OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

PSYCHIATRIC CONDITIONS

Policy #:

CP-16-01

Code/Rule/Case Law Reference:

R.C. 4123.01 and 4123.53

O.A.C.4123-3-08, 4123-3-09, 4123-3-16 and 4123-5-18

Armstrong v. John R. Jurgensen Co., Slip Opinion No. 2013-Ohio-2237

Effective Date:

02/07/2020

Approved:

Ann M. Shannon, Chief of Claims Policy & Support

Origin:

Claims Policy

Supersedes:

Policy # CP-16-01, effective 11/14/16 and Procedure # CP-16-#01.PR1, effective 11/14/16

History:

Previous versions of this policy are available upon request.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

Psychiatric Conditions Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

IV. POLICY

A.          Requirements for Allowance of Psychiatric Conditions in a Claim

B.          Initial Determination Request for a Psychiatric Condition(s)

C.         Additional Allowance Request for a Psychiatric Condition(s)

D.         Approval and Reimbursement for Psychiatric Evaluation and Treatment

E.          Provider Types Allowed to Deliver Psychiatric Services in a Claim

F.          Psychiatric Conditions and Self-Insured Claims

V. PROCEDURES

A.          Standard Claim File Documentation

B.          Requests for Initial Determination and Additional Allowance of Psychiatric Condition(s)

C.         Submission of Medical Documentation to Support a Psychiatric Condition(s)

D.         IME and Physician File Review

E.          Notice of Referral (NOR)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure BWC appropriately allows psychiatric conditions in accordance with the law and rules.

 

II. APPLICABILITY

 

This policy applies to BWC claims services staff.

 

III. DEFINITIONS

 

Forced sexual conduct: Sexual conduct in which the injured worker was forced by threat of physical harm to engage or participate.

 

Injury: For purposes of this policy, includes psychiatric conditions when the injured worker’s psychiatric conditions have arisen from an injury or occupational disease sustained by that injured worker, or where the injured worker’s psychiatric conditions have arisen from forced sexual conduct.

 

Sexual conduct: For purposes of this policy, vaginal intercourse between a male and female; anal intercourse, fellatio, and cunnilingus between persons regardless of gender; and, without privilege to do so, the insertion, however slight, of any part of the body or any instrument, apparatus, or other object into the vaginal or anal cavity of another. Penetration, however slight, is sufficient to complete vaginal or anal intercourse.

 

IV. POLICY

 

A.     Requirements for Allowance of Psychiatric Conditions in a Claim

1.     It is the policy of BWC that a psychiatric condition(s) shall only be considered for allowance in a claim when the claim includes:

a.     A physical injury; or

b.     Forced sexual conduct. A claim arising out of forced sexual conduct is the only instance where the law allows for the initial determination of a claim with psychiatric, emotional or stress conditions absent a physical injury.

2.     Requests for the allowance of a psychiatric condition(s) without an allowed physical injury or forced sexual conduct shall be denied.

3.     Requests for allowance of a psychiatric condition(s) must be accompanied by supporting medical documentation, including a detailed medical report. The medical report must:

a.     Be submitted by a provider listed in Section IV.E.1(a)-(d) of this policy;

b.     Include the following:

i.       The specific psychiatric condition(s) diagnosis with narrative description and the appropriate diagnosis code;

ii.      Causation statement;

iii.     The psychiatric findings;

iv.    Detailed explanation of the causal relationship of the diagnosed psychiatric condition to the work-related injury or occupational disease; and

v.      Information that is clearly reasoned and rationalized.

c.      Verify that the psychiatric condition(s) arose from an injury or occupational disease sustained by the IW or forced sexual conduct; and

d.     Address each psychiatric condition(s) requested.

4.     Requests for an allowance of a psychiatric condition(s) will not be based on a medical report from an Advanced Practice Registered Nurse (APRN) or Advanced Practice Nurse (APN).

