OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Psychiatric Conditions

Policy #:

CP-16-01

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

None

Effective Date:

12/10/2021

Approved:

Ann M. Shannon, Chief of Claims Policy & Support

Origin:

Claims Policy

Supersedes:

Policy # CP-16-01, effective 02/07/2020

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

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that 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 (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.

 

IV. POLICY

 

A.      Requirements for Allowance of Psychiatric Conditions in a Claim

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).

 

B.      Initial Determination Requests for Psychiatric Conditions

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.

 

C.      Additional Allowance Requests for Psychiatric Conditions

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.

 

D.     Approval of and Reimbursement for Psychiatric Evaluation and Treatment

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.

 

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 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.

 

F.      Psychiatric Conditions and Self-Insured (SI) Claims

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.

 

V. PROCEDURE

 

A.      General Claim Note and Documentation Requirements

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.

 

B.      Requests for Initial Determination and Additional Allowance of Psychiatric Conditions

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.

 

C.      Submission of Medical Documentation to Support Psychiatric Conditions

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.

 

D.     IME and PFR

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.

 

E.      NOR

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.