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OhioBWC - Basics: (Policy library) - File

Policy Name:

CLAIM REACTIVATION

Policy #:

CP-03-13

Code/Rule Reference:

O.A.C. 4123-3-15

Effective Date:

02/13/17

Approved:

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

Origin:

Claims Policy (CP)

Supersedes:

Claim Reactivation policy CP-03-13 dated 12/14/16.

History:

New 12/14/16; 02/13/17

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that when BWC receives a request for compensation or medical benefits in a state-fund claim that has had no activity or request for further action for more than a 24 month period, BWC appropriately reactivates the claim if the request is causally related to the allowed condition(s) in the claim and payment is appropriate.

 

II. APPLICABILITY

 

This policy applies to Field Operations staff and Managed Care Organization (MCO) staff.

 

III. DEFINITIONS

 

Active claim:  A claim that has had payment of compensation, a paid date of service or a reactivation within a 24-month period.

 

Inactive claim:  A claim that has had no payment of compensation, no paid date of service and no reactivation for more than a 24-month period.

 

Last Indemnity Paid Date:  The most recent date a compensation payment was made in a claim and the date BWC will use for the active/inactive calculation if the last paid date of service is prior to this date.

 

Last Paid Date of Service (LPDOS):  The most recent date of service for which BWC paid medical benefits in a claim, and the date BWC will use for the active/inactive calculation if the last indemnity paid date is prior to this date.

 

Medical benefits:  For purposes of this policy, including but not limited to office visits, emergency room visits, diagnostics (e.g., x-rays, MRI or CT scan), prosthetics, durable medical equipment, vocational rehabilitation and prescription medication.

 

Reactivation: The process used to update a claim from inactive to active status.

 

Retro C-9:  A medical treatment request for reimbursement of service(s) that the provider has already provided to the injured worker.

 

 

IV. POLICY

 

A.    General information

1.    It is the policy of BWC to pay compensation or medical benefits in a state-fund claim that has had no activity or request for further action in it for more than a 24-month period when it receives a request for compensation or medical benefits that is causally related to the allowed condition(s) in the claim and payment is appropriate.

2.    The claims management system uses the following dates to establish whether a claim is active or inactive:

a.    If payment of compensation has been made, the date payment was made in the claim;

b.    If no payment of compensation has been made, the system chooses the date based on the latest of the following dates:

i.      Date of filing;

ii.     Date of service;

iii.    Date of payment of invoice.

c.    If payment of compensation and medical benefits has been made, the later of the two, subject to the criteria in section IV.A.2.b.

d.    For reactivation, the system uses the date the claims management system is updated by BWC.

3.    It is the policy of BWC that when the request for medical treatment /medical bill payment is not requested within one year and seven days from the date of first denial of the medical bill payment, the request will be denied, except when it is the result of an error by the BWC or the MCO.

4.    A party to the claim may appeal a claim reactivation and medical treatment decision to the Industrial Commission.

 

B.    Request for action in an inactive claim

1.    It is the policy of BWC that any request for action in an inactive claim is a request that requires authorization, the MCO, not BWC, will take action when medical treatment is for a:

a.    Date of service(s) prior to the inactive date; or

b.    Prosthetic, orthotic, vision, hearing or dental device, medical supplies or durable medical equipment (DME) categories as outlined below when such request is the only issue presented:

i.      Canes

ii.     Crutches

iii.    Walkers

iv.   Decubitis care equipment (e.g., heel or elbow protector)

v.    Heat/cold application (e.g., electric heat pad)

vi.   Safety equipment

vii.  Restraints

viii. Other orthopedic devices.

2.    The MCO shall refer a medical treatment request in an inactive claim to BWC for BWC to take action:

a.    When the medical treatment request is accompanied by supporting medical evidence dated not more than 60 days prior to the date of the request, or

b.    When such medical evidence is subsequently provided to the MCO upon request.

3.    The MCO may dismiss without prejudice and without a referral to BWC a request for medical treatment in an inactive claim:

a.    When the request is not accompanied by supporting medical evidence dated not more than 60 days prior to the date of the request; or

b.    When such medical evidence is not subsequently provided to the MCO upon request.

