OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Travel Reimbursement

Policy #:

CP-20-01

Code/Rule Reference:

O.A.C. 4123-3-09; O.A.C 4123-6-40; ORC 4123.52

Effective Date:

11/26/2019

Approved:

Ann M. Shannon, Chief of Claims Policy & Support

Origin:

Claims Policy

History:

Previous versions of this policy are available upon request

 


 

Travel Reimbursement Table of Contents

 

I.                 POLICY PURPOSE

II.                APPLICABILITY

III.               DEFINITIONS

IV.              POLICY

A.          Travel Reimbursement- General Policy Statement

B.          Review

C.          Preauthorization

D.          Reimbursement of Travel Expenses

E.          Obtaining Reimbursement

F.          Pre-Payment and Overpayment of Travel Expenses

V.               PROCEDURE

A.          Standard Claim File Documentation

B.          Claims Services Staff and MCO Responsibilities

C.          Travel Reimbursement Requests for Medical Examinations

D.          Travel Reimbursement Requests Due to Medical Treatment

E.          Travel Reimbursement Requests As Part of Vocational Rehabilitation Services

F.          Pre-Authorization for Travel Expenses

G.         Payment for Transport by Ambulance or Ambulette for Non-Emergency Travel

H.          Travel for the Fifteen Thousand Dollar Medical Only (15K) Program Claims

I.            Calculating and Approving Reimbursement

J.           Denial of Travel Reimbursement

K.          Pre-payment of Travel Expenses

L.           Overpayment of Travel Expenses

M.         Issues Regarding Travel

 


 

I.    POLICY PURPOSE

 

The purpose of this policy and procedure is to ensure consistent and efficient reimbursement to the injured worker (IW) for allowable travel expenses.

 

II.   APPLICABILITY

 

This policy and procedure applies to managed care organization (MCO) staff and BWC staff.

 

III.  DEFINITIONS

 

None

 

IV.  POLICY

 

A.    Travel Reimbursement- General Policy Statement

 

It is the policy of BWC to reimburse an IW for medically necessary, reasonable, and appropriate travel expenses, as detailed in the policy and procedure below.

 

B.    Review

1.    MCO and BWC staff shall review travel expenses prior to reimbursement to ensure medical necessity and appropriateness.

2.    MCO and BWC staff shall discuss travel expense requests, and the MCO shall provide BWC staff with documentation of its efforts to inform and assist the IW regarding travel.

 

C.   Preauthorization

1.    The following types of travel expenses must be pre-authorized by BWC to be reimbursable:

a.    Lodging;

b.    Travel in excess of 400 miles round trip from IW’s residence;

c.     Companion travel; and

d.    Travel by taxicabs, bus, train, non-emergent air transport, or other special transportation.

2.    The MCO may pre-authorize and reimburse medically necessary transportation by ambulance or ambulette.

 

D.   Reimbursement of Travel Expenses

1.    BWC Reimbursement of Travel Expenses

a.    It is the policy of BWC to reimburse an IW for reasonable and necessary travel expenses, upon the filing of a proper request, when the:

i.      IW is required by BWC or the Ohio Industrial Commission (IC) to undergo a medical examination that is more than 45 miles round trip from the IW’s residence;

ii.     MCO has approved medical treatment, including a service contained in an approved vocational rehabilitation plan, that cannot be obtained within 45 miles or less round trip from the IW’s residence; or

iii.    IW’s allowed conditions require the use of taxicab or other special transportation for purposes of obtaining treatment or attending an examination because of an allowed injury or occupational disease, and the taxicab or other special transportation has been pre-authorized (no minimum mileage requirements are necessary in this circumstance).

b.    BWC shall publish reimbursement rates on the Injured Worker Reimbursement Rates for Travel Expenses (C-60A), which also details the criteria for reimbursement of travel expenses.

2.    Employer Reimbursement of Travel Expenses

a.    The employer is responsible for reimbursing the IW for travel expenses when the travel is related to a request for a medical examination by a physician of the employer’s choice.

b.    Reimbursement by the employer of travel expenses under this provision shall not:

i.      Require an order of BWC or the IC, unless there is a dispute; and

ii.     Be subject to the minimum mileage requirement applicable to travel expenses reimbursed by BWC.

3.    Self-Insuring Employer Reimbursement of Travel Expenses

a.    The self-insuring employer is generally responsible for reimbursement of travel expenses if related to a self-insured claim.

b.    BWC is responsible for the reimbursement of travel expenses in a self-insured claim only if the the travel is for an:

i.      Exam to determine percentage permanent partial disability; or

ii.     Appointment related to the provision of a prosthetic device.

