OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Exposure

Policy #:

CP-05-02

Code/Rule Reference:

R.C. 4123.01; R.C. 4123.026

Effective Date:

05/06/19

Approved:

Kevin R. Abrams, Chief Operating Officer

Origin:

Claims Policy

Supersedes:

Policy # CP-05-02, effective 08/07/15

History:

Rev. 05/06/19, 03/22/19; New 08/07/15



 

Exposure Policy and Procedure Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

Emergency Medical Worker

Exposure

Firefighter

Peace Officer

Physical Injury

IV. POLICY

A.          Exposure Claims Without Physical Injury

B.          Exposure Claims With Physical Injury

C.         Contraction of Occupational Disease After Exposure

D.         Firefighters with Cancer and Firefighter Cardiac Claims

V. PROCEDURES

A.          Standard Claim File Documentation

B.          Processing Exposure Claims

C.         Determination of Physical Injury

D.         Exposure Claims With Physical Injury

E.          Exposure Claims Without Physical Injury: Determination of Occupation

F.          Exposure Claims Without Physical Injury Filed by a Firefighter, Peace Officer or Emergency Medical Worker Pursuant to R.C. 4123.026

G.         Exposure Claims Without Physical Injury for All Workers Not Covered Under R.C. 4123.026

H.         No Exposure and No Physical Injury

I.           Contraction of Occupational Disease After Exposure

 

 

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that BWC claims services staff and MCO staff handle claims filed for exposure properly, including claims covered by R.C. 4123.026 (also sometimes referred to as Senate Bill (SB) 223 claims).

 

II. APPLICABILITY

 

This policy applies to BWC claims services 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: When a worker is subjected to a toxic substance or harmful physical agent (e.g., gas, bodily fluid, chemical, poisonous vegetation, etc.) in the course of employment through any route of entry (inhalation, ingestion, skin contact or absorption, etc.).

 

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

 

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).

 

Physical Injury: Any traumatic damage or attack on the physical structure of the body, which results in a wound, tear or abnormal condition.

 

IV. POLICY

 

A.     Exposure Claims Without Physical Injury

1.     It is the policy of BWC that a claim for an exposure without an accompanying injury or occupational disease shall be denied.

2.     In claims without an accompanying physical injury, BWC will not pay or reimburse for post-exposure medical diagnostic services, except as outlined immediately below:

a.     The costs of conducting post-exposure medical diagnostic services and preventative treatment will be reimbursed by BWC or the self-insuring employer when an injured worker (IW) meets all the criteria set forth in R.C. 4123.026:

i.       The IW is a firefighter, peace officer, or emergency medical worker;

ii.      The IW was exposed to the blood or other bodily fluids of another person in the course of and arising out of the IW’s employment, or when responding to an inherently dangerous situation, through any of the following means:

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 on the skin or another opening in the skin, such as an open sore, wound, lesion, abrasion or ulcer; and

iii.     The medical diagnostic services and preventative treatment is consistent with medical, Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) standards for diagnostic and preventive treatment related to the exposure.

b.     The claim meets policy requirements of Claims Handling for Potential Exposure to Opioids, including alleged exposure to opioids.

 

B.     Exposure Claims With Physical Injury

1.     If a claim includes an exposure and a physical injury and all other required factors pursuant to the Initial Claim Determination policy are met, it is the policy of BWC to accept the claim for the specific physical injury, but not for the exposure.

2.     BWC or the self-insuring employer will pay or reimburse for post-exposure medical diagnostic services and/or preventative treatment if:

a.     Such services are causally related to at least one of the allowed physical conditions in the claim and consistent with medical, Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) standards for diagnostic and preventive treatment related to the exposure; or

b.     The IW otherwise meets all the criteria set forth in R.C. 4123.026 and described in IV.A.2(a)(i)-(iii) immediately above.