 

B.     Initial Determination Request for a Psychiatric Condition(s)

1.     An injured worker (IW) may request an initial determination for a psychiatric condition(s) on a First Report of an Injury, Occupational Disease or Death (FROI-1) concurrent with the request for a physical injury, or as a result of forced sexual conduct.

a.     The IW must sign and date the FROI-1 application requesting a psychiatric condition(s); and

b.     BWC does not require an IW declaration statement for a psychiatric condition(s) filed for an initial determination request.

2.     It is the policy of BWC to treat an initial determination requesting a psychiatric condition(s) as a result of forced sexual conduct the same as any other claim for an initial determination.

 

C.    Additional Allowance Request for a Psychiatric Condition(s)

1.     BWC must receive an additional allowance request for a psychiatric condition(s) on a Motion (C-86).

2.     For each motion submitted, BWC must also receive a signed and dated declaration statement from the IW.

a.     The declaration may either be included on the C-86 or in a separate letter.

b.     If submitted in a separate letter, the declaration should read as mandated by rule, "I am aware that this motion is being filed to request that the bureau or commission recognize my emotional problem, nervous condition, or psychiatric disability as being a result of the injury for which this claim is allowed."

3.     BWC will not process requests for a psychiatric condition(s) recommended by a treating physician on a Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) without the IW’s C-86 and declaration statement.

 

D.    Approval and Reimbursement for Psychiatric Evaluation and Treatment

- BWC may approve and/or reimburse for psychiatric evaluations and/or treatment when an IW’s:

1.     Psychiatric condition is:

a.     Allowed in the claim; or

b.     Allowed in the claim and the IW or provider previously paid for an examination performed to provide evidence to support the Motion (C-86);

2.     Psychiatric independent medical examination (IME) is scheduled by BWC for BWC purposes;

3.     Evaluation is part of an authorized pre-admission evaluation for an approved chronic pain program;

4.     Evaluation and/or treatment is part of an:

a.     Approved vocational rehabilitation treatment plan;

b.     Authorized chronic pain program; or

c.      Authorized detoxification or substance abuse program.

5.     Claim is categorized as catastrophic; if so, the IW is entitled to ten visits without a psychological allowance.

 

E.     Provider Types Allowed to Deliver Psychiatric Services in a Claim

1.     The following provider types may submit a medical report accompanying a request for an allowance of a psychiatric condition(s):

a.     Medical Doctors (M.D.);

b.     Doctors of Osteopathic Medicine (D.O.);

c.      Licensed psychiatric specialists;

d.     Clinical psychologists;

e.     Licensed Professional Clinical Counselors (LPCC); or

f.       Licensed Independent Social Workers (LISW).

2.     The following provider types may request and provide psychiatric treatment to IWs independent of a psychiatrist or psychologist, but may not certify periods of disability or sign any forms used for compensation (e.g., MEDCO-14):

a.     Licensed Independent Social Workers (LISW); and

b.     Licensed Professional Clinical Counselors (LPCC).

3.     The following provider types may request and provide psychiatric treatment to IWs, certify periods of disability based on psychiatric allowance(s), and sign forms used for compensation:

a.     Medical Doctors (M.D.);

b.     Doctors of Osteopathic Medicine (D.O.); and

c.      Psychologists.

 

F.     Psychiatric Conditions and Self-Insured Claims

1.     It is the policy of BWC not to schedule exams for psychiatric condition(s) requested in self-insured claims unless the Industrial Commission (IC) orders such an exam.

2.     If an exam is ordered, the self-insured employer is responsible for the cost of the psychiatric condition(s) independent medical examination scheduled at the request of the IC by BWC.

 

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.     Requests for Initial Determination and Additional Allowance of Psychiatric Condition(s)

1.     BWC shall evaluate initial and additional allowance requests for a psychiatric condition(s) in a claim to ensure the condition(s) arises from:

a.     An injury or occupational disease sustained by the injured worker. The requested psychological condition must be causally related to the compensable physical injury and not the mechanism of injury; or

b.     Forced sexual conduct.

