and Procedure Name:
to Dentures, Eyeglasses and Hearing Aids
4123.66; O.A.C. 4123-6-31
R. Abrams, Chief Operating Officer
to Dentures, Eyeglasses and Hearing Aids policy and procedure dated 11/08/13.
The purpose of this
policy is to ensure that a request for payment for the repair or replacement of
dentures, eyeglasses and/or hearing aids damaged in the course of an allowed
industrial injury is appropriate.
This policy applies to
BWC claims services and Managed Care Organization (MCO) staff.
Dentures: Artificial replacement
of a tooth or teeth.
Eyeglasses: For the purpose of
this policy, refers to any removable prescriptive corrective lenses (i.e.,
glasses and contacts).
Hearing Aid: A removable electronic
device used to amplify sound that is worn in or behind the ear of a person with
a hearing impairment.
A. General Policy
Statements for both repair or replacement
1. It is the policy of BWC
to ensure that the repair or replacement of dentures, eyeglasses and hearing
aids damaged in the course of an injury or industrial accident resulting in an
allowed claim is covered regardless of:
a. The allowed
condition(s) in the claim; and
b. Whether or not the
items were in use at the time of the injury. For example, an injured worker
(IW) has a hearing aid in a pocket and not his/her ear at the time of the
injury, but the device is damaged in the course of the industrial accident.
2. BWC pays for repair or
replacement of an item one time for each industrial accident resulting in injury.
B. Repair- The MCO shall
approve only a repair when:
1. The dentures, eyeglasses
or hearing aid is repairable; and
2. The cost of the repair
would be less than the replacement cost.
1. BWC shall only pay for
replacement dentures, eyeglasses or hearing aids when the IW submits documentation
from the original supplier or a servicing provider (e.g., a bill or an itemized
statement of the original item).
2. The MCO shall only approve
a deluxe feature (e.g., anti-reflective or scratch-resistant coating for
glasses, bluetooth-capable hearing aids) on a replacement of dentures, eyeglasses
or hearing aids when the IW submits documentation from the service provider
attesting that a deluxe feature was on the damaged item.
3. The MCO shall only
approve a replacement of dentures, eyeglasses and hearing aids based on the BWC
4. It is the
responsibility of the IW to pay for any exams necessary to obtain replacement
dentures, eyeglasses and hearing aids.
D. BWC shall not pay for any
other personal use items damaged in an industrial accident (e.g., shoes,
jewelry, clothes, wheelchairs).
E. Requests to reimburse
an IW directly for services the IW paid out-of-pocket must be submitted within
the later of:
1. One year of the date of
2. One year after the
a. The Staff Hearing
Officer order; or
b. The final
administrative or judicial order allowing payment.
A. The MCO shall process requests
submitted via the Physician's Request for Medical Service or Recommendation
for Additional Conditions for Industrial Injury or Occupational Disease
(C-9) in accordance with the C-9 procedures.
B. Claims services staff
shall refer all requests for repair or replacement submitted via a Motion
(C-86) to the MCO on an “MCO Referral” letter, in accordance with the Motions
policy and procedure.
C. When the MCO receives a
reimbursement request for repair or replacement of dentures, eyeglasses or
hearing aid that the IW, employer or other third party has already paid, the
MCO shall request:
1. A receipt; and
2. Proof of payment.
D. The MCO shall review
the documentation provided to determine if it is payable.
1. If it is determined
that the service is payable, the MCO shall:
a. Submit to BWC a Service
Invoice (C-19) with the explanation of benefits code 771 referenced; and
b. Reimburse the IW,
employer or other third party.
2. If it is determined the
service is not payable, the MCO shall notify the party requesting