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Policy and Procedure Name:
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CLAIM REACTIVATION
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Policy #:
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CP-03-13
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Code/Rule Reference:
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O.A.C. 4123-3-15; OAC 4123-3-23(D)
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Effective Date:
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05/20/21
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Approved:
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Ann Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-03-13, effective 02/13/17 and Procedure # CP-03-13.PR1,
effective 05/06/2019
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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
IV. POLICY
A. General Information
B. Request for Action in
an Inactive Claim
C. Independent Medical
Examinations (IME) and Physician File Reviews (PFR)
D. Systematically Updating
Claim to Inactive
V. PROCEDURE
A. Standard Claim File
Documentation
B. How the Claims
Management System Establishes Active or Inactive Claims
C. Action Requests in an
Inactive Claim
D. Processing Timeframe
for Requests
E. MCO Process for Medical
Treatment Requests in an Inactive Claim
F. BWC Process in Receipt
of Claim Reactivation and Medical Treatment Request
G. IME and PFR
H. Issuing Decision on
Claim Reactivation and Medical Treatment
I. Changing Claim From
Inactive to Active or Active to Inactive
The purpose of this policy is to
ensure that when BWC receives a request for compensation or medical benefits in
a state-fund claim that has had no activity or request for further action for
more than a 24 month period, BWC appropriately reactivates the claim if the
request is causally related to the allowed condition(s) in the claim and
payment is appropriate.
This policy applies to claims
services staff and managed care organization (MCO) staff.
Active claim: A claim that has had payment of
compensation, a paid date of service or a reactivation within a 24-month
period.
Inactive claim: A claim that has had no payment of
compensation, no paid date of service and no reactivation for more than a
24-month period.
Last Indemnity Paid Date: The most recent date a
compensation payment was made in a claim and the date BWC will use for the
active/inactive calculation if the last paid bill service date is prior to this
date.
Last Paid Bill Service Date:
The most recent date of service for which BWC paid medical benefits in a claim,
and the date BWC will use for the active/inactive calculation if the last
indemnity paid date is prior to this date.
Medical benefits: For purposes of this policy,
including but not limited to office visits, emergency room visits, surgeries, diagnostics
(e.g., x-rays, MRI or CT scan), prosthetics, durable medical equipment,
vocational rehabilitation and prescription medication.
Reactivation: The process used to update a claim from
inactive to active status.
Retro C-9: A medical treatment request for
reimbursement of service(s) that the provider has already provided to the
injured worker.
1. It is BWC’s
policy to pay compensation or medical benefits in a state-fund claim that has
had no activity or request for further action in it for more than a 24-month
period when it receives a request for compensation or medical benefits that is
causally related to the allowed condition(s) in the claim and payment is
appropriate.
2. It is the policy
of BWC that when a request for medical treatment/medical bill payment is not received
within one year and seven days from the date of first denial of the medical
bill payment, the request will be denied, except when it is the result of an
error by the BWC or the MCO.
3. A party to the
claim may appeal a claim reactivation and medical treatment decision to the
Ohio Industrial Commission (IC).
1. It is the policy
of BWC that any request for action in an inactive claim requires authorization
from the MCO, not BWC, when medical treatment is for a:
a. Date of
service(s) prior to the inactive date; or
b. Prosthetic,
orthotic, vision, hearing or dental device, medical supplies or durable medical
equipment (DME).
2. The MCO shall
refer a medical treatment request in an inactive claim to BWC for action when
the medical:
a. Treatment
request is accompanied by supporting medical evidence dated not more than 60
days prior to the date of the request; or
b. Evidence is
subsequently provided to the MCO upon request.
3. The MCO may
dismiss without prejudice and without a referral to BWC, a request for medical
treatment in an inactive claim when they do not receive supporting medical
evidence dated not more than 60 days prior to the date of the request.