2.     Initial Determination

a.     In order to correctly process an initial determination request for psychiatric condition(s), claims services staff shall follow the:

i.       Initial Claim Determination policy and procedures; and

ii.      Guidelines specified immediately below.

b.     Claims services staff shall process a First Report of an Injury, Occupational Disease or Death (FROI-1) requesting an initial determination of a psychiatric condition(s).

i.       If the FROI-1 is signed and dated by the injured worker, claims services staff shall:

a)     Refer to the ICD Modification policy and procedure for steps to request a modification when adding a psychiatric condition(s) to the claims management system when the initial determination is only for a psychiatric condition(s); and

b)     Once claims services staff completes the investigation and the ICD code is added in the claims management system, claims services staff shall publish the initial determination decision on a BWC order. Refer to the Orders, Waivers, Appeals and Hearings policy and procedures. For an initial determination request, claims services staff shall issue an:

i)       “Initial Allowance Order” or

ii)      “Initial Denial Order.”

ii.      If the FROI-1 is not signed and dated by the IW, claims services staff shall:

a)     Attempt to obtain the IW’s signature on the FROI-1 during the 28-day determination period; and

b)     If, at the end of the 28-day determination period, the signed FROI-1 has not been received and cannot be obtained and:

i)       The only condition requested is psychiatric, claims services staff shall dismiss the claim by Miscellaneous Order.   

ii)      Both physical and psychiatric conditions are being requested, claims services staff shall issue an order allowing the physical condition(s) as appropriate and neither allowing nor disallowing the psychiatric condition(s), specifically noting in the order that the psychiatric condition can be addressed upon receipt of appropriate evidence.

iii)    If neither the physical or psychiatric conditions are appropriate the order shall be dismissed.

c.      Claims services staff shall not require a declaration statement for a psychiatric condition(s) as part of an initial determination request.

3.     Additional Allowance

a.     In order to correctly process an initial determination request for psychiatric condition(s), claims services staff shall follow the:

i.       Additional Allowance policy and procedures; and

ii.      Guidelines specified immediately below.

b.     Claims services staff shall ensure that any request for an additional allowance for a psychiatric condition is:

i.       Submitted on a Motion (C-86) and not on a C-9;

ii.      Accompanied by sufficient medical evidence as outlined in Section V.C of this procedure; and

iii.     Accompanied by a declaration, as outlined in Section IV.C of this policy.

c.      If the documentation and evidence is sufficient to allow the motion in its entirety, claims services staff shall staff the claim with their supervisor and issue the additional allowance decision on a BWC Order.

d.     If the motion is not accompanied by a declaration, claims services staff shall:

i.       Request the declaration statement from the IW.

a)     Claims services staff may make this request verbally or in writing.

b)     If the request is made in writing, claims services staff shall use the “Psychiatric Declaration Statement Letter” located on COR and copy the correspondence to all parties in the claim.

ii.      If the declaration statement is not received within 14 days of BWC’s request, claims services staff shall complete a Notice of Referral (NOR) to the Industrial Commission (IC) and recommend dismissal of the motion, referring to Section V.E of this procedure for the NOR language.

C.    Submission of Medical Documentation to Support a Psychiatric Condition(s)

1.     Claims services staff shall ensure that the IW has submitted medical evidence to support each requested psychiatric condition(s).

2.     Medical evidence must meet the criteria laid out in Section IV.A.3(a)-(d) of this policy. If the medical evidence for a psychiatric condition(s) only partially meets or does not meet the criteria:

a.     Claims services staff shall request additional medical evidence to support the initial determination or additional allowance request. Claims services staff may make this request verbally or in writing. If the request is made in writing, claims services staff shall copy the correspondence to all parties in the claim.

b.     If, after 14 days, additional medical evidence was requested but not received, claims services staff shall continue processing the claim.

i.       If the request is for an initial determination, claims services staff shall determine if a physician file review or IME is necessary.

ii.      If the request is for an additional allowance, claims services staff shall determine whether:

a)     A physician file review or IME is necessary; or

b)     The claim should be referred to the IC with a recommendation for dismissal, referring to Section V.E of this procedure for the NOR language.

c.      Claims services staff shall review claims with a BWC attorney as needed.

 

D.    IME and Physician File Review

1.     Claims services staff shall schedule an IME or PFR if there are outstanding issues, a conflict, or dispute with the evidence regarding the request for a psychiatric condition(s).