4.    Responsibilities

a.    The MCO will address a request when the claim is inactive as outlined in section IV.B.1.a.-b.

b.    BWC will address:

i.      Medical Benefits, except in IV.B.1.a.-b.

a)    Causal relationship between the original injury and the current incident that is triggering the medical treatment; and

b)    Necessity and appropriateness of the medical treatment request.

ii.     Compensation benefits

a)    Causal relationship between the original injury and the current incident that is triggering the request for compensation; and/or

b)    Causal relationship between the original injury and the current incident that is triggering the request for an additional allowance.

c.    The MCO shall forward to BWC, and shall work together, to address:

i.      Multiple issues filed concurrently with dates of service both before and after the inactive date on the request; and

ii.     Eligibility and feasibility requests for vocational rehabilitation.

5.    It is the policy of BWC that when prescription medication is prescribed in an inactive claim, the MCO and BWC will evaluate the medical treatment that is triggering the prescription medication.

6.    BWC will not process, and the MCO will dismiss, similar or duplicate medical treatment requests in an inactive claim when new and changed circumstances are not present to re-evaluate the request.

 

C.   Independent medical examinations (IME) and physician file reviews (PFR)

1.    BWC does not have to obtain an IME or PFR when the:

a.    Evidence supports the request; or

b.    Request is untimely, including:

i.      Outside the statute of limitations; or

ii.     Medical bill payment request is outside the one year and seven days of the adjudication of the initial medical bill.

2.    BWC will, if the evidence does not support the request, require a PFR or an IME prior to issuing a BWC order or a notice of referral (NOR) to the IC. BWC must have a PFR or an IME if issuing a denial order.

 

D.   Processing timeframe for claim reactivation requests

1.    The MCO may take up to 16 business days to respond to the treatment request and forward the claim reactivation issue to BWC. This consists of:

a.    Three business days to:

i.      Review the medical treatment request and respond to the provider if medical documentation is not needed; or,

ii.     Pend the request to obtain medical documentation from the provider;

b.    10 business days for the provider to submit additional medical documentation to the MCO, if needed; and

c.    Three business days from receipt of requested additional medical documentation to review and forward the claim reactivation to BWC.

2.    The BWC has 28 calendar days to address the following:

a.    The causal relationship between the original injury and the current incident that is triggering the medical treatment request; and

b.    The necessity and appropriateness of the medical treatment request.

3.    BWC shall address the issue of claim reactivation by:

a.    Issuing a BWC Order; or

b.    Making a recommendation on a NOR to the IC when BWC does not have jurisdiction to issue an order.

4.    Once the decision is final, it is BWC’s policy to notify the MCO of the decision, and the MCO shall notify the provider:

a.    By letter within three business days from receipt of the BWC notification when medical treatment services have not yet been rendered;

b.    By letter within 30 calendar days from receipt of the BWC notification when medical treatment services have been rendered already;

c.    Via bill payment when the MCO pays or adjusts the bill that was originally denied. In this instance, the MCO does not need to send a letter as the payment of the bill shall serve as the notice to the provider.

 

E.    BWC’s claims management system runs a program that systematically updates a claim to inactive when it is 24 months after the last paid date in a claim.

 

 

 

BWC staff may refer to the corresponding procedure for this policy entitled “Procedure for Claim Reactivation” for further guidance.


 

Procedure Name:

PROCEDURE FOR CLAIM REACTIVATION

Procedure #:

CP-03-13.PR1

Policy # Reference:

CP-03-13

Effective Date:

02/13/17

Approved:

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

Supersedes:

Claim Reactivation procedure CP-03-13.PR1 dated 12/14/16.