 

C.    Contraction of Occupational Disease After Exposure

1.     If an IW contracts an occupational disease following an exposure, the IW may make a request for an additional allowance of an occupational disease in the related existing accepted claim; or

2.     If there is not a related existing accepted claim, the IW may file a new claim for an occupational disease.

3.     Additional information may be found in the Occupational Disease Claims policy.

 

D.    Firefighters with Cancer and Firefighter Cardiac Claims

1.     For claims involving firefighters with cancer, refer to the Firefighters with Cancer Occupational Disease Claims policy.

2.     For firefighter cardiac claims, refer to the “Statutory Occupational Disease Claims” section of Occupational Disease Claims policy.

 

V. PROCEDURES

 

A.     Standard Claim File Documentation

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.

 

B.     Processing Exposure Claims

1.     When a claim that alleges an exposure is received, claims services staff shall follow the steps outlined below (and in further detail throughout this procedure).

a.     First, claims services staff shall determine whether the claim includes a physical injury. If the claim:

i.       Includes a physical injury, claims services staff shall continue to process the claim in the same manner as any other claim alleging a work-related injury.

ii.      Does not include a physical injury:

a)     But alleges an exposure to opioids, claims services staff shall follow the guidelines in Claims Handling for Potential Exposure to Opioids.

b)     And does not allege an exposure to opioids, claims services staff shall move on to the next step.

b.     Second, claims services staff shall determine the IW’s occupation. If the IW:

i.       Is not a firefighter, peace officer, or emergency medical worker covered under R.C. 4123.026, post-exposure testing is not covered by BWC. Claims services staff shall deny the claim.

ii.      Is a firefighter, peace officer, or emergency medical worker covered under R.C. 4123.026, claims services staff shall move on to the next step.

c.      Third, claims services staff shall determine what substance the IW alleges having been exposed to. If the IW was exposed to:

i.       Any substance other than blood or another bodily fluid, post-exposure testing is not covered by BWC. Claims services staff shall deny the claim.

ii.      Blood or another bodily fluid, claims services staff shall move on to the next step.

d.     Fourth, claims services staff shall determine the route to the body through which the IW was exposed. If the IW was exposed via:

i.       Any route other than the eye or mouth, or an opening in the skin, post-exposure testing is not covered by BWC. Claims services staff shall deny the claim.

ii.      The eye or mouth, or an opening in the skin, this claim meets all criteria for processing under R.C. 4123.026. Claims services staff shall deny the claim but indicate in the order that post-exposure testing will be covered or reimbursed by BWC.

2.     See the procedure below for detailed directions regarding the processing of exposure claims.

 

C.    Determination of Physical Injury

1.     When a claim that alleges an exposure is received, claims services staff shall first determine if any documentation in the claim also reflects or alleges a physical injury (e.g., needle stick, contact dermatitis, toxic effect of carbon monoxide.

2.     If the First Report of an Injury, Occupational Disease or Death (FROI) or other documentation references only “exposure”, and it is unclear whether the IW also incurred a physical injury (e.g., needle stick, contact dermatitis, toxic effect of carbon monoxide), claims services staff shall conduct additional investigation consistent with the Initial Claim Determination and ICD Modification procedures.

a.     Investigation may include:

i.       Referring to the Compensable Injuries policy and procedure;

ii.      Seeking clarification from treating provider, as necessary;

iii.     Staffing the claim with the supervisor and/or BWC attorney, as necessary; and

iv.    Referring the claim for a medical review, if appropriate.

b.     Example:

i.       A FROI is filed stating the IW was exposed to carbon monoxide.

ii.      The medical documentation reflects that the IW reported headache, dizziness and nausea.

iii.     The doctor’s report states there is exposure to carbon monoxide but does not give a medical diagnosis or condition associated with the exposure.

iv.    Claims services staff conducts further investigation as required by the Initial Claim Determination policy and procedure, sends the claim for medical review, and subsequently receives a medical diagnosis of toxic effect of carbon monoxide (a physical injury).

c.      Example:

i.       A FROI is filed stating the IW was exposed to carbon monoxide.

ii.      The medical documentation reflects that the IW reported having no symptoms as a result of the exposure.

iii.     The doctor’s report states there is exposure to carbon monoxide but does not give a medical diagnosis or condition associated with the exposure.

iv.    Claims services staff conducts further investigation as required by the Initial Claim Determination policy and procedure, sends the claim for medical review, which comes back with no diagnosis.

v.      Claims services staff denies the claim due to no physical injury. Post-exposure testing will not be paid by BWC.

