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Policy and Procedure Name:
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Exposure
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Policy #:
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CP-05-02
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Code/Rule Reference:
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R.C. 4123.01;
R.C. 4123.026
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Effective Date:
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09/15/20
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Approved:
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Ann M. 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-05-02, effective 05/06/19
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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
Corrections Officer
Detention Facility
Drug
Emergency Medical Worker
Exposure
Firefighter
Other Chemical Substance
Peace Officer
Physical Injury
IV. POLICY
A. Exposure Diagnosis
B. Exposure Claims Without
Physical Injury
C. Exposure Claims With
Physical Injury
D. Contraction of
Occupational Disease After Exposure
E. Firefighters with Cancer
and Firefighter Cardiac Claims
V. PROCEDURES
A. General Claim Note and
Documentation Requirements
B. Processing Exposure
Claims
C. Determination of
Physical Injury
D. Exposure Claims With
Physical Injury
E. Exposure Claims Without
Physical Injury: Determination of Occupation
F. Exposure Claims Without
Physical Injury Filed by a Firefighter, Peace Officer, Emergency Medical
Worker, or Detention Facility Employee Pursuant to R.C. 4123.026
G. Exposure Claims Without
Physical Injury for All Workers Not Covered Under R.C. 4123.026
H. No Exposure and No
Physical Injury
I. Contraction of
Occupational Disease After Exposure
The purpose of this policy is to ensure that BWC claims
services staff and MCO staff handle claims filed for exposure properly,
including claims covered by R.C. 4123.026 (also sometimes referred to as Senate
Bill (SB) 223 claims).
This policy applies to BWC claims services staff and MCO
staff.
Corrections
Officer: A person employed by a detention facility as a
corrections officer.
Detention
Facility: Any public or private place used for the
confinement of a person charged with or convicted of any crime in this state or
another state or under the laws of the United States or alleged or found to be
a delinquent child or unruly child in this state or another state or under the
laws of the United States.
Drug: Any article, other than food, intended to affect the
structure or any function of the body of humans or animals. Drugs may include:
·
Amphetamines;
·
Opiates;
·
Cocaine;
·
Benzodiazepines;
·
Barbiturates;
·
Oxycodone;
·
Methadone;
·
Fentanyl;
·
Marijuana; or
·
Hydrocodone.
Emergency
Medical Worker: A first responder, emergency medical
technician-basic, emergency medical technician-intermediate, or emergency
medical technician-paramedic, certified under R.C. Chapter 4765, whether paid
or volunteer.
Exposure:
When a worker is subjected to a toxic substance or harmful physical agent (e.g.,
gas, bodily fluid, chemical, poisonous vegetation, etc.) in the course of
employment through any route of entry (inhalation, ingestion, skin contact or
absorption, etc.).
Firefighter:
A firefighter, whether paid or volunteer, of a lawfully constituted fire
department.
Other
Chemical Substance: Something other than a drug to which an
individual believes they were exposed and for which they sought medical
testing/treatment.
Peace
Officer: An individual legally vested with law enforcement
rights who generally works for a city, county or state public employer and can
be either “traditional” (e.g., police officer) or “non-traditional” (e.g.,
certain park rangers, tax agents or liquor agents).
Physical
Injury: Any traumatic damage or attack on the physical
structure of the body, which results in a wound, tear or abnormal condition.
1. A
diagnosis of “exposure” is not an allowable condition.
2. BWC shall not
allow the condition of “exposure” in any claim.
1. It is the
policy of BWC that a claim for exposure without an accompanying injury or
occupational disease shall be denied.
2. In claims
without an accompanying physical injury, BWC will not pay or reimburse for
post-exposure medical diagnostic services, except when the injured worker (IW)
meets all of the following criteria:
a.
The IW is a firefighter, peace officer, emergency medical worker, or
detention facility employee (including a corrections officer);
b. In the
course of and arising out of the IW’s employment, or when responding to an
inherently dangerous situation, the IW was either exposed to:
i. A
drug or other chemical substance; or
ii. The blood
or other bodily fluids of another person through any of the following means:
a) A splash
or spatter in the eye or mouth, including when received in the course of
conducting mouth-to mouth resuscitation;
b) A puncture
in the skin; or
c) A cut on
the skin or another opening in the skin, such as an open sore, wound, lesion,
abrasion or ulcer.
c. The
diagnostic services and preventative treatment is consistent with medical,
Centers for Disease Control and Prevention (CDC), and Occupational Safety and
Health Administration (OSHA) standards for diagnostic and preventive treatment
related to the exposure.