History:

New 12/14/16; 02/13/17

 

 

I.        BWC staff shall:

A.    Refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim-note requirements and shall follow any other specific instructions included in this procedure; and

B.    Refer to the Jurisdiction policy and procedure to determine if a claim is statutorily open.

 

II.    Request for action in an inactive claim

A.    The MCO or BWC field staff may receive a request in an inactive claim in one of the following ways:

1.    The treating physician submits the Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) form;

2.    A party to the claim files a Motion (C-86);

3.    A party to the claim files a specific application for compensation; or

4.    A provider or a party to the claim makes a verbal request.

B.    Upon receipt of a medical treatment request, the MCO shall:

1.    Process in accordance with this procedure if the date(s) of service is after the inactive date.

2.    Process in accordance with this procedure if the dates of service are both prior to and after the inactive date.

3.    Process the request in accordance with the standard processing protocol if the date(s) of service is prior to the inactive date or it is a request specified in section III.G.2.

C.   The MCO and BWC field staff shall address the medical treatment triggering the request for prescription medication in an inactive claim and will not address the appropriateness of the prescription medication(s).

D.   The MCO and Disability Management Coordinator (DMC) shall consider a referral for vocational rehabilitation in an inactive claim as a request for claim reactivation and shall refer to Chapter 4 of the MCO Policy Reference Guide (MPRG) for additional information.  The MCO and the DMC shall work together with the BWC field staff to publish a BWC Subsequent Allowance order in accordance with section VI. 

 

III.   MCO process for medical treatment requests in an inactive claim

A.    The MCO may view the current inactive date on the bwc.ohio.gov website, and if necessary, may contact BWC field staff to obtain the active/inactive claim history located on the status window under Milestone dates. 

B.    MCO referral to BWC for claim reactivation

1.    The MCO shall refer a medical treatment request to BWC on an inactive claim when the request is supported by:

a.    Medical evidence dated not more than 60 days prior to the date of the request; or

b.    Such evidence is subsequently provided to the MCO upon request (via a C-9-A form or equivalent).

i.      When current medical documentation is not on file, the MCO shall request such documentation from the provider via the Request for Additional Medical Documentation for C-9 (C-9-A) form or equivalent; and

ii.     Document the request in the MCO notes.

2.    When documentation requested from a provider is not received, the MCO shall dismiss the request in accordance with section III.F.

3.    The MCO, prior to making a recommendation to allow or deny the medical treatment request, may indicate an independent medical examination (IME) or physician file review (PFR) is necessary.  The MCO and BWC shall collaborate to have the IME/PFR completed.  Once the report/review is on file, the MCO shall provide the clinical findings note.

4.    When referring to BWC for a reactivation review, the MCO shall:

a.    Review and make a recommendation to BWC field staff;

b.    Send the recommendation to BWC field staff copying the supervisor in a secure email that includes:

i.      Standard subject title:  “Request for Claim Reactivation Review”; and

ii.     A message that consists of, at a minimum, the following:

a)    Claim number;

b)    Injured worker name;

c)    Name of provider requesting the medical treatment;

d)    The date(s) of the C-9, C-86 or verbal request;

e)    A detailed description of the medical treatment request;

f)     The frequency and duration of the medical treatment request;

g)    The beginning and ending dates of the medical treatment requested (to determine duplicate requests);

h)    The body part being treated, including ICD code(s);

i)      An indication if the medical treatment has been previously rendered or not;

j)      The MCO recommendation to allow or deny the request;

k)    The medical evidence relied upon to support the MCO recommendation;

l)      An indication of which prong(s) of Miller the treatment does not meet, if the recommendation is to deny request;

m)  The MCO Medical Director’s opinion and recommendation (when applicable); and

n)    Any other information the MCO would like to relay to BWC.

5.    The MCO shall create, at the same time it sends the secure email to BWC, a clinical findings note with a title that reflects its content (e.g., “Claim Reactivation Clinical Findings”).  The note should include, at a minimum:

a.    The date(s) of the C-9, C-86 or verbal request;

b.    A detailed description of the medical treatment request;

c.    The frequency and duration of the medical treatment request;

d.    The beginning and ending dates of the medical treatment requested (to determine duplicate requests);

e.    The body part being treated, including ICD code(s);

f.     An indication if the medical treatment has been previously rendered or not;

g.    The MCO recommendation to allow or deny the request;

h.    The medical evidence relied upon to support the MCO recommendation;

i.      An indication of which prong(s) of Miller the treatment does not meet, if the recommendation is to deny request;

j.      The MCO Medical Director’s opinion and recommendation (when applicable); and

k.    Any other information the MCO would like to relay to BWC.