4.    IC-Scheduled Examinations- When the IC schedules an examination, the associated travel is reimbursed by:

a.    BWC for state-fund claims; and

b.    The self-insuring employer for self-insured claims.

5.    Travel Reimbursement Requests Due to an Approved Vocational Rehabilitation Plan

a.    When travel expenses are authorized as part of an approved vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan, BWC shall pay travel reimbursement.

b.    Vocational services that may be eligible for travel reimbursement include, but are not limited to:

i.      Training;

ii.     Job simulation;

iii.    Job search outside the IW’s community.

c.     Any travel reimbursement requests related to an approved vocational rehabilitation plan are subject to the requirements of the procedures below.

 

E.    Obtaining Reimbursement

1.    To obtain reimbursement for travel expenses, the IW must complete and submit to the party responsible for payment an Injured Worker Statement for Reimbursement of Travel Expense (C-60), or an equivalent documented travel expense request.

2.    Travel expenses must be submitted within two years of the IW’s date of travel.

 

F.    Pre-Payment and Overpayment of Travel Expenses

1.    BWC may, at its sole discretion, assist an IW by pre-paying allowable lodging and transportation expenses, such as airplane or railroad fares.

2.    BWC shall collect any overpayment of travel expenses to the IW.

 

V.   PROCEDURE

 

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.    Claims Services Staff and MCO Responsibilities

1.    Claims services staff responsibilities include:

a.    Reviewing the C-60 or equivalent to determine if it contains complete and accurate information;

b.    Requesting IW information or supporting documents (e.g., receipts, when applicable) that are missing or require clarification;

c.     Determining if the travel expense request is medically necessary and reasonable under the requirements of these procedures; and

d.    Processing requests for travel expenses within seven calendar days upon receipt of the C-60 or equivalent, or within 14 calendar days if additional information or clarification was requested.

2.    MCO Responsibilities- Education & Notice to the IW

a.    The MCO shall make the following efforts to minimize unnecessary or unreasonable travel expenses:

i.      The MCO shall provide written notice to the IW regarding travel reimbursement.  The written notice shall use the following language: “Travel for medical treatment in excess of 45 miles round trip from your residence may be eligible for expense reimbursement. Any travel expenses related to this treatment request must meet the requirements of Ohio Administrative Code rule 4123-6-40 to be reimbursed, and may require pre-authorization.  For more information, please contact your CSS at {contact info here}.”

ii.     When an IW requests treatment, the MCO shall contact the provider and/or IW to attempt to determine who is providing the service, where treatment will occur, and whether it will require travel in excess of 45 miles round trip from the IW’s residence.

iii.    If the provider or IW informs the MCO that treatment will require travel in excess of 45 miles round trip from the IW’s residence, the MCO shall:

a)   Evaluate BWC’s certified provider list to determine whether there are treatment alternatives that either eliminate or minimize the amount the IW must travel.

b)   If no BWC certified provider is available, evaluate whether there are non-certified providers willing to enroll with BWC that can provide necessary services that either eliminate or minimize the amount the IW must travel.

c)   Provide assistance to the IW in locating treatment options that are closer to home.

iv. If alternate treatment options all require travel in excess of 45 miles round trip from the IW’s residence, the MCO shall work with the IW to minimize the amount of travel, in a manner that is reasonable and necessary.

b.    The MCO shall provide written documentation to the BWC claim file of its effort to educate and inform individual IWs when travel expense requests are made (e.g. entering a claim note).

 

C.   Travel Reimbursement Requests for Medical Examinations

1.    If the IW’s travel is for a BWC-ordered or authorized exam (including ADR) for a state-fund claim, claims services staff shall:

a.    Verify the IW attended the exam;

b.    Verify the required mileage was met;

c.     Review appropriateness of other expense requests (e.g. meals, tolls, parking, etc.); and

d.    Grant the travel reimbursement request if all requirements are met.

2.    If the IW travels for an IC-ordered exam, the IC shall review travel expense requests for appropriateness and upload the C-60 or equivalent to the claim file:

a.    For a self-insured claim, the IC will send the employer a cover letter and the approved C-60 or equivalent for payment.

b.    For a state-fund claim, the IC will send the approved C-60 or equivalent to BWC Benefits Payable for payment.

