OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Medicare and Medicaid Requests for Reimbursement & Release of Information

Policy #:


Code/Rule Reference:

R.C.5160.35-5160.43; O.A.C. 5160-1-08; O.A.C. 4123-3-23; and 42 U.S.C.§ 1395y(b)(2)

Effective Date:



Ann M. Shannon, Chief of Claims Policy and Support


Claims Policy


All Injury Management policies, directives and memos regarding Medicare and Medicaid request for reimbursement and release of Information claims that predate the effective date of this policy.


Previous versions of this policy are available upon request



The purpose of this policy is to provide direction on how to respond to inquiries from Medicare, Medicaid and its agents requesting reimbursement or release of information from the Bureau of Workers’ Compensation (BWC) for injured workers (IW) with allowed Ohio workers’ compensation claims.



This policy applies to BWC claims services staff and Managed Care Organization (MCO) staff.




A.     General Claim Note and Documentation Requirements

1.     BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note and documentation requirements; and

2.     Shall follow any other specific instructions for claim notes and documentation included in this procedure.


B.     When claim service specialists (CSS) receive a Medicare request for reimbursement from the Centers for Medicare and Medicaid Services (CMS), a private collection agency on behalf of CMS or from the MCO, the CSS should email the request to the BWC Medicare Medical email box at  BWCMedicareMedical@bwc.state.oh.us. Questions may be directed to BWC Medicare Medical telephone number at (614) 644-7862.


C.    When Medical Billing and Adjustments (MB&A) receives a Medicare request for reimbursement, they will ensure that there is an image of the request in the claim file, research and respond to the request.


D.    When the IW or the IW’s representative requests assistance due to the denial by CMS or Medicare Benefits Coordination & Recovery Center (Medicare BCRC) of a medical service or medical equipment request, the CSS or medical claim specialist (MCS) should:

1.     Send the request for assistance regarding denial of service issues to the BWC Medicare Inquiries email box at INQUIRIES.M.1@bwc.state.oh.us or complete a Medicare Referral Form and send to BWC Medicare Inquiries email box.

a.     Include the following information on the Medicare Referral Form or in the email:

i.       IW’s name;

ii.      Claim number(s);

iii.     IW’s current telephone number;

iv.    Medicare Beneficiary Identifier; and

v.      Verified IW’s home address in PowerSuite.

a)     If the IW’s address is incorrect, the CSS or MCS should provide the correct home address for the IW; or

b)     If the IW’s home address cannot be located, the CSS or MCS should contact the IW to obtain the IW’s correct home address.


E.     When the CSS receives a request for Medicaid reimbursement, the CSS should do the following:

2.     Image the Medicaid Recovery request into the claim file in the document management system and title the request, “Medicaid Recovery Request”;

1.     Send the Medicaid request for reimbursement to the MCO managing the IW’s medical care; and

2.     Document in the claims management system that the Medicaid request for reimbursement was sent to the MCO.