3.     If claims services staff determine that the claim includes a physical injury, claims services staff shall follow the procedures outlined below in section V.D.

4.     If claims services staff determine that the claim does not include a physical injury and is solely for exposure, claims services staff shall then determine the occupation of the IW, following the procedures outlined below in section V.E.

 

D.    Exposure Claims With Physical Injury

1.     If, upon investigation, claims services staff determines that a physical injury occurred and all other factors pursuant to the Initial Claim Determination policy are met, claims services staff shall:

a.     Accept the claim for the physical injury only, using the Initial Allowance Order;

b.     Enter the appropriate ICD code related to the physical injury (not the exposure) pursuant to the Initial Claim Determination and ICD Modification policy and procedure;

c.      Enter a note in the claims management system that indicates that the claim is accepted for the physical injury but not for the exposure; and

d.     Continue to process the claim in the same manner as any other claim alleging a work-related physical injury.

2.     The MCO shall:

a.     Ensure that all post-exposure testing is related to an allowed physical condition(s) in the claim;

b.     Accept the Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) standards for diagnostic and preventive treatment related to exposure to blood or other potentially infectious materials (OPIM); and

c.      Submit bills to BWC’s Medical Billing and Adjustments (MB&A) unit.

3.     Example:

a.     A FROI is filed alleging a work-related exposure to poison ivy.

b.     The medical documentation reflects that the IW has an area of skin with swelling, redness and blisters which are symptoms consistent with poison ivy exposure, but there is no diagnosis of a physical injury included in the claim.

c.      Claims services staff sends the claim for a medical review and subsequently receive a diagnosis of contact dermatitis (a physical injury).

d.     Claims services staff enters the appropriate ICD code for contact dermatitis and processes the claim in the same manner as any other claim alleging a work-related physical injury.

4.     Example:

a.     A FROI is submitted alleging that a corrections officer sustained a laceration on the arm and was smeared with an inmate’s blood.

b.     Upon investigation, claims services staff determines that:

i.       A physical injury occurred; and

ii.      The blood entered the wound on the IW’s arm.

c.      Claims services staff:

i.       Enters the appropriate ICD code for the laceration; and

ii.      Accepts the claim for the laceration only; noting in “add-text” in the Initial Allowance Order that, while BWC does not allow claims for exposure, BWC will pay or reimburse for post-exposure testing related to the laceration.

d.     The MCO receives a request for post-exposure diagnostics and preventative treatment for exposure to blood.

e.     Because the exposure is directly related to the allowed physical injury, the MCO approves the request and submits the bills to BWC for payment.

5.     Example:

a.     A FROI is submitted alleging that a corrections officer sustained a laceration on the arm and was smeared with an inmate’s blood.

b.     Upon investigation, claims services staff determines that:

i.       A physical injury occurred; but

ii.      The blood was smeared on the IW’s neck only.

c.      Claims services staff:

i.       Enters the appropriate ICD code for the laceration; and

ii.      Accepts the claim for the laceration only; noting in “add-text” in the Initial Allowance Order that post-exposure testing will not be paid for because it is not related to the physical injury.

d.     The MCO receives a request for post-exposure diagnostics and preventative treatment for exposure to blood.

e.     Because the exposure is not directly related to the allowed physical injury, the MCO denies the request.

