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OhioBWC - Basics: (Policy library) - File

Drug Related Issues Policy

Policy Name:

DRUG RELATED ISSUES

Policy #:

CP-04-02

Code/Rule Reference:

R.C. 4123.66

O.A.C. 4123-6-21, 4123-6-21.3, and 4123-6-26.

Effective Date:

10/21/15

Approved:

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

Origin:

Claims Policy

Supersedes:

Drug Related Issues number CP-04-02 dated 05/18/12.

History:

New 05/18/12; Rev. 10/21/15

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure BWC field operations staff appropriately updates an injured worker’s address in the claims management system and processes independent medical examinations in a claim to assist the multifaceted Pharmacy Benefits program.

 

II. APPLICABILITY

 

This policy applies to BWC’s Field Operations staff.

 

III. DEFINITIONS

 

Drug Utilization Review (DUR): a medical management strategy performed by the MCO and BWC to review prescription medications in a claim and to evaluate the medical necessity and appropriateness of the prescription medication treatment.  DURs may identify inappropriate utilization (over-utilization or under utilization) of services.

 

Pharmacy Benefits Manager (PBM):  The PBM is a single-source for accepting and adjudicating prescription drug information and is separate from the Managed Care Organizations (MCOs).  The PBM processes outpatient medication bills for State-Fund, Self-Insured Bankrupt, Black Lung, and Marine Industry Fund claims.  This program does not apply to claims managed by self-insured employers.

 

Pharmacy Benefits Program:  BWC’s Pharmacy benefits program streamlines the billing process for pharmacy providers and meets BWC’s mission of providing a quality, customer-focused program for Ohio’s employers and injured workers.

 

IV. POLICY

 

A.    It is the policy of BWC that drug related issues are to be handled through the Pharmacy Department, Pharmacy Benefits Manager (PBM) and Managed Care Organizations, except in the following situations when BWC field staff shall:

1.    Address updates made in the claims management system as a result of a PBM Address verification request.

2.    Schedule independent medical examinations as requested by the Pharmacy Department or Managed Care Organization.

 

B.    It is the policy of BWC that prescription medication issue(s) shall not be referred to the Industrial Commission unless a party to the claim files an appeal to a BWC Order.

 

C.   It is the policy of BWC that when prescription medication(s) is denied as a result of an inactive claim, that the request is handled in accordance with the Claim Reactivation policy.

 

 

BWC staff may refer to the corresponding procedure for this policy entitled “Procedure for Drug Related Issues” for further guidance.

 

 

 

Procedure Name:

Procedure for Drug Related Issues

Procedure #:

CP-04-02.PR1

Policy # Reference:

CP-04-02

Effective Date:

11/14/16

Approved:

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

Supersedes:

10/21/15; Procedure for Drug Related Issues number CP-04-02.PR1, effective 05/18/2012.

History:

New 05/18/12; Rev. 10/21/15; 11/14/16

 

 

I.      BWC 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.

 

II.    General pharmacy information

 

A.    Field staff shall send all questions about drug related issues issues solely through the “BWC Pharmacy Benefits” (pharmacy.benefits@bwc.state.oh.us) mailbox.  Field staff shall not use any other email mailbox for questions.

 

B.    All claims management system updates regarding drug related issues including drug authorizations and denials shall be updated by the pharmacy department.

 

C.   Field staff may identify a claim that needs a drug utilization review (DUR) based on factors considered red flags.  The Managed Care Organization (MCO) will investigate the claim to determine if a DUR is or is not warranted in the claim.  When field staff identify a potential DUR, field staff shall send:

1.    A request for a DUR in an email to the MCO; and

2.    The reason for the DUR referral.

 

D.   Durable Medical Equipment (DME) and disposable medical supplies obtained at a pharmacy are handled through the MCO and in some cases BWC field staff, not the pharmacy benefit manager (PBM).

 

E.    Field staff shall refer to the Claim Reactivation policy and procedure when an outpatient drug(s) is denied as a result of a claim being inactive.

 

F.    BWC field staff may reference the MCO Policy Reference Guide and/or the Provider Billing and Reimbursement Manual for additional information regarding Pharmacy Department, Pharmacy Benefits Manager (PBM) and MCO responsibilities.

