Policy and Procedure Name:
|
Psychiatric Conditions
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Policy #:
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CP-16-01
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Code/Rule 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
|
Industrial Commission (IC) Resolution/Memo
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None
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Effective Date:
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12/10/2021
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Approved:
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Ann M. Shannon, Chief of Claims Policy & Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-16-01, effective 02/07/2020
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History:
|
Previous versions of this policy are available upon
request
|
Table of
Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Forced Sexual Conduct
Injury
Sexual Conduct
IV. POLICY
A. Requirements for
Allowance of Psychiatric Conditions in a Claim
B. Initial Determination
Requests for Psychiatric Conditions
C. Additional Allowance
Requests for Psychiatric Conditions
D. Approval of and
Reimbursement for Psychiatric Evaluation and Treatment
E. Provider Types Allowed
to Deliver Psychiatric Services in a Claim
F. Psychiatric Conditions
and Self-Insured (SI) Claims
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. Requests for Initial
Determination and Additional Allowance of Psychiatric Conditions
C. Submission of Medical
Documentation to Support Psychiatric Conditions
D. IME and PFR
E. NOR
The purpose of this policy is to ensure that BWC
appropriately allows psychiatric conditions in accordance with the law and
rules.
This policy applies to BWC Claims Services staff.
Forced Sexual Conduct:
Sexual conduct in which the injured worker (IW) was forced by threat of
physical harm to engage or participate.
Injury:
For purposes of this policy, includes psychiatric conditions when the IW’s psychiatric
conditions have arisen from an injury or occupational disease sustained by that
IW, or where the IW’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.
1. It
is the policy of BWC that psychiatric conditions will 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 psychiatric conditions without an allowed physical injury
or forced sexual conduct will be denied.
3. Requests
for allowance of psychiatric conditions 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)-(e) of this policy;
b. Include
the following:
i.
The diagnosis of the specific psychiatric condition 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 conditions
to the work-related injury or occupational disease; and
v. Information
that is clearly reasoned and rationalized.
c. Verify
that the psychiatric conditions arose from an injury or occupational disease
sustained by the IW or forced sexual conduct; and
d. Address
each psychiatric condition requested.
4. Requests
for an allowance of psychiatric conditions will not be based on a medical
report from an Advanced Practice Registered Nurse (APRN) or Advanced Practice
Nurse (APN).
1. An
IW may request an initial determination for a psychiatric condition on a First
Report of an Injury, Occupational Disease or Death (FROI-1):
a. Concurrent
with the request for a physical injury; or
b. As a
result of forced sexual conduct.
2. The
IW must sign and date the FROI-1 application requesting a psychiatric condition.
3. BWC
does not require an IW declaration statement for psychiatric conditions filed
for an initial determination request.
4. BWC
will treat an initial determination requesting psychiatric conditions as a
result of forced sexual conduct the same as any other claim for an initial
determination.
1. BWC
must receive an additional allowance request for psychiatric conditions 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 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.
1. BWC
may approve and/or reimburse for psychiatric evaluations and/or treatment when
an IW’s:
a. Psychiatric
condition is:
i.
Allowed in the claim; or
ii. Allowed
in the claim and the IW or provider previously paid for an examination
performed to provide evidence to support the C-86;
b. Psychiatric
independent medical examination (IME) is scheduled by BWC for BWC purposes;
c. Evaluation
is part of an authorized pre-admission evaluation for an approved chronic pain
program; or
d. Evaluation
and/or treatment is part of an:
i.
Approved vocational rehabilitation treatment plan;
ii. Authorized
chronic pain program; or
iii. Authorized
detoxification or substance abuse program.
2. BWC
may also approve and/or reimburse for psychiatric evaluations and/or treatment
when an IW’s claim is categorized as catastrophic. If so, the IW is entitled to
10 visits without a psychological allowance.
1. The
following provider types may submit a medical report accompanying a request for
an allowance of psychiatric conditions:
a.
Medical Doctors (MD);
b. Doctors
of Osteopathic Medicine (DO);
c. Clinical
psychologists;
d. Licensed
Professional Clinical Counselors (LPCC); or
e. 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 allowances, and sign forms
used for compensation:
a. MDs;
b. DOs;
and
c. Psychologists.
1. It
is the policy of BWC not to schedule exams for psychiatric conditions requested
in SI claims unless the Ohio Industrial Commission (IC) orders such an exam.
2. If
an exam is ordered, the SI employer is responsible for the cost of the
psychiatric condition IME scheduled at the request of the IC by BWC.
1. BWC
staff will refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Must
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. BWC
must evaluate initial and additional allowance requests for a psychiatric
condition in a claim to ensure the condition arises from:
a. An
injury or occupational disease sustained by the IW. The requested psychological
condition must be causally related to the allowed physical condition 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 a
psychiatric condition, claims services staff must follow the:
i.
Initial
Claim Determination policy and procedures; and
ii. Guidelines
specified immediately below.
b. Claims
services staff will process a FROI-1 requesting an initial determination of a
psychiatric condition.
i.
