|
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
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.
This policy applies to the CSS and CAT nurse.
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.
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.
- It is the policy of BWC that a
CAT nurse determines whether a claim meets the criteria of being deemed a CAT
claim.
- 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.
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.
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.
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.
- 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.