enter an Expiration date 45 calendar days into the future.

k)     Deselect the Override Auto Assignment box.

l)       Click Finish tab.

4.     Once the claim is determined to be catastrophic, the CAT nurse will notify (e.g., email, phone call) the CSS and MCO of their determination that the claim will be handled as a CAT claim and inform them that an informal staffing will be scheduled with the MCO, CSS, and the CAT nurse.

 

D.    Non-CAT Claim

 - If the CAT nurse determination does not support categorization of the claim as catastrophic, the CAT nurse shall:

1.     Enter a note in the claims management system documenting the decision and rationale for not classifying the claim as a CAT claim.

2.     Notify the MCO and CSS of the decision by email.

3.     Ensure that the the Catastrophic Injury box is unchecked in the claims management system.