1. If a claim
includes an exposure and a physical injury and all other required factors
pursuant to the Initial
Claim Determination policy are met, it is the policy of BWC to accept
the claim for the specific physical injury, but not for the exposure.
2. BWC or the
self-insuring employer will pay or reimburse for post-exposure medical
diagnostic services and/or preventative treatment if:
a. Such services
are causally related to at least one of the allowed physical conditions in the
claim and consistent with medical, CDC, and OSHA standards for diagnostic and
preventive treatment related to the exposure; or
b. The IW
otherwise meets all the criteria set forth in R.C. 4123.026 (detailed above).
1. If an IW
contracts an occupational disease following an exposure, the IW may make a
request for an additional allowance of an occupational disease in the related
existing accepted claim; or
2. If there
is not a related existing accepted claim, the IW may file a new claim for an
occupational disease.
3. Additional
information may be found in the Occupational
Disease Claims policy.
1. For claims
involving firefighters with cancer, refer to the Firefighters
with Cancer Occupational Disease Claims policy.
2. For
firefighter cardiac claims, refer to the “Statutory Occupational Disease
Claims” section of Occupational
Disease Claims policy.
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 and documentation
included in this procedure.
1. When a
claim that alleges an exposure is received, claims services staff shall follow the
steps outlined below (and in further detail throughout this procedure).
a. First,
claims services staff shall determine whether the claim includes a physical
injury. If the claim:
i. Includes
a physical injury, claims services staff shall continue to process the claim in
the same manner as any other claim alleging a work-related injury.
ii. Does
not include a physical injury, claims services staff shall move on to
the next step.
b. Second,
claims services staff shall determine the IW’s occupation. If the IW:
i. Is
not a firefighter, peace officer, emergency medical worker, or
detention facility employee (including a corrections officer) covered under R.C.
4123.026, post-exposure testing is not covered by BWC. Claims services staff
shall deny the claim.
ii. Is
a firefighter, peace officer, emergency medical worker, or detention facility
employee (including a corrections officer) covered under R.C. 4123.026, claims
services staff shall move on to the next step.
c. Third,
claims services staff shall determine what substance the IW alleges having been
exposed to. If the IW was exposed to:
i. Any
substance other than a drug or other chemical substance, or blood or another
bodily fluid, post-exposure testing is not covered by BWC. Claims
services staff shall deny the claim.
ii. A
drug or other chemical substance, this claim meets all criteria for processing
under R.C. 4123.026. Claims services staff shall deny the claim but indicate in
the order that post-exposure testing will be covered or reimbursed by BWC.
iii. Blood
or another bodily fluid, claims services staff shall move on to the
next step.
d. Fourth,
claims services staff shall determine the route to the body through which the
IW was exposed. If the IW was exposed to blood or another body fluid via:
i. Any
route other than the eye or mouth, or an opening in the skin, post-exposure
testing is not covered by BWC. Claims services staff shall deny the claim.
ii. The
eye or mouth, or an opening in the skin, this claim meets all criteria
for processing under R.C. 4123.026. Claims services staff shall deny the claim
but indicate in the order that post-exposure testing will be covered or
reimbursed by BWC.
2. See the
procedure below for detailed directions regarding the processing of exposure
claims.
1. When a
claim that alleges an exposure is received, claims services staff shall first determine
if any documentation in the claim also reflects or alleges a physical injury
(e.g., needle stick, contact dermatitis, toxic effect of carbon monoxide.
2. If the
First Report of an Injury, Occupational Disease or Death (FROI) or other
documentation references only “exposure”, and it is unclear whether the IW also
incurred a physical injury (e.g., needle stick, contact dermatitis, toxic
effect of carbon monoxide), claims services staff shall conduct additional
investigation consistent with the Initial Claim Determination and ICD
Modification procedures.
a. Investigation
may include:
i. Referring
to the Compensable
Injuries policy and procedure;
ii. Seeking
clarification from treating provider, as necessary;
iii. Staffing
the claim with the supervisor and/or BWC attorney, as necessary; and
iv. Referring the
claim for a medical review, if appropriate.
b. Example:
i. A
FROI is filed stating the IW was exposed to carbon monoxide.
ii. The
medical documentation reflects that the IW reported headache, dizziness and
nausea.
iii. The
doctor’s report states there is exposure to carbon monoxide but does not give a
medical diagnosis or condition associated with the exposure.
iv. Claims services
staff conducts further investigation as required by the Initial Claim
Determination policy and procedure, sends the claim for medical review, and
subsequently receives a medical diagnosis of toxic effect of carbon monoxide (a
physical injury).