2.     Claims services staff may request a psychiatric IME or physician file review to receive a medical opinion on the following:

a.     The presence of a psychiatric condition in a claim as an initial determination or an additional allowance request;

b.     The necessity and appropriateness of psychiatric treatment; and

c.      The extent of a psychiatric disability.

3.     If claims services staff determine that an IME or physician file review is needed:

a.     Claims services staff:

i.       Must consult with an IMS and MSS for a physician file review referral.

ii.      Are not required to consult an MSS to request an IME for an additional allowance for a psychiatric condition(s).

b.     Claims services staff shall:

i.       Inform the Disability Evaluator Panel (DEP) physician to review only the psychiatric condition(s) that is supported by the medical evidence; and

ii.      Utilize the applicable physician file review and IME questions available on Claims On-line Resources (COR).

c.      For claims requiring IMEs, claims services staff shall schedule the examination with a psychiatrist or psychologist from the DEP physician list.

4.     Upon receipt of the medical report, claims services staff shall review and evaluate the report following the:

a.     Independent Medical Exams (IME) and Physician File Reviews (PFR) policy and procedures; and

b.     Guidelines specified immediately below.

5.     Claims services staff shall review the report to determine if:

a.     Special handling considerations are necessary, such as confidentiality of information included in the written report;

b.     A conflict exists in the medical evidence, such as the diagnosis and/or the causal relationship to the allowed condition(s); and

c.      The report recommends the allowance of a psychiatric condition(s) not requested on the motion.

6.     If the condition(s) is not requested, claims services staff shall not address the condition(s) unless the IW or his/her legal representative requests allowance of the psychiatric condition on a motion. For example:

a.     The IW requests allowance of chronic depression in the claim. 

b.     The IME report agrees with allowance of chronic depression but also states that organic psychosis is present. 

c.      Claims services staff shall not address the condition “organic psychosis” since the IW did not request it to be allowed in the claim.

7.     Multi-Claim Psychiatric IME for the Same IW Workflow

a.     Claims services staff shall process a motion for a psychiatric condition(s) allowance for multiple claims for the same IW.

b.     Claims services staff shall complete a note titled “Multiple Psych Exam Scheduled.”

c.      Claims services staff shall prepare a medical packet for each claim involved.

d.     Upon receipt of a Multiple Psych IME Referral, claims services staff shall:

i.       Schedule the exam in the claims management system exam scheduling window while completing the following steps:

a)     Update the claims management system exam scheduler window using the most recent claim;

b)     Stop the standard claims management system “Independent Medical Examination Injured Worker Notice” from being mailed;

c)     Complete the IW notification letter titled “Psych IME IW Notification letter” located on COR;

d)     Send a copy of the letter to all parties in the claim and to the claim via RightFax;

e)     Generate correspondence for the physician notification, including the following statement: “Please see the Motion (C-86) for the requested condition(s) in claims (Example:  00-123456 and 99-789654).  See the attached medical packets for all allowed conditions in these claims.”; and

f)       Mail copies of the IW notification letter and exam packet to the DEP physician as outlined in the exam scheduler-training manual.

e.     The DEP physician shall, as referenced in Document P of the DEP Manual:

i.       Write one IME report addressing each claim separately;

ii.      Send the IME report and service invoice(s) to the claims services staff for review; and

iii.     Determine which claim to assign the code:  W1603, Psych Exam, Single Claim; W1604, Subsequent Claims, same IW, same date of service, each 10-minutes (6 units max per claim).  *Note:  DEP physicians shall bill each subsequent claim on a separate service invoice in 10-minute billing units with W1604.

f.       Claims services staff shall forward the IME report invoice(s) for any claims received to BWC Medical Billing and Adjustments (MB&A) Department via:

i.       Fax 614-621-1398; or

ii.      Scan onto MB&A worklist.

g.     MB&A shall send any questionable IME report invoices to DEP Central Unit to review and authorize payment as needed.