 

III.   When a reimbursement check or correspondence addressed to the injured worker (IW) is returned to the pharmacy benefits manager (PBM)

 

A.    If the returned envelope contains a forwarding address, the PBM shall notify BWC of the new address by faxing the Pharmacy Benefits Manager (PBM) Address Verification Request (AVR) form (PBM AVR-1) to BWC at fax number 866-336-8352 not more than five (5) business days from receipt of reimbursement check or correspondence.

 

B.    If the returned envelope does not contain a forwarding address, the PBM shall check for an updated address for the IW in the PBM system and:

1.    If an updated address exists, shall resend the reimbursement check or correspondence to the IW not more than three (3) business days from receipt of reimbursement check or correspondence.

2.    If an updated address does not exist, shall fax the PBM AVR-1 form to BWC at fax number 866-336-8352 not more than five (5) business days from receipt of reimbursement check or correspondence.

 

C.   PBM shall not more than 60 days from date of issuance, check the PBM system to see if an updated IW address was received prior to cancelling the check.  (Stale date = 90 days from date of issuance).  If an updated address exists, see section IV. B. 1.

 

IV.  BWC receives PBM AVR-1 form

 

A.    The PBM AVR-1 form shall be indexed in the claim as document type “PBM AVR – Address Verification Request Form.”

 

B.    The PBM AVR-1 form shall be reviewed and require one of two actions:

1.    If the PBM provides an updated address on the PBM AVR-1 form, then the field staff shall:

a.    Verify the address is current.  If address is not current, see section IV. B. 2. a-b.

b.    Update the IW’s current address and enter a note in the claims management system.

c.    Respond to the PBM AVR-1 form by sending a cover sheet with no attachment using RightFax to the PBM at the fax number listed on the form and to BWC Imaging.  The fax cover sheet shall contain:

i.      Injured worker’s name;

ii.     Claim number;

iii.    BWC field staff response (example below); and

“The correct address for this injured worker has been verified and updated in our claims management system.  Thank you, Diane”

iv.   In RightFax under more options tab, complete the “From” section.  (Note: Once you have entered your information in the “From” section it will save the data and self populate so the user will not have to enter it each time.)

2.    If the PBM did not provide an updated address on the PBM AVR-1 form or the address provided by the PBM is not current; the field staff shall review and investigate the PBM AVR-1 form not more than five (5) business days from receipt.

a.    Review existing documents in imaging and claim notes contained in the claims management system; if an updated address is located, the field staff shall follow the steps in IV. B. 1. a-c.

b.    If an updated address is not located, the field staff shall:

i.      Attempt to contact IW by phone (if IW number is invalid or there is no number for IW, contact the IW representative, employer, employer representative, MCO, and/or provider).

ii.     If a corrected address is located, the field staff shall follow the steps in section IV. B. 1. a-c.

iii.    If a corrected address is not obtained and a message is left with the IW, employer, their representative (if applicable), the MCO, and/or provider, the field staff shall set a three (3) business day task to follow-up.

a)    If no response after three (3) business days, the field staff shall make a second attempt to obtain the updated IW address.  The second attempt shall be different than the initial attempt (different contact person, different time of day, etc.).

b)    If a corrected address is obtained, the field staff shall follow steps in section IV. B. 1. a-c.

iv.   Enter note in the claims management system with action taken.

v.    After two unsuccessful attempts to obtain IW’s current address, the field staff shall:

a)    Enter PBM AVR note in the claims management system; and

b)    Respond to the PBM AVR-1 form by sending a cover sheet with no attachment using RightFax to the PBM at the fax number listed on the form and to BWC Imaging.  The fax cover sheet shall contain:

i)      Injured worker’s name;

ii)     Claim number;

iii)    BWC field staff response (see example below); and

Example:

I have made two unsuccessful attempts to obtain a current address for this injured worker.  Thank you, Diane

iv)   In RightFax under more options tab, complete the “From” section.  (Note: Once you have entered your information in the “From” section it will save the data and self populate so the user will not have to enter it each time.)

 

V.    Request for independent medical examination (IME) and Inpatient detoxification (detox) program

 

A.    Field staff will receive a request for an IME on drug related issues in the following manner:

1.    An email from the MCO; or

2.    A referral task from the Pharmacy Department.

 

B.    When field staff receive a request via an email from the MCO or a task from the Pharmacy Department for an IME on drug related issues including the specific IME questions to be addressed, field staff shall:

1.    Create an Exam Scheduling case in the claims management system; and

a.    Standard IME exam;

b.    Use Miscellaneous;

c.    Exam Scheduling case.