3.    If BWC receives a C-60 or equivalent for a medical examination scheduled or requested by a state-fund employer, claims services staff shall:

a.    Return the request to the IW; and

b.    Advise the IW that the request must be submitted to the state-fund employer for reimbursement.

4.    If BWC receives a C-60 or equivalent and the IW is employed by a self-insuring employer:

a.    Claims services staff shall:

i.      Return the request to the IW; and

ii.     Advise the IW that the request must be submitted to the self-insuring employer for reimbursement, unless the travel is for:

a)    An exam prior to a determination for percentage permanent partial disability; or

b)    The provision of a prosthetic device pursuant to the Artificial Appliance Requests policy.

b.    If the travel reimbursement request is related to V.C.4.a.ii immediately above, claims services staff shall review the request for appropriateness of payment.

5.    In the event an IW is medically unable to self-transport to a BWC-scheduled exam due to the allowed condition(s) in a claim, the minimum mileage requirement will be waived.

Example: The IW’s allowed conditions are two broken legs. The IW does not have personal access to transportation that accomodates a wheelchair. In this case, BWC would pay for round trip travel to the exam, regardless of the distance.

 

D.   Travel Reimbursement Requests Due to Medical Treatment

1.    When the provider or IW informs the MCO that requested medical treatment would require the IW to travel more than 45 miles roundtrip from the IW’s residence, the MCO:

a.    Shall identify whether there is a closer provider of the service, utilizing the hierarchy of distance (i.e., a provider in the following order of preference: within the local community, regional community, statewide community, or contiguous states where services can be obtained);

b.    May may need to investigate to determine the location of the rendering provider or medical treatment facility in order to determine if the IW will need to travel for medical treatment; and

c.     Shall document all actions taken in claim notes.

2.    If equivalent medical treatment can be obtained closer to the IW’s residence, the MCO shall:

a.    Discuss its recommendations regarding closer treatment options with the treating physician and the IW before authorizing treatment and document this discussion in claim notes; and

b.    Inform the IW that travel expenses will not be reimbursed should the IW choose medical treatment that requires travel. If the treating physician and IW do not agree to move the treatment to a closer facility, the MCO shall also document this information in claim notes.

3.    If the MCO has determined that treatment necessary for the IW’s allowed condition is required and cannot be obtained 45 miles or less round trip from the IW’s residence, the MCO shall notify BWC and BWC shall proceed with its review under V.I of this procedure.

4.    The MCO shall advise the IW to contact BWC for more information regarding requirements and procedures for obtaining reimbursement of travel expenses.

 

E.    Travel Reimbursement Requests As Part of Vocational Rehabilitation Services

1.    The DMC shall review all requests for travel reimbursement when travel is being requested as part of vocational rehabilitation services.

2.    For appeals of travel reimbursement requests associated with vocational rehabilitation, please see the Disputes Regarding Vocational Rehabilitation Decisions policy and procedures.

3.    The DMC shall staff any issues with the BWC Rehab Policy Unit.

 

F.    Pre-Authorization for Travel Expenses

1.    The MCO and claims service staff shall work together to inform and assist the IW when pre-authorization for travel expenses is necessary.

2.    The MCO shall review the medical treatment to determine if closer treatment options are available as outlined in Section V.D. above.

3.    If closer treatment options are not available and requested treatment has been determined to be medically necessary, claims services staff shall contact the IW to:

a.    Provide information regarding pre-authorization requirements; and

b.    Obtain information on which type of travel expenses the IW anticipates incurring and additional details regarding lodging and special transportation (e.g., selected hotel and mode of transportation).

4.    If the pre-authorization request is for travel reimbursement for special transport (e.g. taxicab, bus, train, or air), claims services staff shall:

a.    Discuss with the MCO to determine if there is a medical necessity for special transportation due to the allowed conditions in the claim;

b.    Review to determine whether the type of transportation expenses requested are a reasonable means of transportation for the IW.

5.    If the IW submits a valid request for travel reimbursement for special transport due to medical necessity, there is no minimum mileage requirement.

6.    Upon receipt of the request for pre-authorization of travel expenses, claims services staff shall:

a.    Review MCO notes to verify need for travel;

b.    Confirm that the travel expenses requested are reasonable;

c.     If necessary, contact the IW via phone in an attempt to resolve any questions or problems related to the pre-authorized travel reimbursement request; e-authorized or not;

d.    Prepare written approval or denial of pre-authorization for travel expenses;

e.    Send a letter to the IW notifying the IW of BWC’s decision regarding the pre-authorization of travel expenses; and

f.      Document the decision in a claim note.