4. Responsibilities
a. The
MCOs’ role is to review all incoming Request for Medical Service Reimbursement
or Recommendation for Additional Conditions for Industrial Injury or Occupational
Disease (C-9) forms for appropriateness under the Miller Case Criteria
policy and procedure, and make medical recommendations on inactive claims in
accordance with this policy. The MCO will address a request when the claim is
inactive as outlined in Section IV.B.1.a.-b. (above).
b. BWC’s
role is to review the MCO’s recommendations on the C-9 on inactive claims, and issue
a decision on the issues in accordance with this policy. BWC will address:
i. Medical
Benefits, except in Section IV.B.1.a.-b. (above).
a) Causal
relationship between the original injury and the current incident that is
triggering the medical treatment; and
b) Necessity
and appropriateness of the medical treatment request.
ii. Compensation
benefits, including the causal relationship between the original injury and the
current incident that is triggering the request for compensation; and/or
c. BWC’s role
is to review an additional allowance request, including the causal relationship
between the original injury and the current incident that is triggering the
request for an additional allowance.
d. The
MCO shall forward and work together with BWC to address:
i. Multiple
issues filed concurrently with dates of service both before and after the
inactive date on the request; and
ii. Eligibility
and feasibility requests for vocational rehabilitation.
5. It
is the policy of BWC that when prescription medication is prescribed in an
inactive claim, the MCO and BWC will evaluate the medical treatment that is
triggering the request for prescription medication.
6. It
is BWC’s policy that BWC will not process, and the MCO will dismiss, similar or
duplicate medical treatment requests in an inactive claim when new and changed
circumstances are not present to re-evaluate the request.
7. The MCO and
Disability Management Coordinator (DMC) shall consider a referral for
vocational rehabilitation in an inactive claim as a request for claim
reactivation and shall refer to the vocational rehabilitation Referrals,
Eligibility and Feasibility policy for additional information. The MCO
and the DMC shall work together with the BWC claim services staff to publish a
BWC Subsequent Order in accordance with Section V.H.
1. BWC does not have
to obtain an IME or PFR for claim reactivation when the:
a. Evidence
supports the request; or
b. Request is
untimely, including:
i. Outside
the statute of limitations; or
ii. Medical
bill payment request is outside the one year and seven days of the adjudication
of the initial medical bill.
2. BWC will, if the
evidence does not support the request, require a PFR or an IME prior to issuing
a BWC order or a notice of referral (NOR) to the IC. BWC must have a PFR or an
IME if issuing a denial order.
- BWC’s claims management system
runs a program that systematically updates a claim to inactive when it is 24
months after the last paid date in a claim.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Shall
follow any other specific instructions for claim notes included in this
procedure.
- The claims management system uses the following criteria
to establish claim activity:
1. If payment of
compensation has been made, the date payment was made in the claim;
2. If payment of
medical benefits has been made, the system chooses the date based on the latest
of the following dates:
a. Last paid bill
service date; or
b. If no last paid
bill service date exists, latest bill payment date.
3. If both payment
of compensation and medical benefits have been made, then the later of the two,
based on the criteria in Section V.B.2.
4. If neither
compensation or medical benefits has been paid, the system uses the claim
filing date.
5. For
reactivation, the system uses the date the claims management system is updated
by BWC.
1. The MCO or
claims services staff may receive a request in an inactive claim in one of the
following ways:
a. The
treating physician submits the C-9;
b. A party to
the claim files a Motion (C-86);
c. A party to
the claim files a specific application for compensation; or
d. A provider
or a party to the claim makes a verbal request.
2. Upon
receipt of a medical treatment request, the MCO shall:
a. Process in
accordance with this procedure if the date(s) of service is:
i. After
the inactive date.
ii. Both
prior to and after the inactive date.
b. Process
the request in accordance with the MCO
Policy Reference Guide (MPRG) if the date(s) of service is prior to the
inactive date or it is a request specified in Section V.E.7.