2.    Schedule the IME based on the request and include the specific questions to the DEP Physician.

3.    Notify the MCO/pharmacy department in the appropriate manner when IME exam is complete and report is received.

4.    Close the Exam Scheduling case in the claims management system.

 

C.   Inpatient detoxification program indicated in IME report

1.    Field staff shall notify the prescribing physician that it is his/her responsibility to coordinate the authorization of the inpatient detox program with the MCO.

2.    Field staff shall notify, communicate and work with the MCO to facilitate the outcome with the prescribing physician.

 

VI.  Requests for Drug Dependency as a condition in the claim

 

A.    When in receipt of a request for an additional allowance of drug dependency as a condition the claim, field staff shall:

1.    Contact and ask IW to dismiss the Motion (C-86); and

2.    Contact and ask the MCO and/or IW to speak to the doctor about filing a Completing the Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) for detoxification (in dependency cases) and/or counseling (only warranted in addiction cases).

 

B.    Field staff shall process a request for drug dependency in the same manner as a psychiatric condition request when the contact with the IW results in a refusal to dismiss the C-86.  Refer to the Psychiatric Conditions policy and procedure.

 

C.   When the additional allowance of drug dependency as a condition in the claim is requested on a C-9, field staff shall follow the instruction provided in the Additional Allowance policy and procedure.

 

VII. Phone inquiries for drug related issues

 

A.    Phone inquiries: Field staff shall send an email to the “BWC Pharmacy Benefits” mailbox for all phone inquiries regarding outpatient drug benefits or other drug related issues not more than forty-eight (48) hours from receipt of the call.  Field staff shall include in the email:

1.    Name of injured worker,

2.    Claim number,

3.    Name of person calling,

4.    Description of the issue, and

5.    Phone number to return call.

 

B.    The pharmacy department shall handle all phone inquiries and enter notes in the claims management system not more than forty-eight (48) hours from receipt of the field staff email.

 

VIII.        Motions (C-86) and written requests for drug related issues

 

A.    C-86 Motions and written requests:  Field staff shall enter a note in the claims management system and  send an task to the “BWC Pharmacy Benefits” mailbox notifying them of all C-86 Motions and written requests for drug related issues not more than five (5) business days from the imaged date of the document in the claim.  Field staff shall include in the task:

1.    Name of injured worker;

2.    Claim number;

3.    Issue to be addressed:

a.    C-86 Motion or written request, and

b.    Date of image.

 

B.    Field staff shall update the C-86 motion status in the claims management system as follows:

1.    Create a Legal Case Management case;

2.    Set a 30-day task to follow-up on the outcome of the C-86 Motion;

3.    Close the Legal Case Management case once the decision is final on the C-86 Motion.

 

C.   The pharmacy department shall:

1.    Address C-86 Motions which shall result in one of the following:

a.    Dismissal, or

b.    Suspension, or

c.    BWC Order to allow and/or deny.

2.    C-86 Motions for drug related issues shall be suspended when another request is filed and in process that will have a significant and demonstrable bearing on the drug related issue thereby making the information necessary in order to properly administer the requested action.  (e.g., Additional Allowance request)

3.    Enter a note in the claims management system with the action taken and outcome as a result of a C-86 Motion or written request.

 

IX.  Industrial Commission (IC) hearing orders on drugs related issues

 

A.    Field staff shall set a Pharmacy Tech task not more than three (3) business days from receipt of the imaged date of all IC hearing orders regarding drug related issues.  Field staff shall include in the task:

1.    Issue to be addressed;

2.    Date of imaged document; and

3.    Type of hearing order (District Hearing Officer (DHO) or Staff Hearing Officer (SHO)).

 

B.    The pharmacy department shall create (if case does not exist) or update the Medical Management case in the claims management system and enter a new row for each drug or authorization on all IC hearing order decisions concerning drugs on DHO hearing orders after the appeal period has expired (if no appeal has been filed), and upon receipt of an IC SHO order.

 

C.   The pharmacy department shall contact the appropriate BWC field attorney for appeals or staffing as the situation warrants by creating a Case Event task – Notice to BWC Legal in the claims management system.

 


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