C.   Multiple medical treatment request(s) when claim reactivation is in process:

1.    When the MCO receives a similar or duplicative medical treatment request(s) and a previous request sent to BWC is pending, the MCO shall:

a.    Send the request to BWC if the prior request is at a point in time where all the requests can be handled together on one BWC order.

i.      The MCO shall immediately contact BWC field staff to make BWC field staff aware there is an additional request(s) that must be addressed.

ii.     BWC field staff shall address all medical treatment requests at the same time, which may include obtaining an addendum to an IME/PFR.

a)    BWC field staff may not address the medical treatment request if the BWC order is already issued; and

b)    BWC field staff shall immediately notify the MCO if an order has already been issued.

b.    Not send it to BWC when a BWC order has already been issued.  The MCO shall:

i.      Notify the provider the medical treatment request is deferred for consideration and will not be addressed until the current claim reactivation/medical treatment request is resolved and all appeals are exhausted.

ii.     Include the following statement on medical treatment requests in a letter to the provider, “C-9 is pended as claim reactivation review is currently in process based on a prior medical treatment request dated <Enter Date of Request>.”

2.    When the MCO receives a new medical treatment request that is not a similar or duplicate request of a previous request pending before the BWC or the IC, the MCO shall staff with BWC field staff to determine if the new request for medical treatment is to be included or not with the current medical treatment request for claim reactivation.

a.    If the new medical treatment request will be addressed with the prior request, the MCO shall:

i.      Prepare clinical findings note that contains each of the elements listed in section III.B.5; and

ii.     Send a secure email that contains each of the elements listed in section III.B.4.

b.    If the new medical treatment request will not be included with the prior request, the MCO shall:

i.      Defer consideration of the medical treatment request until the previous request pending is resolved and decision is final; and

ii.     Notify the provider that the request is deferred for consideration as indicated in section III.C.1.b.i.-ii.

D.   Similar or duplicate medical treatment request when the claim reactivation decision is final

1.    For a final decision denying the prior request, the MCO shall review the documentation in the claim to determine if there are new and changed circumstances that would impact the previous claim reactivation denial. 

a.    If there is documentation of new and changed circumstances that may impact the previous claim reactivation denial, the MCO shall perform the claim reactivation review pursuant to section III.B.

b.    If there is no documentation of new and changed circumstances that would impact the previous claim reactivation denial, the MCO shall dismiss subsequent medical treatment requests that are similar or duplicate pursuant to section III.F.

c.    For example, when an additional condition(s) in the claim has recently been allowed, this could be considered a new and changed circumstance that justifies consideration of an apparent duplicate treatment request.  In this situation, it is appropriate to address the request for treatment through the claim reactivation process.

2.    For a final decision allowing the prior request, the MCO shall address and process deferred or subsequent C-9/medical treatment requests utilizing the standard processing protocol. 

E.    The MCO shall refer a request to BWC for BWC to issue a denial when the request is not submitted within one year and seven days from the adjudication date of the previously submitted and denied medical bill, except in cases of an error by BWC or the MCO.

1.    Example:  a medical bill for treatment rendered on 12/21/2014 is denied on 1/5/2015; the MCO receives a request on 1/6/2016 for payment for medical treatment rendered on 12/21/2014.  MCO/BWC will process request. 

2.    Example:  a medical bill for treatment rendered on 12/21/2014 is denied on 1/5/2015; the MCO receives a request on 1/20/2016 for payment for medical treatment on 12/21/2014.  BWC will deny the request for reactivation.

3.    Example of MCO error:  MCO receives and approves a C-9 request for medical treatment on 11/1/2014; a medical bill (for approved C-9 on 11/1/2014) for medical treatment rendered on 12/21/2014 is denied on 1/5/2015; the MCO receives a request on 2/29/16 in an inactive claim for payment of medical treatment on 12/21/2014.  MCO denied the bill in error since treatment was prior approved.  MCO/BWC will process request. 

