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OhioBWC - Basics: (Policy library) - File

Policy Name:

Exposure to Blood or Other Potentially Infectious Materials

Policy #:

CP-05-02

Code/Rule Reference:

R.C. 4123.01; R.C. 4123.026

Effective Date:

08/07/15

Approved:

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

Origin:

Claims Policy

Supersedes:

All Injury Management policies, directives and memos regarding claims for exposure to a potentially infectious disease that predate the effective date of this policy.

History:

New

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that field staff and MCO staff handle claims filed for exposure to blood or other potentially infectious materials properly, including claims covered by R.C. 4123.026 (also referred to as Senate Bill (SB) 223 claims).

 

II. APPLICABILITY

 

This policy applies to field staff and MCO staff.

 

III. DEFINITIONS

 

Emergency Medical Worker: As defined by R.C. 4123.026, a first responder, emergency medical technician-basic, emergency medical technician-intermediate, or emergency medical technician-paramedic, certified under R.C. Chapter 4765, whether paid or volunteer.

 

Exposure: The condition of being subjected to a potentially infectious agent, which may have a harmful effect.

Airborne exposure: Transmission of potentially infectious agents through the air, typically by sneezing, coughing, raising dust, spraying of liquids or similar activities likely to generate aerosol particles or droplets.

Blood borne exposure: When potentially infectious blood or another body fluid that may contain blood, comes in contact with the eye, mouth, other mucous membrane, non-intact skin or through parenteral contact (injected, infused, or implanted). Note: The exposure required by R.C. 4123.026/SB 223 falls within this definition.

 

Firefighter: As defined by R.C. 4123.026, a firefighter, whether paid or volunteer, of a lawfully constituted fire department.

 

Other potentially infectious materials (OPIM): A term used by the Occupational  Safety and Health Administration (OSHA) which refers to human body fluids other than blood, but which may contain blood, such as saliva or semen.

 

Peace Officer: As defined by R.C. 2935.01, an individual legally vested with law enforcement rights who generally works for a city, county or state public employer and can be either “traditional” (e.g., police officer) or “non-traditional” (e.g., certain park rangers, tax agents or liquor agents).

 

IV. POLICY

 

A.    It is the policy of BWC that a claim for an exposure without an accompanying physical injury will be disallowed. See section IV.D below for provisions made for claims filed pursuant to R.C. 4123.026/SB 223.

 

B.    If a claim for exposure includes evidence of a physical injury, the claim shall be allowed for the physical injury if all other required factors relating to jurisdiction and initial allowance are met.

1.    In an allowed claim, BWC will pay for the costs of conducting post-exposure medical diagnostic services to investigate whether the injured worker (IW) contracted an occupational disease from the exposure.

2.    BWC will also pay for the costs of related preventive treatment in accordance with Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control and Prevention (CDC) exposure treatment protocols.

 

C.   If an IW contracts a disease after being exposed, the IW may:

1.    Make a request for an additional allowance of an occupational disease in the related existing allowed claim; or

2.    If there is not a related existing allowed claim, file a new claim for an occupational disease.

 

D.   Exposure by a Firefighter, Peace Officer or Emergency Medical Worker Under R.C. 4123.026/SB 223

1.    It is the policy of BWC that BWC or the self-insuring public employer will pay the costs of conducting post-exposure medical diagnostic services, consistent with the standards of medical care existing at the time of the exposure, when the following criteria are met:

a.    The IW is a:

i.      Firefighter of a lawfully constituted fire department;

ii.     Peace officer; or

iii.    Emergency medical worker; and

b.    The IW has come into contact with the blood or other body fluid of another person, in the course of and arising out of the IW’s employment or when responding to an inherently dangerous situation,  through:

i.      A splash or spatter in the eye or mouth, including when received in the course of conducting mouth-to-mouth resuscitation;

ii.     A puncture in the skin; or

iii.    A cut in the skin or another opening in the skin, such as an open sore, wound, lesion, abrasion or ulcer.

2.    Airborne exposure is not included under R.C. 4123.026/SB 223; the exposure must be of the nature described in IV.D.1.b.

3.    An accompanying physical injury is not required for coverage of post-exposure medical diagnostic services and preventive treatment under R.C. 4123.026/SB 223.

 

BWC staff may refer to the corresponding procedure for this policy entitled “Exposure to Blood or Other Potentially Infectious Materials” for further guidance.