 

G.   Payment for Transport by Ambulance or Ambulette for Non-Emergency Travel

1.    If there is a request for medical treatment but no specific request for special transportation (e.g. ambulance or ambulette) exists, the MCO may:

a.    Review to determine whether there is a need for special transportation; and

b.    Pre-authorize special transportation if there is an urgent, time-driven need (e.g., IW needs to be moved by ambulance from a hospital to a step-down facility) without staffing with claims services staff.

2.    When the MCO determines that special transportation (e.g. ambulance or ambulette) is necessary and supported by the medical evidence on file, the MCO shall:

a.    Document its efforts to pre-authorize the travel for special transportation by ambulance or ambulette;

b.    Ensure the transportation provider is eligible to become or is enrolled as a certified provider;

c.     Obtain a C-9 request retrospectively whenever possible, or document rationale as to why a C-9 was not obtained; and

d.    Arrange for payment for special transportation as an MCO medical payment.

 

H.   Travel for the Fifteen Thousand Dollar Medical Only (15K) Program Claims

1.    When claims services staff receives a travel reimbursement request, staff shall verify if the claim is enrolled in the 15K program.

2.    If the claim is enrolled, claims services staff shall follow the procedures for travel reimbursement outlined in the $15,000 Medical-Only Program policy.

 

I.      Calculating and Approving Reimbursement

1.    If travel expenses associated with approved medical treatment in the claim appear necessary, claims services staff shall determine reasonableness of the travel expenses by calculating reimbursement in the following manner:

a.    Reimbursement for travel by a personal vehicle shall be at the rate indicated on the C-60A, per mile, for the date(s) of travel.

i.      The total reimbursement is determined by multiplying the number of miles traveled by the per mile rate.

ii.     Internet resources may be used as a tool to help determine reasonable and necessary mileage.

b.    Reimbursement for the reasonable cost for meals shall be at the rates indicated on the C-60A when the travel:

i.      Includes an overnight stay; or

ii.     Totals more than 12 hours in one day.

c.     Pre-authorized lodging for the IW shall be reimbursed at reasonable actual cost (receipts required), up to the maximum amount indicated on the C-60A, plus applicable taxes.

d.    Travel by taxi, train, airplane, bus or other special transportation shall be reimbursed at actual and necessary cost (receipts required).

e.    Miscellaneous travel expenses, such as tolls and parking, shall be reimbursed at the actual amount (receipts required).

f.      Approved travel expenses related to pre-authorized companions shall be reimbursed at the same rates permitted for the IW, except:

i.      Claims services staff shall not reimburse for lodging for the companion unless special circumstances require the companion to have a separate room; and

ii.     Claims services staff shall only reimburse mileage to the IW.

2.    To process and document the C-60 form, claims services staff shall:

a.    Enter the calculations in the appropriate section of the “Official Use Only” section of the form;

b.    Indicate the appropriate procedure code(s) to be charged;

c.     Check the “Surplus Fund” box if the travel expenses are related to:

i.      A percentage permanent partial exam;

ii.     Services in an approved vocational rehabilitation plan;

iii.    A prosthetic provided to the IW pursuant to the Artificial Appliance Requests policy; or

iv.   A medical exam for a denied statutory occupational disease. (See the Occupational Disease Claims policy for further information).

d.    Sign, date, enter their phone number and “A” number where indicated, image a copy of the C-60 into the claim and, send a copy to the IW with a copy of the C-60A; and

e.    Fax a copy of the completed C-60 or equivalent to BWC Benefits Payable.

i.      Benefits Payable will notify claims services staff if a C-60 or equivalent is not completed properly.

ii.     Claims services staff shall be responsible for correcting and resubmitting the C-60 or equivalent.

3.    If the request for travel reimbursement has not been submitted on a C-60, claims services staff shall process and document the request noting on the request or any attached document:

a.    Calculations of reimbursable travel expenses;

b.    The related procedure codes, as designated on the C-60; and

c.     Whether any charges are to be made to the Surplus Fund.

4.    If any of the IW’s travel reimbursement request appears unreasonable or unnecessary, or is otherwise questionable, claims services staff shall contact the IW in an attempt to resolve.

Example: Mileage submitted by IW is 30 miles more than an online resource indicates the trip would be, using the most direct route. Contact with the IW reveals that there was an accident causing a detour, resulting in the additional miles.