If the FROI-1 is signed and dated by the IW, claims services staff must:
a) Refer
to the ICD
Modification policy and procedure for steps to request a modification
when adding psychiatric conditions to the claims management system when the
initial determination is only for psychiatric conditions; and
b) Once
claims services staff completes the investigation and the ICD code is added in
the claims management system, claims services staff must 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 must 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 will:
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 must
dismiss the claim by Miscellaneous Order.
ii) Both
physical and psychiatric conditions are being requested, claims services staff
will issue an order:
a. Allowing
the physical conditions as appropriate; and
b. Neither
allowing nor disallowing the psychiatric conditions, specifically noting in the
order that the psychiatric conditions can be addressed upon receipt of
appropriate evidence.
iii) Neither the
physical nor psychiatric conditions are appropriate, claims services staff will
dismiss the claim.
c. Claims
services staff will not require a declaration statement for a psychiatric
conditions as part of an initial determination request.
3. Additional
Allowance
a. In
order to correctly process an additional allowance request for psychiatric
conditions, claims services staff must follow the:
i.
Additional
Allowance policy and procedures; and
ii. Guidelines
specified immediately below.
b. Claims
services staff will ensure that any request for an additional allowance for a
psychiatric conditions is:
i.
Submitted on a 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 must 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 statement, claims services staff
must:
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 will use the “Psychiatric
Declaration Statement Letter” located on COR and copy the correspondence to all
parties in the claim.
e. If
the declaration statement is not received within 14 days of BWC’s request,
claims services staff must complete a Notice of Referral (NOR) to the IC and
recommend dismissal of the motion, referring to Section V.E of this procedure
for the NOR language.
1.
Claims services staff will ensure that the IW has submitted medical
evidence to support each requested psychiatric condition.
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 only partially
meets or does not meet the criteria:
a. Claims
services staff must request additional medical evidence to support the initial
determination or additional allowance request.
i.
Claims services staff may make this request verbally or in writing.
ii. If
the request is made in writing, claims services staff will 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 will continue processing the claim.
i.
If the request is for an initial determination, claims services staff
must determine if a physician file review (PFR) or IME is necessary.
ii. If
the request is for an additional allowance, claims services staff must
determine whether:
a) A
PFR 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 must review claims with a BWC attorney as needed.
1. Claims
services staff will schedule an IME or PFR if there are outstanding issues, a
conflict, or dispute with the evidence regarding the request for a psychiatric
condition.
2. Claims
services staff may request a psychiatric IME or PFR 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 PFR is needed:
a. Claims
services staff:
i.
Must consult with an IMS and MSS for a PFR referral.
ii. Are
not required to consult an MSS to request an IME for an additional allowance
for a psychiatric condition.
b. Claims
services staff will:
i.
Inform the Disability Evaluator Panel (DEP) to review only the
psychiatric conditions that are supported by the medical evidence; and
ii. Utilize
the applicable PFR and IME questions.
c. For
claims requiring IMEs, claims services staff will schedule the examination with
a psychiatrist or psychologist from the DEP physician list.
4. Upon
receipt of the medical report, claims services staff must 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 will 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 conditions; and
The report
recommends the allowance of psychiatric conditions not requested on the
motion.
6. If
the condition is not requested, claims services staff must not address the
condition unless the IW or their 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 will 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 must process a motion for psychiatric conditions allowance for
multiple claims for the same IW.
b. Claims
services staff will complete a note titled “Multiple Psych Exam Scheduled.”
c. Claims
services staff will prepare a medical packet for each claim involved.
d. Upon
receipt of a Multiple Psych IME Referral, claims services staff must:
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 will, 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 invoices to 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 (six units
max per claim). *Note: DEP physicians will bill each subsequent claim on a
separate service invoice in 10-minute billing units with W1604.
f.
Claims services staff will forward the IME report invoices 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
will send any questionable IME report invoices to DEP Central Unit to review
and authorize payment as needed.
1. Claims
services staff will 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 that the motion be dismissed because there is no signed and
dated declaration statement from the injured worker (IW). A signed and dated
declaration statement was requested from the IW on <<Enter date>>,
but has not been received.
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.
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 that the motion be dismissed as the injured worker (IW) has not
met the burden of proof. A signed declaration statement and medical evidence
supporting the requested condition(s) were requested on <<Enter
date>>, but have not been received.
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
medical doctor (MD), a doctor of osteopathic medicine (DO), 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.
4. No
medical evidence submitted: When an additional allowance request does not
include medical evidence, and the IW fails to submit requested additional
medical evidence, include the following language in the NOR:
a. Reason/Position:
BWC recommends that the motion be dismissed as the injured worker (IW) has not
met the burden of proof. No supporting medical evidence has been submitted. It
was requested on <<Enter date>>, but has not been received.
b. Based
on: Ohio law requires medical evidence to support a requested condition
from a medical doctor (MD), a doctor of osteopathic medicine (DO), 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.
5. Medical
evidence submitted from an incorrect provider type: When an additional
allowance request does not include medical evidence from a correct provider
type (including MD, DO, clinical psychologists, LPCC, or LISW), and the IW
fails to submit supporting evidence from a correct provider type, include the
following language in the NOR:
a. Reason/Position:
BWC recommends that the motion be dismissed as the injured worker (IW) has not
met the burden of proof. The supporting medical evidence submitted is from an
incorrect provider type. Evidence from a correct provider type was
requested on <<Enter date>>, but has not been received.
b. Based
on: Ohio law requires medical evidence to support the requested
condition(s) from a medical doctor (MD), a doctor of osteopathic medicine (DO),
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.
6. 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 that the motion be denied as the injured worker (IW) has not met
the burden of proof. The IW has not provided supporting medical evidence for
the requested condition(s). It was requested on <<Enter date>>, but
has not been received.
b. Based
on: Ohio law requires medical evidence to support a requested condition
from a medical doctor (MD), a doctor of osteopathic medicine (DO), 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.