3. If claims
services staff determine that the claim includes a physical injury, claims
services staff shall follow the directions detailed in the Exposure Claims With Physical Injury section
of this procedure.
4. If claims
services staff determine that the claim does not include a physical injury and
is solely for exposure, claims services staff shall then determine the
occupation of the IW, following the directions detailed in the Exposure Claims Without Physical Injury:
Determination of Occupation section of this procedure.
D.
Exposure Claims With Physical Injury
1. If, upon
investigation, claims services staff determines that a physical injury occurred
and all other factors pursuant to the Initial
Claim Determination policy are met, claims services staff shall:
a. Accept the
claim for the physical injury only, using the Initial Allowance Order;
b. Enter the
appropriate ICD code related to the physical injury (not the exposure) pursuant
to the Initial
Claim Determination and ICD
Modification policy and procedure;
c. Enter
a note in the claims management system that indicates that the claim is
accepted for the physical injury but not for the exposure; and
d. Continue
to process the claim in the same manner as any other claim alleging a
work-related physical injury.
2. The MCO
shall:
a. Ensure
that all post-exposure testing is related to an allowed physical condition(s)
in the claim;
b. Accept the
CDC and OSHA standards for diagnostic and preventive
treatment related to exposure to blood or other potentially infectious
materials (OPIM); and
c. Submit
bills to BWC’s Medical Billing and Adjustments (MB&A) unit.
3. Example:
a. A FROI is
filed alleging a work-related exposure to poison ivy.
b. The
medical documentation reflects that the IW has an area of skin with swelling,
redness and blisters which are symptoms consistent with poison ivy exposure,
but there is no diagnosis of a physical injury included in the claim.
c. Claims
services staff sends the claim for a medical review and subsequently receive a
diagnosis of contact dermatitis (a physical injury).
d. Claims
services staff enters the appropriate ICD code for contact dermatitis and processes
the claim in the same manner as any other claim alleging a work-related
physical injury.
4. Example:
a. A FROI is
submitted alleging that a nurse sustained a laceration on the arm and was
smeared with a patient’s blood.
b. Upon
investigation, claims services staff determines that:
i. A
physical injury occurred; and
ii. The
blood entered the wound on the IW’s arm.
c. Claims
services staff:
i. Enters
the appropriate ICD code for the laceration; and
ii. Accepts
the claim for the laceration only; noting in “add-text” in the Initial
Allowance Order that, while BWC does not allow claims for exposure, BWC
will pay or reimburse for post-exposure testing related to the laceration.
d. The MCO
receives a request for post-exposure diagnostics and preventative treatment for
exposure to blood.
e. Because
the exposure is directly related to the allowed physical injury, the MCO
approves the request and submits the bills to BWC for payment.
5. Example:
a. A FROI is
submitted alleging that a nurse sustained a laceration on the arm and was
smeared with a patient’s blood.
b. Upon
investigation, claims services staff determines that:
i. A
physical injury occurred; but
ii. The
blood was smeared on the IW’s neck only.
c. Claims
services staff:
i. Enters
the appropriate ICD code for the laceration; and
ii. Accepts
the claim for the laceration only; noting in “add-text” in the Initial
Allowance Order that post-exposure testing will not be paid for because it
is not related to the physical injury.
d. The MCO
receives a request for post-exposure diagnostics and preventative treatment for
exposure to blood.
e. Because
the exposure is not directly related to the allowed physical injury, the MCO
denies the request.
6. Example:
a. A FROI is
filed alleging that a nurse incurred a needle stick after injecting a patient.
b. Claims
services staff enters the appropriate ICD code for the needle stick; and accepts
the claim for the physical injury only;
c. Post-exposure
testing and preventative treatment, consistent with standards of medical care,
will be covered for the exposure to blood from the needle stick.
E.
Exposure Claims Without Physical Injury: Determination of Occupation
1. For
purposes of exposure claim processing, claims services staff must determine
whether the IW’s occupation meets the statutory criteria laid out in R.C.
4123.026.
2. When BWC
receives a claim that indicates the IW may be a firefighter, peace officer,
emergency medical worker, or detention facility employee (including a
corrections officer):
a. Claims
services staff shall verify that the IW is:
i.