1. The
MCO has up to 16 business days to respond to a treatment request and forward
the claim reactivation issue to BWC.
a. Three business days to:
i. Review
the medical treatment request and respond to the provider if medical
documentation is not needed; or,
ii. Pend the
request to obtain medical documentation from the provider;
b. 10
business days for the provider to submit additional medical documentation to
the MCO, if needed; and
c. Three
business days from receipt of requested additional medical documentation to
review and forward the claim reactivation to BWC.
2.
BWC has 28 calendar days to address the following:
. The
causal relationship between the original injury and the current incident that
is triggering the medical treatment request; and
a. The necessity
and appropriateness of the medical treatment request.
3. BWC shall
address the issue of claim reactivation by:
a. Issuing a BWC
Order; or
b. Making a
recommendation on a NOR to the IC when BWC does not have jurisdiction to issue
an order.
4. Once the
decision is final, BWC will notify the MCO of the decision, and the MCO shall
notify the provider by:
a. Letter within three
business days from receipt of the BWC notification when medical treatment services
have not yet been rendered;
b. Letter within 30
calendar days from receipt of the BWC notification when medical treatment
services have been rendered;
c. Bill
payment when the MCO pays or adjusts the bill that was originally denied. In
this instance, the MCO does not need to send a letter as the payment of the
bill shall serve as the notice to the provider.
1. The MCO
may view the current inactive date on the bwc.ohio.gov website, and if
necessary, contact BWC claims
services staff for additional information.
2. MCO Referral
to BWC for Claim Reactivation
a. The MCO
shall refer a medical treatment request to BWC on an inactive claim when the
request is supported by:
i. Medical
evidence dated not more than 60 days prior to the date of the request; or
ii. Such
evidence is subsequently provided to the MCO upon request (via a Request for
Additional Medical Documentation for C-9 (C-9-A) form or equivalent).
a) When
current medical documentation is not on file, the MCO shall request such
documentation from the provider via the C-9-A or equivalent; and
b) Document
the request in the MCO notes.
b. When
documentation requested from a provider is not received, the MCO shall dismiss
the request in accordance with Section V.E.6. (below).
c. The MCO,
prior to making a recommendation to allow or deny the medical treatment
request, may indicate an independent medical examination (IME) or physician
file review (PFR) is necessary. The MCO and BWC shall collaborate to have the
IME or PFR completed. Once the report/review is on file, the MCO shall provide
the clinical findings note.
d. When
referring the medical treatment request recommendation to BWC, the MCO shall email
the recommendation to BWC claims services staff copying the supervisor in a
secure email that includes:
i. Standard
subject title: “Request for Claim Reactivation Review”; and
ii. A message
that consists of, at a minimum, the following:
a) Claim
number;
b) Injured
worker name;
c) Name of
provider requesting the medical treatment;
d) The
date(s) of the C-9, C-86 or verbal request;
e) A detailed
description of the medical treatment request;
f) The
frequency and duration of the medical treatment request;
g) The
beginning and ending dates of the medical treatment requested (to determine
duplicate requests);
h) The body
part being treated, including International Classification of Diseases (ICD)
code(s);
i) An
indication if the medical treatment has been previously rendered or not;
j) The MCO
recommendation to allow or deny the request;
k) The
medical evidence relied upon to support the MCO recommendation;
l) An
indication of which prong(s) from the Miller Case Criteria
policy and procedure treatment it does not meet, if the recommendation is to
deny request;
m) The MCO
Medical Director’s opinion and recommendation (when applicable); and
n) Any other
information the MCO would like to relay to BWC.
e. The MCO
shall create, at the same time it sends the secure email to BWC, a clinical
findings note with a title that reflects its content (e.g., “Claim Reactivation
Clinical Findings”). The note should include, at a minimum:
i. The
date(s) of the C-9, C-86 or verbal request;
ii. A
detailed description of the medical treatment request;
iii. The
frequency and duration of the medical treatment request;
iv. The
beginning and ending dates of the medical treatment requested (to determine
duplicate requests);
v. The body
part being treated, including ICD code(s);
vi. An
indication if the medical treatment has been previously rendered or not;
vii. The MCO recommendation
to allow or deny the request;
viii. The
medical evidence relied upon to support the MCO recommendation;
ix. An
indication of which prong(s) of Miller Case Criteria
policy and procedure treatment does not meet, if the recommendation is to deny
request;
x. The MCO
Medical Director’s opinion and recommendation (when applicable); and
xi. Any other
information the MCO would like to relay to BWC.
