and Medicaid Requests for Reimbursement and Release of Information
O.A.C. 5160-1-08; O.A.C. 4123-3-23; and 42 U.S.C.§ 1395y(b)(2)
Abrams, Chief Operating Officer
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.
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
the staff of BWC and the MCOs.
A. When the claim service
specialist (CSS) receives 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.
B. 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.
C. 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)
1. Send the request for
assistance regarding denial of service issues to the BWC Medicare Inquires
email box at INQUIRES.M.firstname.lastname@example.org or complete a Medicare
Referral Form and send to BWC Medicare Inquires email box.
2. Include the following
information on the Medicare Referral Form or in the email:
a. IW’s name;
b. Claim number(s);
current telephone number; and
d. Verified IW’s home
address in PowerSuite.
IW’s address is incorrect, the CSS or MCS should provide the correct home
address for the IW; or
ii. 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.
D. When the CSS receives a
request for Medicaid reimbursement, the CSS should do the following:
1. Image the Medicaid
Recovery request into the claim file in the document management system and
title the request, “Medicaid Recovery Request”;
2. Send the Medicaid
request for reimbursement to the MCO managing the IW’s medical care; and
3. Document in the claims
management system that the Medicaid request for reimbursement was sent
to the MCO.