6.     Example:

a.     A FROI is filed alleging that a nurse incurred a needle stick after injecting a patient.

b.     Claims services staff enters the appropriate ICD code for the needle stick; and accepts the claim for the physical injury only;

c.      Post-exposure testing and preventative treatment, consistent with standards of medical care, will be covered for the exposure to blood from the needle stick.

 

E.     Exposure Claims Without Physical Injury: Determination of Occupation

1.     For purposes of exposure claim processing, claims services staff must determine whether the IW’s occupation meets the statutory criteria laid out in R.C. 4123.026.

2.     When BWC receives a claim that indicates the IW may be a firefighter, peace officer or emergency medical worker:

a.     Claims services staff shall verify that the IW is a:

i.       Firefighter of a lawfully constituted fire department;

ii.      Peace officer as defined by R.C. 2935.01, including, but not limited to:

a)     Sheriff;

b)     Deputy sheriff;

c)     Marshal;

d)     Deputy marshal; or

e)     Member of an organized police department; or an

iii.     Emergency medical worker, certified under R.C. Chapter 4765 and listed below:

a)     First responder;

b)     Emergency medical technician-basic;

c)     Emergency medical technician-intermediate; or

d)     Emergency medical technician paramedic.

b.     If it is unclear whether the IW meets the criteria listed above, claims services staff shall:

i.       Contact the parties to the claim (IW, employer, and/or the IW and employer representatives) to request evidence to that the IW’s occupation qualifies under R.C. 4123.026; and/or

ii.      Staff the claim with a supervisor and/or BWC attorney, as necessary.

3.     Example:

a.     A FROI is filed, alleging that a corrections officer was exposed to blood in the eye.

b.     Claims services staff is uncertain whether the IW qualifies as a peace officer, so claims services staff staffs the findings with a supervisor and a BWC attorney.

c.      Following the staffing, there is still uncertainty as to whether the IW qualifies as a peace officer, so claims services staff contacts the employer to request supporting evidence.

d.     The employer provides claims services staff the IW’s position description showing that the IW is officially a sheriff’s deputy.

e.     The claims services staff now has enough information to determine that, while the IW was identified on the FROI as a corrections officer, the IW meets the statutory definition as a peace officer.

4.     Example:

a.     A FROI is filed, alleging that a corrections officer was exposed to blood in the eye.

b.     Claims services staff is uncertain whether the IW qualifies as a peace officer, so claims services staff staffs the findings with a supervisor and a BWC attorney.

c.      Following the staffing, there is still uncertainty as to whether the IW qualifies as a peace officer, so claims services staff contacts the employer to request supporting evidence.

d.     The employer informs claims services staff that the IW is, in fact, a corrections officer with no distinction as a peace officer.

e.     Claims services staff now has enough information to determine that the IW does not meet the statutory qualification as a peace officer, and therefore the claim does not qualify for processing pursuant to R.C. 4123.026.

5.     If, upon investigation, claims services staff determines that the IW’s occupation is covered under R.C. 4123.026, claims services staff shall follow the procedures outlined below in section V.F.

6.     If upon investigation, claims services staff determines that the IW’s occupation is not covered under R.C. 4123.026, claims services staff shall follow the procedures outlined below in section V.G.

 

F.     Exposure Claims Without Physical Injury Filed by a Firefighter, Peace Officer or Emergency Medical Worker Pursuant to R.C. 4123.026

1.     After verification that the IW’s occupation is covered by R.C. 4123.026, claims services staff shall identify the IW’s occupation in the claims management system as one of the following:

a.     Firefighter SB223;

b.     Peace Officer SB223; or

c.      EMT-SB223.

2.     Claims services staff shall then determine if 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.     If claims services staff is unable to determine whether the IW has been exposed to blood or another body fluid via one (or more) of the routes described in section V.F.2(a)-(c) above, claims services staff shall staff the claim with a supervisor, a nurse, and/or a BWC attorney, as necessary.