3. Multiple medical
treatment request(s) when claim reactivation is in process:
a. When the
MCO receives a similar or duplicative medical treatment request(s) and a
previous request sent to BWC is pending, the MCO shall:
i. Send the
request to BWC if the prior request(s) can be handled together on one BWC
order.
a) The MCO
shall immediately contact BWC claims services staff to make BWC claims services
staff aware there is an additional request(s) that must be addressed.
b) BWC claims
services staff shall address all medical treatment requests at the same time,
which may include obtaining an addendum to an IME or PFR.
i) BWC claims
services staff may not address the medical treatment request if the BWC order
is already issued; and
ii) BWC claims
services staff shall immediately notify the MCO if an order has already been
issued.
ii. Not
send the medical treatment request to BWC when a BWC order has already been
issued. The MCO shall:
a) Notify the
provider the medical treatment request is deferred for consideration and will
not be addressed until the current claim reactivation/medical treatment request
is resolved and all appeals are exhausted.
b) Include
the following statement on medical treatment requests in a letter to the
provider, “C-9 is pended as claim reactivation review is currently in process
based on a prior medical treatment request dated <Enter Date of
Request>.”
b. When the
MCO receives a new medical treatment request that is not a similar or duplicate
request of a previous request pending before the BWC or the IC, the MCO shall
staff with BWC claims services staff to determine if the new request for
medical treatment is to be included or not with the current medical treatment
request for claim reactivation.
i. If the
new medical treatment request will be addressed with the prior request, the MCO
shall:
a) Prepare
clinical findings note that contains each of the elements listed in Section V.E.2.e.
(above); and
b) Send a
secure email that contains each of the elements listed in Section V.E.2.d.
(above).
ii. If the
new medical treatment request will not be included with the prior request, the
MCO shall:
a) Defer
consideration of the medical treatment request until the previous request
pending is resolved and decision is final; and
b) Notify the
provider that the request is deferred for consideration as indicated in Section
V.E.3.a.ii.
4. Similar or
duplicate medical treatment request when the claim reactivation decision is
final.
a. For a
final decision denying the prior request, the MCO shall review the
documentation in the claim to determine if there are new and changed
circumstances that would impact the previous claim reactivation denial.
i. If there
is documentation of new and changed circumstances that may impact the previous
claim reactivation denial, the MCO shall perform the claim reactivation review
pursuant to this policy.
ii. If
there is no documentation of new and changed circumstances that would impact
the previous claim reactivation denial, the MCO shall dismiss subsequent
medical treatment requests that are similar or duplicate pursuant to Section V.E.6.
(below).
iii. For
example, when an additional condition(s) in the claim has recently been allowed,
this could be considered a new and changed circumstance that justifies
consideration of an apparent duplicate treatment request. In this situation,
it is appropriate to address the request for treatment through the claim
reactivation process.
b. For a
final decision allowing the prior request, the MCO shall address and process
deferred or subsequent C-9/medical treatment requests utilizing the MPRG.
5. The MCO
shall refer a request to BWC for BWC to issue a denial when the request is not
submitted within one year and seven days from the adjudication date of the
previously submitted and denied medical bill, except in cases of an error by
BWC or the MCO.
a. Example:
a medical bill for treatment rendered on 12/21/2014 is denied on 1/5/2015; the
MCO receives a request on 1/6/2016 for payment for medical treatment rendered
on 12/21/2014. MCO/BWC will process request.
c. Example of
MCO error: MCO receives and approves a C-9 request for medical treatment on
11/1/2014; a medical bill (for approved C-9 on 11/1/2014) for medical treatment
rendered on 12/21/2014 is denied on 1/5/2015; the MCO receives a request on
2/29/16 in an inactive claim for payment of medical treatment on 12/21/2014.