4.    Example of BWC error:  On 12/23/2014, the provider files an additional allowance (AA) request on a C-9 with a medical bill for treatment rendered on 12/21/2014. On 1/5/2015, the MCO denies the medical bill for treatment rendered on 12/21/2014 and forwards the C-9 to BWC to address the AA request.  BWC processes the AA request and allows the condition; however, BWC fails to notify the MCO of the final decision as required.  On 5/12/2016, the MCO receives a request to adjudicate the previously denied medical bill for payment of treatment rendered on 12/21/2014. Since BWC failed to provide notification to the MCO of the final decision on the AA request, the MCO/BWC will process the request.

F.    MCO Dismissal

1.    When the MCO dismisses a request, the MCO shall:

a.    Notify all parties to the claim;

b.    Notify the provider;

c.    Fax to BWC:

i.      A copy of the request and the dismissal to the provider;

ii.     Include the C-9-A or equivalent used to communicate with the provider to request additional medical documentation.

2.    For a dismissal of a similar or duplicate medical treatment request that was previously denied, the MCO shall ensure that the dismissal also includes:

a.    Date of the final BWC/Industrial Commission (IC) order that denied claim reactivation;

b.    Date of the C-9/medical service request; and

c.    Specific medical treatment requested.

3.    The MCO shall ensure there is no appeal language in the dismissal.

4.    The MCO shall ensure there are no new and changed circumstances prior to issuing a dismissal.

5.    The MCO shall dismiss without prejudice, and without referral to BWC, a medical treatment request that:

a.    Is not accompanied by supporting medical evidence dated not more than 60 days prior to the date of the request; and

b.    Such evidence is requested by, but not subsequently provided to, the MCO.

G.   The MCO shall refer all medical treatment requests to BWC staff in an inactive claim, except in the following situations:

1.    The medical treatment request is for a date of service(s) prior to the inactive date;

2.    The medical treatment request is only requesting the following:

a.    Prosthetics;

b.    Orthotics;

c.    Durable medical equipment (DME) categories as outlined in the Centers for Medicare and Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS), Level II codes:

i.      Canes

ii.     Crutches

iii.    Walkers

iv.   Decubitis Care Equipment (e.g., heel or elbow protector)

v.    Heat/Cold Application (e.g., electric heat pad)

vi.   Safety equipment

vii.  Restraints

viii. Other orthopedic devices, (e.g., adjustable elbow extension)

d.    Vision, hearing and dental devices (e.g., eye glasses, hearing aids, dentures);

e.    Medical supplies (e.g., hearing aid battery).

3.    The MCO may request BWC update the claim to active status when the medical treatment request does not need a referral to BWC and the MCO allows the request.  The MCO shall send a secure email to BWC staff that:

a.    Requests BWC staff to update the claim to active in the claims management system; and

b.    Provides the rationale to support making the claim active.

 

IV.  BWC process when in receipt of a claim reactivation and medical treatment request

A.    BWC field staff shall identify when a claim is inactive by looking in the claims management system on the status window and the status reason would be “Inactive Claim.”  Field staff may also see under milestone dates, the active/inactive history.

B.    BWC field staff shall update the status in the claims management system by opening a claim and selecting:

1.    “Status”;

2.    “Claim Status”;

3.    “Update claim status to “Reactivation Requested” to process request;

4.    Create a Legal Case Management Case.

C.   Upon request for medical services on an active claim, BWC shall notify the MCO to process the request in accordance with the MCO standard processing protocol. 

D.   BWC may receive a request for action in an inactive claim for issues other than requested medical treatment (e.g., compensation, additional allowance, lump sum settlement).  Field staff shall process the request as directed in the policy and procedure specific to the request.  If an application for compensation is approved, field staff shall refer to section VII.A.-B. to make the claim active prior to issuing payment.  Requests that will impact the active/inactive status include, but are not limited to: 

1.    When the BWC or IC modifies or alters an award of compensation or benefits that has been previously granted;

2.    When the BWC or IC grants a new award of compensation or settles the claim;

3.    When the injured worker files for an allowance of an additional condition or compensation benefits that have not been previously considered; or

4.    When an injured worker dies and there is potential entitlement for accrued benefits or payment of medical bills, or the decedent’s dependent(s) is requesting death benefits due to relatedness between the allowed conditions in the claim and the death.