 

 

 

Procedure Name:

Procedure for Exposure to Blood or Other Potentially Infectious Materials

Procedure #:

CP-05-02.PR.1

Policy # Reference:

CP-05-02

Effective Date:

11/14/16

Approved:

Rick Percy, Chief of Operational Policy, Analytics & Compliance (Signature on File)

Supersedes:

Procedure CP-05-02.PR.1, effective 08/07/15.

History:

New 08/07/15

 

 

I.      BWC staff shall refer to the Standard Claim File Documentation policy and procedure for claim-note requirements and shall follow any other documentation-specific instructions included in this procedure.

 

II.    Unless otherwise noted, the procedures listed below apply to all claims of exposure, including those that meet the criteria of R.C. 4123.026/Senate Bill (SB) 223.

 

III.   Investigating the Claim

A.    When the managed care organization (MCO) receives a claim that includes an exposure which may meet the criteria of R.C. 4123.026/SB 223, the MCO shall:

1.    Indicate “Alleged exposure to blood or body fluid” in the “Description of Accident” section on the First Report of Injury, Occupational Disease or Death (FROI); and

2.    File the FROI with BWC in the usual manner.

B.    When a claim is received by BWC alleging an exposure, field staff shall  determine if the injured worker (IW):

1.    Was exposed through:

a.    An airborne exposure (e.g., being in a room where an infectious person sneezes or coughs); or

b.    A bloodborne exposure (e.g., blood splashed on an open cut, spit in the eye). Field staff shall recognize that physical contact with blood or another body fluid does not automatically equate to a blood borne exposure; and

2.    Suffered a physical injury in addition to the alleged exposure (e.g., a needle stick from a bloody needle may be an exposure to blood or other potentially infectious materials (OPIM) and the punctured skin from the needle stick would be a physical injury).

C.   When there is any question regarding whether the incident is an exposure-only claim or whether there is a physical injury, field staff shall:

1.    Refer to the Compensability policy; and

2.    Staff the claim with the supervisor, medical service specialist and/or BWC attorney, as necessary.

D.   Field staff shall also determine if the claim meets the criteria of R.C. 4123.026/SB 223. The criteria are:

1.    The IW is a:

a.    Firefighter of a lawfully constituted fire department;

b.    Peace officer, such as a:

i.      Sheriff;

ii.     Deputy sheriff;

iii.    Marshal;

iv.   Deputy marshal;

v.    Member of an organized police department; or

vi.   Non-traditional peace officer such as some park rangers, tax and liquor agents, officers of metropolitan housing authorities, and transit authorities; or an

vii.  Emergency medical worker; and

2.    The IW has come into contact with the blood or other body fluid of another person in the course of and arising out of the IW’s employment, or when responding to an inherently dangerous situation through:

a.    A splash or spatter in the eye or mouth, including when received in the course of conducting mouth-to mouth resuscitation;

b.    A puncture in the skin; or

c.    A cut in the skin or another opening in the skin, such as an open sore, wound, lesion, abrasion, or ulcer.

3.    Field staff shall staff with the BWC attorney if it is unclear if the IW meets the criteria of R.C. 4123.026/SB 223.

 

IV.  Processing the Claim

A.    Exposure to a contaminant: If field staff determines the IW was not exposed to blood or OPIM but was exposed to another contaminant (e.g., chemicals), field staff shall determine if there was a physical injury and process the claim consistent with the Initial Claim Determination policy and/or any other applicable policy.

B.    No exposure/no physical injury: When field staff determines the IW was not exposed to blood or OPIM and the claim does not include a physical injury, field staff shall:

1.    Disallow the claim due to no physical injury or disease; and

2.    If the claim meets the criteria of R.C. 4123.026/SB 223, include in the order the “Exposure” insert “SB223 Exposure Claims (no contact w/blood or body fluid)”.

3.    See “Exposure-Denial order inserts (including SB223)” under “Correspondence” on COR.

C.   Exposure without a physical injury

1.    When field staff determines the IW has been exposed to blood or OPIM, but there is no accompanying physical injury, field staff shall:

a.    Enter ICD-10 code T75.89xA;

b.    Ensure the narrative description of the code is modified to reflect an exposure to blood or other body fluid. (See the ICD Modification policy for further information); and

c.    Disallow the claim due to no physical injury.