MCO denied the bill in error since treatment was prior approved. MCO/BWC will
process request.
d. Example of
BWC error: On 12/23/2014, the provider files an additional allowance (AA)
request on a C-9 with a medical bill for treatment rendered on 12/21/2014. On
1/5/2015, the MCO denies the medical bill for treatment rendered on 12/21/2014
and forwards the C-9 to BWC to address the AA request. BWC processes the AA
request and allows the condition; however, BWC fails to notify the MCO of the
final decision as required. On 5/12/2016, the MCO receives a request to
adjudicate the previously denied medical bill for payment of treatment rendered
on 12/21/2014. Since BWC failed to provide notification to the MCO of the final
decision on the AA request, the MCO/BWC will process the request.
6. MCO
Dismissal
a. The MCO
shall dismiss without prejudice, and without referral to BWC, a medical
treatment request that:
i. Is not
accompanied by supporting medical evidence dated not more than 60 days prior to
the date of the request; and
ii. Such
evidence is requested by, but not subsequently provided to, the MCO.
b. When the
MCO dismisses a request, the MCO shall:
i. Notify
all parties to the claim;
ii. Notify
the provider;
iii. Send to
BWC following the MCO imaging requirements.
c. For a
dismissal of a similar or duplicate medical treatment request that was
previously denied, the MCO shall ensure that the dismissal also includes:
i. Date of
the final BWC/IC order that denied claim reactivation;
ii. Date of
the C-9/medical service request; and
iii. Specific
medical treatment requested.
d. The MCO
shall ensure there is no appeal language in the dismissal.
e. The MCO
shall ensure there are no new and changed circumstances prior to issuing a dismissal.
7. The MCO
shall refer all medical treatment requests to BWC claims services staff in an
inactive claim, except in the following situations:
a. The
medical treatment request is for a date of service(s) prior to the inactive
date;
b. The
medical treatment request is only requesting the following:
i. Prosthetics;
ii. Orthotics;
iii. DME
categories as outlined in the Centers for Medicare and Medicaid Services (CMS)
Healthcare Common Procedure Coding System (HCPCS), Level II codes:
a) Canes;
b) Crutches;
c) Walkers;
d) Decubitis
Care Equipment (e.g., heel or elbow protector);
e) Heat/Cold
Application (e.g., electric heat pad);
f) Safety
equipment;
g) Restraints;
and
h) Other
orthopedic devices, (e.g., adjustable elbow extension).
iv. Vision,
hearing and dental devices (e.g., eye glasses, hearing aids, dentures); and
v. Medical
supplies (e.g., hearing aid battery).
c. The MCO
may request BWC update the claim to active status when the medical treatment
request does not need a referral to BWC and the MCO allows the request. The
MCO will send a secure email to BWC staff that:
i. Requests
BWC staff to update the claim to active in the claims management system; and
ii. Provides
the rationale to support making the claim active.
1. BWC claims
services staff may obtain the active/inactive claim history located on the
status window under Milestone dates and assist the MCO with the active and
inactive history.
2. BWC claims
services staff shall identify when a claim is inactive by looking in the claims
management system on the Status > Details window and the status reason would
be “Inactive Claim.”
3. Upon
request for medical services in an active claim that had previously been
believed to have been inactive, BWC shall notify the MCO to process the request
in accordance with the MPRG.
4. BWC may
receive a request for action in an inactive claim for issues other than
requested medical treatment (e.g., compensation, additional allowance, lump sum
settlement).
a. BWC claims
services staff shall process the request as directed in the policy and
procedure specific to the request.
b. CSS shall
follow the steps to open a claim to process the request as outlined in the Claim
Reactivation Job Aid.
c. If an
application for compensation is approved, BWC claims services staff shall refer
to Section V.I.1.-2.(below) to make the claim active prior to issuing payment.