E.    Upon request for medical treatment (and/or a combination request of multiple issues) on an inactive claim, BWC shall:

1.    Immediately begin processing the request when it is a request for claim reactivation and medical treatment received from the MCO; or

2.    Forward the request to the MCO if field staff determines that the MCO has not seen the request.

3.    When the request to reactivate the claim is vague and non-specific, and there is no other request for specific benefits and/or medical treatment, field staff shall:

a.    Contact the filing party to determine the specific benefits and/or medical treatment requested;

b.    Send the request to the MCO to begin processing if specific benefits and/or medical treatment is identified;

c.    Dismiss the request to reactivate the claim by using the “Dismissal Letter” if specific benefits and/or medical treatment cannot be identified;

d.    Note the request and outcome in claim notes.

F.    When field staff receives a secure email from the MCO for a claim reactivation and medical treatment request, field staff shall respond to the MCO in a secure email within three business days notifying the MCO that the claim reactivation request was received and that BWC has started processing the request. 

G.   BWC investigation

1.    If the medical treatment request is made more than five years from the date of injury and the claim is inactive, field staff shall ensure the claim is statutorily active, as referred to in section I.B. of this procedure.

2.    If the claim is an inactive self-insured bankrupt claim, field staff shall audit the claim to determine the following prior to beginning the investigation:

a.    All allowed conditions are documented in the claims management system;

b.    The claim is appropriately labeled as inactive;

c.    Validation the claim is statutorily open.

3.    BWC field staff shall provide due process by attempting to call the parties to the claim at least once; however, when phone contact is unsuccessful, field staff shall send:

a.    The “Claim Reactivation IW Due Process” letter; and

b.    The “Claim Reactivation Employer Due Process” letter.

4.    Field staff shall investigate issues prompting the medical treatment request to determine if the requested medical treatment is causally related to the original claim allowance. Field staff may staff with the appropriate discipline (e.g., BWC attorney on the timeliness of filing a medical treatment request) as the situation warrants.

5.    Field staff may, as part of the investigation, send the Claim Reactivation Investigation Questions to the:

a.    Employer;

b.    Injured worker; and

c.    Provider.

 

V.   IME and PFR

A.    Field staff may refer the claim for an IME or PFR as the situation warrants.  Field staff shall create the appropriate medical exam scheduling case or medical file review case in the claims management system.

B.    Field staff shall have a PFR completed in the claim prior to issuing a BWC Subsequent Allowance Order when BWC is recommending denial of request.

C.   Field staff shall document in notes and notify the supervisor when the IME or PFR will cause the processing of the request to exceed 28 days.

D.   Field staff shall add the appropriate set of questions for all issues being addressed (e.g., additional allowance and/or temporary total compensation), to the questions that address the medical treatment and claim reactivation request.

 

VI.  Issuing the decision on claim reactivation and medical treatment

A.    Field staff shall:

1.    Issue a BWC Subsequent Allowance Order when:

a.    Allowing the request in its entirety;

b.    Denying the request in its entirety;

c.    Allowing the request in part and denying in part (e.g., the request may be causally related to the original injury and current incident; however, the requested medical treatment may not be appropriate to allow in its entirety as a portion of the medical treatment requested is for experimental treatment); and

d.    The issue is for eligibility and feasibility of vocational rehabilitation. Field staff shall work with the DMC and MCO for the appropriate order insert.

2.    Issue a BWC Subsequent Allowance Order when:

a.    The decision includes multiple issues including the request for medical treatment (e.g., additional allowance and/or temporary total compensation); and

b.    BWC has jurisdiction to address all the issues in the request. Field staff shall select the appropriate order inserts.

3.    Send a Notice of Referral (NOR) to the IC when BWC does not have jurisdiction to issue a decision on all of the requests (e.g., we have requests for medical treatment, an additional allowance and temporary total compensation, and the evidence does not support the additional allowance or the temporary total requests).  The NOR shall include all of the requests because field staff shall not address some issues via an order and send the remaining issues to the IC.