2.    If the claim does not meet the criteria of R.C. 4123.026/SB 223, field staff shall issue the appropriate denial order using the applicable “Exposure” insert.

a.    The order shall include language advising the IW that the employer may be required to pay for the cost of testing and/or preventive treatment.

b.    See “Exposure-Denial order Inserts (including SB223)” under “Correspondence” on COR.

3.    If the claim does meet the criteria of SB 223:

a.    Field staff shall:

i.      Update information in the claims handling statement to reflect “falls under 223”;

ii.     Enter a note in the claims management system that indicates the following: SB223 applies-claim is disallowed due to no physical injury but the worker did have a qualifying blood or body fluid exposure; HPP notified and packet sent to IW.

iii.    Prepare and print locally the appropriate denial order using the applicable “Exposure” insert. (See “Exposure-Denial Order inserts (including SB223)” under “Correspondence” on COR). The order shall include language advising the IW that BWC will reimburse the IW the cost of:

a)    Conducting post-exposure medical diagnostic service to investigate whether the IW contracted an occupational disease from the exposure, consistent with the standards of medical care existing at the time of the exposure; and

b)    Any related preventive treatment in accordance with OSHA’s exposure treatment protocol.

iv.   Send the IW a packet that includes:

a)    An “SB223-Exposure-No injury with contact” letter;

b)    The denial order; and

c)    An SB 223 Fact Sheet.

b.    The MCO shall:

i.      Accept the Centers for Disease Control and Prevention (CDC) and OSHA standards for diagnostic and preventive treatment related to exposure to blood or OPIM;

ii.     Not require prior authorization and shall not deny services that are consistent with OSHA and CDC standards;

iii.    Price bills submitted for these services at $0.00; and

iv.   Submit the bill to BWC’s Medical Billing and Adjustments (MB&A) unit.

c.    Services that may be required due to exposure to blood or OPIM include:

i.      Office visits;

ii.     Emergency Department visits;

iii.    Treatment, such as cleaning, suturing, and dressing of the area;

iv.   Tetanus, HIV or hepatitis testing;

v.    Counseling;

vi.   Prophylactic treatment/medication; and

vii.  Follow-up testing and treatment.

D.   Exposure With a Physical Injury

1.    When field staff determines the IW was exposed to blood or OPIM and also suffered a physical injury, field staff shall:

a.    Allow the claim for the physical injury, if all other required factors relating to jurisdiction and initial allowance are met;

b.    Enter the ICD code applicable to the physical injury;

i.      No code shall be entered for the exposure to blood or OPIM.

ii.     An ICD code is only entered for exposure to blood or OPIM when there is no physical injury and the claim is being disallowed.

iii.    Exposure to blood or OPIM is never an allowed condition.

c.    If the claim meets the criteria of R.C. 4123.026/SB 223:

i.      Enter a note in the claims management system that indicates the following: SB223 applies-claim is allowed for the physical injury but not for the exposure. Letter and fact sheet sent to the IW; and

ii.     Send the IW a packet that includes:

a)    “SB223 – Exposure – Injury with contact” letter (available on COR);

b)    BWC initial allowance order; and

c)    “Exposure to Blood and Other Bodily Fluids under SB223 – BWC Fact Sheet” (available on COR).

2.    The MCO shall:

a.    Accept the CDC and OSHA standards for diagnostic and preventive treatment related to exposure; and

b.    Not require prior authorization and shall not deny services that are consistent with OSHA and CDC standards.

 

V.    Contraction of Occupational Disease after Exposure

A.    Field staff shall consider an application for the contraction of an occupational disease after exposure either as:

1.    An additional allowance to an allowed existing related claim; or

2.    A new claim, if there is not an allowed existing related claim.

B.    Examples:

1.    Additional Allowance

a.    The IW files a claim for exposure to blood and a needle stick.

b.    The claim is allowed due to the physical injury of the needle stick.

c.    Medical treatment is approved for the needle stick and for diagnostic testing and preventive treatment for the exposure.

d.    The IW later contracts an occupational disease related to the exposure.

e.    The IW files for an additional allowance in the existing allowed claim for the occupational disease contracted from the exposure.

2.    New Claim

a.    The IW files a claim for exposure to blood or OPIM, but there is no physical injury.

b.    The claim is disallowed for the exposure, and the IW does not qualify under R.C. 4123.026/SB 223.

c.    The IW later is found to have contracted an occupational disease related to the exposure.

d.    The IW files a new claim for occupational disease.

 


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