5. Upon
request for medical treatment (and/or a combination request of multiple issues)
on an inactive claim, BWC shall:
a. Immediately
begin processing the request when the MCO has acted upon it and sent its
recommendations to BWC; or
b. Forward
the request to the MCO if BWC claims services staff determines that the MCO has
not seen the request.
c. When the
request to reactivate the claim is vague and non-specific, and there is no
other request for specific benefits and/or medical treatment, BWC claims
services staff shall:
i. Contact
the filing party to determine the specific benefits and/or medical treatment
requested;
ii. Send
the request to the MCO to begin processing if specific benefits and/or medical
treatment is identified;
iii. Dismiss
the request to reactivate the claim by using the “Dismissal Letter” if specific
benefits and/or medical treatment cannot be identified;
iv. Note the
request and outcome in claim notes.
6. When BWC
claims services staff receives a secure email from the MCO with its
recommendations for the claim reactivation and medical treatment request, BWC
claims services staff shall respond to the MCO in a secure email within three
business days notifying the MCO that its recommendations were received and that
BWC has started processing the request.
7. BWC Investigation
a. If the
medical treatment request is made more than five years from the date of injury
and the claim is inactive, BWC claims services staff shall ensure the claim is
statutorily active, as referred to in the Jurisdiction
policy and procedure on COR.
b. If the
claim is an inactive self-insured bankrupt claim, BWC claims services staff shall
audit the claim to determine the following prior to beginning the investigation:
i. All
allowed conditions are documented in the claims management system;
ii. The
claim is appropriately labeled as inactive; and
iii. Validate
that the claim is statutorily open.
c. BWC claims
services staff shall provide notification of the pending request by attempting
to call the parties to the claim at least once. If the BWC claims services staff
is able to leave a message, allow three business days for the parties to provide
a response.
d. When phone
contact is unsuccessful, BWC claims services staff shall send the letter(s)
below located on COR; when sending by fax or email allow three full business
days and if by mail allow seven (plus four days per Mailbox Rule
policy) calendar days for response:
i. The
“Claim Reactivation IW Due Process” letter; and
ii. The
“Claim Reactivation Employer Due Process” letter.
d. BWC claims
services staff shall investigate issues prompting the medical treatment request
to determine if the requested medical treatment is causally related to the
original claim allowance. BWC claims services staff may staff with the
appropriate discipline (e.g., BWC attorney on the timeliness of filing a
medical treatment request) as the situation warrants.
e. BWC claims
services staff may, as part of the investigation, send the Claim Reactivation
Investigation Questionaire letter to the:
i. Employer;
ii. Injured
worker; and
iii. Provider,
and allow seven calendar days for response.
1. BWC claims
services staff may refer the claim for an IME or PFR as the situation
warrants. BWC claims services staff shall create the appropriate medical exam
scheduling case or medical file review case in the claims management system.
2. BWC claims
services staff shall document in notes and notify the supervisor when the IME
or PFR will cause the processing of the request to exceed 28 days.
3. BWC claims
services staff shall add the appropriate set of questions for all issues being
addressed (e.g., additional allowance and/or temporary total compensation), to
the questions that address the medical treatment and claim reactivation
request.
1. If BWC
claims services staffs’ recommendation is to deny the request, an IME or PFR
must be on file to support the denial prior to issuing the BWC Subsequent
Order.
2. BWC claims
services staff shall:
a. Issue a
BWC Subsequent Order when:
i. Allowing
the medical treatment request in its entirety;
ii. Denying
the medical treatment request in its entirety;
iii. Allowing
the medical treatment request in part and denying in part (e.g., part of the
treatment request is causally related to the original injury and appropriate but
a portion of the medical treatment requested is for experimental treatment and
cannot be approved); and
iv. The issue
is for eligibility and feasibility of vocational rehabilitation. BWC claims
services staff shall work with the DMC and MCO for the appropriate order
insert.
v. The
decision includes multiple issues including the request for medical treatment
(e.g., additional allowance and/or temporary total compensation); and
vi. BWC has
jurisdiction to address all the issues in the request. BWC claims services staff
shall select the appropriate order inserts.
b. Send a
Notice of Referral (NOR) to the IC when BWC does not have jurisdiction to issue
a decision on all parts of the request for reactivation (e.g., The reactivation
request is for medical treatment, an additional allowance and temporary total
compensation, but the evidence does not support the additional allowance or the
temporary total requests. BWC does not have jurisdiction to deny the additional
allowance or temporary total so the entire reactivation request must be
referred to the IC).
