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Policy and Procedure Name:
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Catastrophic Claims and Extremely Severe Injuries
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Policy #:
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CP-03-14
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Code/Rule Reference:
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R.C.
4123.511; R.C.
4121.121(B)(3)
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Effective Date:
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10/13/23
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Approved:
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Shawn Crosby, Chief Operations Officer
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-03-14, effective 04/01/21
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History:
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Previous versions of this policy are available upon
request
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Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Catastrophic (CAT) Claim
Extremely Severe Injury Claim
IV. POLICY
A. Claim Review and
Referral
B. Claim
C. MCO Role in CAT Claims
and Collaboration with BWC
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. Claim Review and
Referral
C. CAT Claim Determination
Process
D. CAT and Extremely Severe
Injury Claim Handling by Special Claims II Team
The purpose of this policy is to ensure that BWC claims
services staff identify and manage catastrophic claims appropriately during
initial claim determination.
This policy applies to BWC claims services staff.
Catastrophic
(CAT) 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 injured worker
(IW) to perform activities of daily living and has a high probability of
resulting in permanent disability.
Extremely Severe
Injury Claim: A claim in which there is an injury that, while not
deemed to meet the definition of a CAT claim, is significant enough that it may
include multiple significant conditions, involvement of multiple body parts, high
risk of complications, or extended projected length of disability, and thus
requires special handling.
1. It is
BWC’s policy that CAT claims may include, but are not limited to:
a. Brain
injuries, moderate to severe;
b. Amputations,
fractures, or crush injuries of a major extremity, or loss of use of one or
more limbs;
c. Spinal
cord injuries such as paraplegia, quadriplegia, hemiplegia or diplegia;
d. Total occupational
blindness;
e. Severe
burns, including second-or third-degree burns on more than 25 percent of the
body;
f. Actual
and anticipated hospitalization in excess of four weeks, (i.e., ventilators, intensive
care unit, psychiatric hospitalization);
g. Severe
occupational diseases and bloodborne pathogens (not end stage);
h. Toxic
exposure with long term complications; and
i. Any
other medical diagnoses identified by the managed care organization (MCO) and CAT
nurse.
2. It is the policy
of BWC that claims services staff refer claims with the indicators outlined above
to the CAT nurse for determination of catastrophic claim status.
Assignment
1. It is the
policy of BWC that CAT claims and claims involving extremely severe injuries
are handled by a specialized team called Special Claims II.
2. A CAT
nurse decides whether a claim meets the appropriate criteria to be deemed a CAT
claim.
3. Claims not
deemed CAT will be reviewed by a supervisor to decide whether they meet the
criteria of an extremely severe injury to be handled by the Special Claims II team.
1. The MCO,
not the CAT nurse, is responsible for providing case management for all CAT
claims including, but not limited to, on-site visits.
2. The BWC
CAT nurse provides oversight and assists the MCO with issues that may arise
during the case management process.
3. For
additional details on MCO management of CAT claims, please refer to the Catastrophic
Claims portion of the MCO Policy Reference Guide.
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.
1. Claims
services staff will monitor their assigned claims for indicators or changes in
the IW’s condition that would suggest that the claim is or may become catastrophic.
If there is insufficient medical evidence on file to make this determination,
claims services staff must work with the MCO to ensure that it has been
requested.
a. If claims
services staff is unsure whether a claim should be referred to the CAT nurse
for CAT claim determination, they will staff the claim with a supervisor.
b. Claims
services staff will refer a claim meeting the criteria listed in this policy to
the CAT nurse within three business days of receipt of the claim.
2. Upon
referral to a CAT nurse, claims services staff will:
a. Enter a
note in the claim indicating the reasoning for the need for the referral being
made to the CAT nurse.
b. Create a
work item in the claim.
i. From
the task template drop down select “Review for Possible Catastrophic Claim;”
ii. Select
the Assign to team radio button;
iii. From the
Team drop down select ‘Nurse – Catastrophic;’
iv. Enter the name
of the MCO in the Description box; and
v. Click
the finish button.
3. When a new
claim is referred to the CAT nurse for review, a referral should not
also be made to a medical services specialist (MSS).
1. Upon
receipt of a claim referred for CAT claim determination, the CAT nurse will use
the medical evidence on file to assist with making a determination within two
business days, whenever possible.
2. If the CAT
nurse receives a claim referral without medical or other relevant evidence, the
CAT nurse will review claim notes to ensure that the evidence has been
requested.
a. If evidence
has been requested, the CAT nurse will use their discretion to determine the
CAT status or to leave the referral open and wait until the evidence is
received to make a determination.
b. If the
CSS is unsuccessful at obtaining missing documentation, the CAT nurse will
contact the MCO to obtain the evidence.
3. If the CAT
nurse determines that the claim is catastrophic:
a. The CAT
nurse will:
i. Review
and determine the appropriate allowances and obtain a physician review, if
indicated;
ii. Enter
a claim note documenting the decision, using the appropriate note template.
iii. Place the
ICD-10 code recommendations into the claims management system and request
modifications, if necessary;
iv. Update the
claims management system to designate the claim as a CAT claim (for information
on this process, refer to the CoreSuite – Catastrophic Advocate Nurse (CAT)
Group manual); and
v. Notify
the claims services specialist (CSS), injury management supervisor (IMS) of the
Special Claims II team, and MCO that:
a) The claim
will be handled as a CAT claim (including the information contained in the
claim note template referenced in Section V.C.3.a.ii above); and
b) ICD
modification is complete, if applicable.
b. The IMS of
the Special Claims II team will reassign the claim to a CSS on Special Claims
II.
4. If the CAT
nurse determines that the claim is NOT catastrophic:
a. The CAT
nurse will:
i. Enter
a claim note documenting the decision, using the appropriate note template;
ii. Send
an email to the referring CSS, IMS of the Special Claims II team, and the MCO
informing them of the decision; and
iii. Ensure
that the Catastrophic Injury box is unchecked in the claims management system.
b. The IMS of
the Special Claims II team will review the claim to determine whether the claim
will be considered an extremely severe injury.
i. If
so, the claim will be reassigned to the Special Claims II Team for handling.
ii. If
not, the claim will remain with the referring CSS.
D.
CAT and Extremely Severe Injury Claim Handling by Special Claims II Team
1. Claims
managed by the Special Claims II team will be staffed by a multidisciplinary
team (including BWC Legal and Policy) as needed.
2. In
general, these claims will remain with the Special Claims II team for the life
of the claim. Claims will be reassigned to another team in cases:
a. Of
statutory occupational disease;
b. Where the
IW is found permanently and totally disabled; and
c. When
the IW dies and BWC receives an application for death benefits.
3. The CSS
will establish communication with the IW. If the CSS is unable to speak to the
IW because the IW is unreachable due to hospitalization or incapacitation, the
CSS will attempt to contact the following individuals to obtain necessary
information:
a. The IW’s
attorney of record, if applicable;
b. The IW’s
guardian or health care power of attorney, if applicable;
c. The
IW’s family member(s) or other individuals that have knowledge of the IW; or
d. The IW’s
employer of record.