B.    Field staff shall include in the BWC Subsequent order the following information:

1.    The date(s) of the C-9, C-86 or request;

2.    A detailed description of the requested medical treatment, without CPT codes;

3.    The frequency and duration of requested treatment, if appropriate;

4.    The beginning and ending dates of the requested treatment, if appropriate;

5.    The supporting justification used for the determination;

C.   BWC field staff shall notify the MCO when:

1.    The BWC order or NOR is issued;

2.    An appeal is filed to the BWC or IC order; and

3.    The appeal period has expired for a final decision of a BWC or IC order.

D.   After all appeals have been adjudicated, BWC field staff shall:

1.    If the decision is to grant the claim reactivation, update the claim status to “reactivation approved” the claim in the claims management system.

2.    If the decision is to deny the claim reactivation, notify the MCO of the final decision, update claim notes and once the final decision is to deny claim reactivation, the claim status is changed to “inactive claim.”

E.    The MCO shall, upon notification from BWC of a final decision, notify the provider in the following manner:

1.    If the medical treatment request is denied, the MCO shall:

a.    Provide written notification to the provider within three business days from receipt of the BWC notification; or

b.    If the medical treatment has previously been rendered, communicate the bill payment decision to the provider within 30 calendar days from receipt of the BWC notification.

2.    If the medical treatment request is allowed, the MCO shall:

a.    Approve the medical treatment request; or

b.    Pay/adjust the bill originally denied, which serves as notice to the provider.

 

VII.         Process to change the claim from inactive status to active status or active to inactive in the claim management system

A.    Field staff shall activate a claim in the claims management system when:

1.    The MCO requests, with support, that the claim be made active;

2.    Field staff is processing a Tentative Order granting a 1% or more for percentage of permanent partial disability or increase of permanent partial disability award;

3.    Field staff is paying compensation in a claim;

4.    BWC issues a “Approval of Settlement Agreement” letter; or

5.    Field staff finds that the situation warrants the claim be made active.  For example:

a.    BWC receives a request from the MCO for claim reactivation for an IW with an approved prosthetic for new bolts and screws;

b.    IW has received new bolts and screws for the approved prosthetic every other year for the last 16 years.  The request was later than usual this year as the provider was unavailable and IW could not get in to see the provider until after the claim became inactive.

c.    BWC/MCO shall staff the claim and grant the request without an order to avoid further delay for the necessary bolts and screws.

6.    Field staff shall activate a claim in the claims management system by:

a.    Opening a Claim;

b.    Selecting Status;

c.    Change Status Reason to:  Reactivation Requested;

d.    If approved, Change Status Reason to: Reactivation approved.

e.    Clicking Save.

B.    Field staff may make a claim inactive in the claims management system as follows:

1.    If a claim is activated, field staff may reset the claim to inactive status if the claim was:

a.    Placed in active status inappropriately;

b.    Placed in active status to update data that will not result in a payment.

2.    When payment is made for medical benefits or compensation, the claim cannot be reset to an inactive status unless, after review, field staff determines it was not appropriate to make payment for medical benefits and/or compensation.

a.    For payment of compensation, field staff shall make an adjustment(s) to the Indemnity Benefit plan and the claims management system will adjust the last indemnity paid date in the claim and evaluate for closure.

b.    For payment of medical, field staff shall make the claim inactive as indicated in section VII.B.3. and ensure the medical treatment bill is adjusted and a new medical paid date will be sent and the claims management system will evaluate for closure.

c.    Field staff shall ensure that a note is entered in the claims management system documenting the action completed.

3.    Field staff shall make a claim inactive in the claims management system by:

a.    Opening a Claim;

b.    Ensure all compensation and/or medical recovery steps are complete;

c.    Any open cases are closed;

d.    Selecting Status;

e.    Change Status to “Close Claim”;

f.     Change Status Reason to:  “Inactive Claim”;

g.    Clicking Save.

4.    Field staff shall not set the claims management system to an inactive status when an appropriate medical treatment or indemnity payment is made in the claim.

 

 


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