2. BWC claims
services staff shall include in the BWC Subsequent Order the following
information:
a. The
date(s) of the C-9, C-86 or request;
b. A detailed
description of the requested medical treatment, without Current Procedural
Terminology (CPT) codes;
c. The
frequency and duration of requested treatment, if appropriate;
d. The
beginning and ending dates of the requested treatment, if appropriate;
e. The
supporting justification used for the determination;
3. BWC claims
services staff shall notify the MCO when:
a. The BWC
order or NOR is issued;
b. An appeal
is filed to the BWC or IC order; and
c. The appeal
period has expired for a final decision of a BWC or IC order.
4. After all
appeals have been adjudicated, BWC claims services staff shall update the
claims management system to the appropriate status.
5. The MCO
shall, upon notification from BWC of a final decision, notify the provider in
the following manner:
a. If the
medical treatment request is denied, the MCO shall:
i. Provide
written notification to the provider within three business days from receipt of
the BWC notification; or
ii. If the
medical treatment has previously been rendered, communicate the bill payment
decision to the provider within 30 calendar days from receipt of the BWC
notification.
b. If the
medical treatment request is allowed, the MCO shall:
i. Approve
the medical treatment request; or
ii. Pay/adjust
the bill originally denied, which serves as notice to the provider.
1. BWC claims
services staff shall activate a claim in the claims management system when:
a. The MCO
requests, with support, that the claim be made active. For example:
i. BWC
receives a request from the MCO for claim reactivation for an injured worker
with an approved prosthetic for new bolts and screws;
ii. The
injured worker has received new bolts and screws for the approved prosthetic
every other year for the last 16 years. The request was later than usual this
year as the provider was unavailable and the injured worker could not get in to
see the provider until after the claim became inactive.
iii. BWC and
the MCO shall staff the claim and grant the request without an order to avoid
further delay for the necessary bolts and screws.
b. BWC claims
services staff is paying compensation in a claim;
c. BWC issues
a “Approval of Settlement Agreement” letter; or
d. There is a
final decision approving reactivation of a claim.
2. BWC claims
services staff may make a claim inactive in the claims management system as
follows:
a. If a claim
is activated, BWC claims services staff may reset
the claim to inactive status if the claim was:
i. Placed
in active status inappropriately;
ii. Placed
in active status to update data that will not result in a payment.
b. When
payment is made for medical benefits or compensation, the claim cannot be reset
to an inactive status unless, after review, BWC claims services staff determines
it was not appropriate to make payment for medical benefits and/or
compensation.
i. For inappropriate
payment of compensation, BWC claims services staff shall make an adjustment(s)
to the Indemnity Benefit plan and the claims management system will adjust the
last indemnity paid date in the claim and evaluate for closure. Please refer to
the Adjustment of
Overpaid Compensation policy and procedures for details about this
process.
ii. For inappropriate
payment of medical, BWC claims services staff shall ensure the medical
treatment bill is adjusted and a new medical paid date will be sent, and the
claims management system will evaluate for closure.
iii. BWC
claims services staff shall ensure that a note is entered in the claims
management system documenting the action completed.
c. BWC claims
services staff shall not set the claims management system to an inactive status
when an appropriate medical treatment or indemnity payment is made in the
claim.
3. BWC claims services staff shall refer to the Claim
Reactivation Job Aid on COR for procedures on activating and
inactivating a claim in the claims management system.