 

E.     Notice of Referral (NOR)

1.     Claims services staff shall complete a NOR to the IC, following the Notice of Referral to the Industrial Commission policy and procedures and notify a BWC attorney when the hearing is scheduled so they can attend and request a referral back if necessary when:

a.     A declaration statement is not received within 14 days of BWC’s request.

b.     The employer disagrees with the IW’s request;

c.      BWC is recommending:

i.       Denial;

ii.      Dismissal; or

iii.     A combination of allowance/denial/dismissal.

2.     No declaration statement submitted: When an additional allowance request does not include a signed and dated declaration statement, and the IW fails to submit the requested declaration statement, include the following language in the NOR:

a.     Reason/Position: BWC recommends the dismissal of the motion as the injured worker (IW) has not met the burden of proof. The IW has not provided a signed and dated declaration statement. BWC requested that the IW submit a signed and dated declaration statement on <<Enter Date>> and it has not been received as of the date of this referral.

b.     Based on: Ohio law requires a signed and dated declaration statement from the IW prior to considering the additional allowance of a psychiatric condition(s).

3.     No declaration statement or medical evidence submitted: When an additional allowance request does not include a signed and dated declaration statement and no medical evidence is attached, and the IW fails to submit the requested declaration and medical evidence, include the following language in the NOR:

a.     Reason/Position: BWC recommends the dismissal of the motion as the injured worker (IW) has not met the burden of proof. The IW has not provided a sign declaration statement and medical evidence to support the requested conditions from a licensed psychiatric specialist, a clinical psychologist, a Licensed Professional Clinical Counselor (LPCC), or a Licensed Independent Social Worker (LISW). BWC requested that the IW sign, date and submit the declaration statement and medical evidence on <<Enter Date>>. The declaration statement and medical evidence have not been received as of the date of this referral.

b.     Based on: Ohio law requires a declaration statement be signed and submitted by the IW and medical evidence to support the requested condition(s) from a licensed psychiatric specialist, a clinical psychologist, a Licensed Professional Clinical Counselor (LPCC), or a Licensed Independent Social Worker (LISW) prior to consideration for the additional allowance of a psychiatric condition(s).

4.     Insufficient or no medical evidence submitted: When an additional allowance request does not include medical evidence, or the attached medical evidence is insufficient (i.e., not from a licensed psychiatric specialist, a clinical psychologist, a Licensed Professional Clinical Counselor (LPCC), or a Licensed Independent Social Worker (LISW), and the IW fails to submit requested additional/sufficient medical evidence, include the following language in the NOR:

a.     Reason/Position: BWC recommends the dismissal of the motion as the injured worker (IW) has not met the burden of proof. The IW has not provided medical evidence from a licensed psychiatric specialist, a clinical psychologist, a Licensed Professional Clinical Counselor (LPCC), or a Licensed Independent Social Worker (LISW) to support the request. BWC requested that the IW submit the required medical evidence on <<Enter Date>> and it has not been received as of the date of this referral.

b.     Based on: Ohio law requires medical evidence to support requested conditions from a licensed psychiatric specialist, a clinical psychologist, a Licensed Professional Clinical Counselor (LPCC), or a Licensed Independent Social Worker (LISW) prior to consideration for the additional allowance of a psychiatric condition(s).

5.     Medical evidence does not support requested conditions: When an additional allowance request includes medical evidence, but it does not support the requested conditions, include the following language in the NOR:

a.     Reason/Position: BWC recommends the dismissal of the motion as the injured worker (IW) has not met the burden of proof. The IW has not provided medical evidence to support the requested conditions from a licensed psychiatric specialist, a clinical psychologist, a Licensed Professional Clinical Counselor (LPCC), or a Licensed Independent Social Worker (LISW) to support the request. BWC requested that the IW submit the required medical evidence on <<Enter Date>> and it has not been received as of the date of this referral.

b.     Based on: Ohio law requires medical evidence to support requested conditions from a licensed psychiatric specialist, a clinical psychologist, a Licensed Professional Clinical Counselor (LPCC), or a Licensed Independent Social Worker (LISW) prior to consideration for the additional allowance of a psychiatric condition(s).