 

J.     Denial of Travel Reimbursement

1.    If, after reviewing the C-60 or other submitted documentation, claims services staff determines that all or some of the submitted travel expenses do not meet the criteria for reimbursement, claims services staff shall publish a miscellaneous order which states:

a.    “After a thorough review of your request for travel reimbursement filed on [date], BWC has determined that [a portion of] your request does not meet the criteria listed below:”

b.    The appropriate travel denial reason; and

c.     Any additional explanation needed to explain the basis for the denial and the following statement: “Therefore, we have denied [a portion of] your request for travel reimbursement.”

2.    If only a portion of a travel reimbursement request is denied, claims services staff shall do the following after all administrative appeals are finalized:

a.    Strike out the denied expenses on the C-60;

b.    Calculate the totals for the allowed expenses and indicate the amount of reimbursement;

c.     Image a copy of the amended C-60 into the claim and send a copy to the IW with a copy of the C-60A; and

d.    Fax the amended C-60 to BWC Benefits Payable.

 

K.    Pre-payment of Travel Expenses

1.    If the IW requests assistance from BWC to prepay lodging and other transportation expenses (e.g., hotel, airfare, bus fare), claims services staff shall submit the request to BWC management (i.e., team leader, supervisor or claims director) for review and approval as soon as possible prior to travel.

a.    The Pre-Pay Travel (PPT) unit shall be available for consultation via the BWC Pre-Pay Travel email box.

b.    Claims services staff shall also advise the IW that approval must be granted before any travel arrangements are made.

2.    Claims services staff and BWC management shall staff the request.

a.    If approved by BWC management, claims services staff, in consultation with the IW, shall complete the Injured Worker Travel Card Authorization Log (A-53), located on COR, and submit it to the PPT unit BWC Pre-Pay Travel email box for final approval or disapproval.

b.    Within two business days of receipt of the A-53, the PPT unit will approve or disapprove the request and notify claims services staff by email.

i.      If approved, the PPT unit will proceed with making travel arrangements.

ii.     If disapproved, the A-53 will be cancelled and returned to claims services staff.

iii.    Claims services staff shall document the approval or disapproval in the claim notes.

3.    To process the approved A-53:

a.    The PPT unit will:

i.      Document the travel arrangements on the A-53 with the confirmed vendor, dates of travel, the total cost of travel and the confirmation numbers;

ii.     Attach any itineraries received from the appropriate vendors and fax this information along with the approved A-53 to claims services staff; and

iii.    Maintain the completed and confirmed copy of the A-53 and fax a copy to BWC Benefits Payable to be processed.

b.    Claims services staff shall:

i.      Image the A-53 and document the travel approval in the claim notes;

ii.     Prepare a letter of confirmation to send to the IW, which includes the arrangements made by the PPT unit, any itineraries, and a C-60 or equivalent for any expenses incurred by the IW that are not prepaid but approved, or otherwise meet the requirements of these procedures;

iii.    Set a work item for the next business day after the expected return date of the IW’s travel;

iv.   Verify the IW traveled and kept the appointment per the arrangements confirmed on the A-53 and document the verification in claim notes; and

v.     Ensure that any travel reimbursement request submitted by the IW does not include the pre-paid travel arrangements.

c.     If claims services staff determines that the prearranged travel was not utilized, claims services staff shall:

i.      Contact the IW to determine if there are justifiable reasons or circumstances that prevented the travel; and

ii.     Document the details of the contact in claim notes.

4.    If, for any reason, the IW cancels the arrangements and does not make alternative arrangements, claims services staff shall notify the PPT unit immediately via the BWC Pre-Pay Travel email box. The PPT unit will contact the vendors and cancel the arrangements to avoid fees or penalties.

a.    Upon receipt of the cancellation notice, the PPT unit shall send a copy of the A-53 with the required cancellation notations, including any fees or penalties to BWC Benefits Payable;

b.    Claims services staff shall document the travel cancellation in the claim notes; and

c.     If new travel arrangements are made, a new A-53 shall be prepared and processed consistent with these procedures.

 

L.    Overpayment of Travel Expenses

1.    If there is an overpayment of travel expenses, claims services staff shall issue an order indicating the overpayment and that the overpayment will be collected at 100% from any future approved travel expense reimbursement to the IW.

2.    The IW may also repay the overpayment amount at any time.

 

M.   Issues Regarding Travel

1.    Claims services staff shall staff any questions and unusual situations regarding travel pre-authorization and reimbursement with a BWC attorney as needed.

2.    The MCO shall staff catastrophic and complex injury travel issues with the BWC catastrophic nurse assigned to the claim.