L. Johnson, Chief of Medical Services (Signature on file)
policies, procedures, directives and memos regarding on-site case management claims
that predate the effective date of this policy/procedure.
I. POLICY PURPOSE
purpose of this policy is to ensure that the Bureau of Workers’ Compensation
(BWC) provides direction to the managed care organizations (MCO) for completing
an on-site case management visit(s) and for developing and/or managing an
individualized care plan for the injured worker (IW).
policy applies to BWC catastrophic nurse advocates (CNAs) and MCO staff.
Case Management Plan: Compilation of all information that
the medical case manager has gathered from the IW, the physician and the
employer as well as any other pertinent sources that impact the progress and
successful outcome of the claim resolution; action- oriented, time-bound and specific
to the intervention(s) and resources to be used to assist the injured worker in
achieving the specified goals specified within each phase of the plan; ensures
that accountabilities are established so that all participants are aware of
respective responsibilities in meeting the goals.
Catastrophic Claim: A claim in which there is a serious injury or occupational
disease resulting in limited mobility and/or cognition related to the allowed
conditions in the claim that severely limits the ability of the IW to perform
activities of daily living and has a high probability of resulting in permanent
Case Management: Collaboration to assess, plan, implement, coordinate,
monitor and evaluate options and services to meet an IW’s health needs using
communication and available resources to promote quality cost-effective
outcomes; within the Ohio workers’ compensation program, includes identifying
and minimizing potential barriers to recovery, identifying and assessing future
treatment needs, evaluating appropriateness and necessity of medical services,
authorizing reimbursement for medical services, resolving medical disputes and
facilitating successful return to work or claim resolution for injured workers;
can be telephonic and/or on-site depending on the need of the IW.
claim that does not involve a catastrophic injury or occupational disease, but requires
an on-site visit to remove barriers that undermine a case manager’s effective
management of the claim.
Case Management: Oversight of a claim that requires a case manager to travel
to various settings (e.g., hospital, home, rehabilitation center) when assessing,
planning, implementing, coordinating, monitoring and evaluating the options and
services required to meet the IW’s health and human service needs;
characterized by face-to-face advocacy, communication and resource management that
promotes quality and cost-effective interventions and outcomes.
Visit: A one-time case management activity with a specific
purpose or objective.
is the policy of BWC that on-site case management visit(s) may be conducted for
catastrophic and non-catastrophic injuries for injured workers who reside in
Ohio. Examples of claim issues or conditions that may require an on-site case
management visit(s) include, but are not limited to, the following:
catastrophic injuries or occupational diseases:
injuries, moderate to severe;
major extremity amputations, multiple complex fractures, crush injuries, loss
of use of one or more limbs;
cord injuries such as paraplegia, quadriplegia, hemiplegia or diplegia;
occupational blindness (blindness that occurs as a result of work or
burns, such as second or third degree burns on more than 25 percent of the
hospitalization in excess of four weeks, i.e., ventilators, ICU, psychiatric
occupational diseases (not end stage); bloodborne pathogens; and toxic exposure
with long term complications; and
other medical diagnosis identified by the MCO and CNA.
non-catastrophic injuries or occupational diseases where the case manager has
clearly documented the barriers in the claim:
to obtain medical records precipitating the need for on-site record review
unsuccessful telephonic case management;
transfer of an injured worker from the hospital to another facility for
rehabilitation or other care;
extended hospital stay, recurrent admissions and failed or repeated surgeries;
with physician and/or rehabilitation appointments;
of an acceptable support system for the IW;
return to work;
by an employer, physician, injured worker, and/or the injured worker’s family
and/or representative request on-site case management;
recommendation for an on-site case management visit; and/or
and /or the MCO’s medical director determine that on-site case management would
remove barriers that may impede the injured worker’s return to work.
is the policy of BWC that on-site case management visit(s) shall be executed as
minimum of one, unless waived by BWC’s CNA; and
than one visit at the discretion of the MCO.
minimum number of visit(s) required; and
or more visit(s) as determined by the MCO.
is the policy of BWC that on-site visit(s) shall be integrated into an individualized
case management plan for cases that are in active case management in accordance
with chapter three of the MPRG. The case management plan shall clearly outline
how such visit(s) can support or address care of the IW.
is the policy of BWC that cases not in active case management but requiring the
case manager to execute a task-based visit shall be documented in the claims management
notes or integrated into a case management plan.
is the policy of BWC that only one task-based on-site visit shall be permitted on
claims that are not in active case management and it shall be documented in claims
management notes. If more than one on-site visit is necessary to address the
IW’s care or to remove barriers, a case management plan shall be developed or
reactivated to reflect the current condition of the IW.
MCO shall ensure that on-site case management visit(s) are executed for
catastrophic and non-catastrophic claims, as appropriate.
case manager develops an individualized case management plan for catastrophic
any planned on-site case management visit(s), clearly outlining how such
visit(s) will support or address care of the IW; and
and evaluates options and services needed to meet the IW’s needs.
case manager shall develop the case management plan and share it with
appropriate individuals, as needed, when on-site case management is deemed
MCO shall ensure that a summary of the on-site case management visit(s) is
documented in the claims management system using a standard note title “MCO
On-site Case Management Visit.”
on-site case management note shall include, but is not limited to, the
date of visit;
name of participants and their roles;
clinical justification or purpose for visit;
summary of the visit including accomplishments and objectives met during visit;
follow-up steps from visit.
MCO shall send a request for waiver of an on-site case management visit to the
BWC CNA mailbox at email@example.com
the subject line “Request for a Waiver.” The email shall include the following
of the injured worker;
of injury; and
BWC CNA shall ensure that any case management visit(s) that he or she waives is
documented in notes.
CNA may waive on-site case management visit(s) for catastrophic claims when:
CNA makes a clinical determination that an on-site case management visit is not
claim is managed by Paradigm.
waiving an on-site case management visit, the CNA shall:
a careful assessment of the catastrophic claim to determine if it is
appropriate to waive the on-site case management visit; and
the rationale in notes.