4.     If claims services staff determines that the IW has been exposed to blood or another bodily fluid via one (or more) of the routes described in section V.F.2(a)-(c) above, and there is no accompanying physical injury:

a.     Claims services staff shall:

i.       Enter ICD-10 code T75.89xA Other specified effects of external causes, initial encounter;

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

iii.     Issue an Initial Denial Order:

a)     Select “SB223 Denial” as the First Denial Reason; and

b)     Under “SB223 Reasons”, select the insert, “SB223 no disease with testing payable”.

iv.    Send notice to the MCO to facilitate payment of the diagnostic and preventive treatment related to the exposure:

a)     In Claim Details>Details>Claim Handling>Is this a denied claim requiring bill payment?, mark “Yes”; and

b)     Select SB 223 from the resulting drop-down box (because the claim met all of the criteria set forth in R.C. 4123.026.

v.      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.

b.     The MCO shall:

i.       Accept the CDC and OSHA standards for diagnostic and preventive treatment related to exposure to blood or OPIM;

ii.      Not require prior authorization for and shall not deny services that are consistent with CDC and OSHA standards. Post-exposure medical diagnostic services that may be appropriate due to exposure to blood or other body fluid include, but are not limited to:

a)     Office visits,

b)     Emergency Department visits;

c)     Treatment, such as cleaning, suturing, and dressing of the area;

d)     Tetanus, HIV or hepatitis testing;

e)     Counseling;

f)       Prophylactic treatment/medication; and

g)     Follow-up testing and treatment.

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.

5.     If claims services staff determine that the IW was exposed to blood or other body fluid, but not through any of the routes described in section V.F.2(a)-(c) above; or was exposed to another potentially harmful substance without an accompanying physical injury, claims services staff shall issue an Initial Denial Order:

i.       Select “SB223 Denial” as the First Denial Reason; and

ii.      Under “SB223 Reasons”, select the insert, “SB223 no contact with body fluid”.

 

G.    Exposure Claims Without Physical Injury for All Workers Not Covered Under R.C. 4123.026

1.     If the IW incurred an exposure with no physical injury, claims services staff shall:

a.     Deny the claim due to no physical injury, using Initial Denial Order;

i.       Select “SB223 Denial” as the First Denial Reason; and

ii.      Under “SB223 Reasons”, select the insert, “Not SB223 Exposed but no disease” (This will provide language on the order indicating that the IW’s employer may be required to pay for diagnostic testing and treatment).

2.     Example:

a.     A FROI is filed by a nurse/IW alleging a work-related exposure to blood (blood smeared on the IW’s hand while treating a patient).

b.     A smear of blood on the hand by itself does not constitute a physical injury and documentation does not indicate that the IW has any physical injury related to the incident causing the blood smear.

c.      Claims services staff denies the claim because there is no physical injury.

 

H.    No Exposure and No Physical Injury

1.     If evidence does not support that the IW suffered an exposure or a physical injury, claims services staff shall deny the claim due to lack of physical injury; and

2.     Send an Initial Denial Order.

 

I.       Contraction of Occupational Disease After Exposure

1.     Claims services staff shall consider an application for the contraction of an occupational disease after exposure consistent with the Occupational Disease Claims policy, either as:

a.     An additional allowance to a related allowed claim; or

b.     A new claim, if the related claim was not allowed (or there was no other related claim).

2.     Examples:

a.     Additional Allowance

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

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

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

iv.    The IW later develops hepatitis B (an occupational disease) related to the exposure.

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

b.     New Claim

i.       The IW files a claim for exposure to blood or other body fluid, but there is no physical injury.

ii.      The claim meets the criteria of R.C. 4123.026.

iii.     The claim is disallowed due to no physical injury, but the IW is reimbursed for diagnostic testing and preventive treatment for the exposure, consistent with standards of medical care.

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

v.      The IW files a new claim for occupational disease, which is processed consistent with the Occupational Disease Claims policy.