A firefighter of a lawfully constituted fire department;
ii. A peace
officer as defined by R.C. 2935.01, including, but not limited to:
a) Sheriff;
b) Deputy
sheriff;
c) Marshal;
d) Deputy
marshal; or
e) Member of
an organized police department;
iii. An emergency
medical worker, certified under R.C. Chapter 4765 and listed below:
a) First
responder;
b) Emergency
medical technician-basic;
c) Emergency
medical technician-intermediate; or
d) Emergency
medical technician paramedic;
iv. A detention
facility employee (including a corrections officer).
b. If it is
unclear whether the IW meets the criteria listed above, claims services staff shall:
i. Contact
the parties to the claim (IW, employer, and/or the IW and employer
representatives) to request evidence to that the IW’s occupation qualifies
under R.C. 4123.026; and/or
ii. Staff
the claim with a supervisor and/or BWC attorney, as necessary.
3. If, upon
investigation, claims services staff determines that the IW’s occupation is
covered under R.C. 4123.026, claims services staff shall follow the directions detailed
in the next section of this procedure.
4. If upon
investigation, claims services staff determines that the IW’s occupation is not
covered under R.C. 4123.026, claims services staff shall follow the directions
detailed in the Exposure Claims Without
Physical Injury for All Workers Not Covered by R.C. 4123.026 section of
this procedure.
F.
Exposure Claims Without Physical Injury Filed by a Firefighter, Peace
Officer, Emergency Medical Worker, or Detention Facility Employee Pursuant to R.C.
4123.026
1. After verification
that the IW’s occupation is covered by R.C. 4123.026, claims services staff
shall enter the IW’s occupation in the claims management system.
2.
Claims services staff shall then determine if, in the course of and
arising out of the IW’s employment, the IW has come into contact with either:
a. A drug or
other chemical substance; or
b. The blood
or other body fluid of another person through:
i. A
splash or spatter in the eye or mouth, including when received in the course of
conducting mouth-to mouth resuscitation;
ii. A
puncture in the skin; or
iii. A cut in
the skin or another opening in the skin, such as an open sore, wound, lesion,
abrasion or ulcer.
3. Claims
services staff shall staff the claim with Legal by sending an e-mail to BWC Exposure Claims to
assist in determining whether the exposure type qualifies the claim for medical
bill payment under R.C. 4123.026.
4. If claims
services staff determines (and Legal staffing confirms) that the IW has been
exposed to a drug or other chemical substance, or blood or another bodily fluid
via one (or more) of the routes described above, and there is no accompanying
physical injury:
a. Claims
services staff shall:
i. Enter
a proper ICD-10 code and ensure that the narrative description of the code
reflects, or is modified to reflect, an exposure to blood or other body fluid,
or an exposure to a drug or other chemical substance (see the ICD
Modification policy and procedure for further information);
ii. Issue
an Initial Denial Order:
a) Select
“SB223 Denial” as the First Denial Reason; and
b) Under
“SB223 Reasons”, select the insert, “SB223 no disease with testing payable”.
iii. Send
notice to the MCO to facilitate payment of the diagnostic and preventive treatment
related to the exposure:
a)
In Claim Details>Details>Claim Handling>Is this a denied claim
requiring bill payment?, mark “Yes”; and
b) Select SB
223 from the resulting drop-down box (because the claim met all of the criteria
set forth in R.C. 4123.026.
iv. Enter a note in
the claims management system that indicates the following: RC 4123.026 applies-claim
is disallowed due to no physical injury but the worker did have a qualifying exposure
to a drug or other chemical substance, or blood or body fluid.
b. The MCO
shall:
i.
Accept the CDC and OSHA standards for diagnostic and preventive
treatment related to exposure to a drug or other chemical substance, or blood
or OPIM;
ii. Not
require prior authorization for and shall not deny services that are consistent
with CDC and OSHA standards. Post-exposure medical diagnostic services that may
be appropriate due to exposure to blood, or other body fluids include, but are
not limited to:
a) Office
visits,
b) Emergency
Department visits;
c) Treatment,
such as cleaning, suturing, and dressing of the area;
d) Tetanus,
HIV or hepatitis testing;
e) Counseling;
f) Prophylactic
treatment/medication; and
g) Follow-up
testing and treatment.
iii. Price
bills submitted for these services at $0.00; and
iv. Submit the bill
to BWC’s MB&A unit.
5. If claims
services staff determine (and Legal staffing confirms) that the IW did not
suffer a physical injury and was exposed to any substance other than a drug or
other chemical substance or blood or other body fluid, OR if the exposure to
blood or another body fluid was not through any of the routes described above, claims services staff shall issue an Initial
Denial Order:
a. Select “SB223
Denial” as the First Denial Reason; and
b. Under
“SB223 Reasons”, select the insert, “SB223 no contact with body fluid”.
G.
Exposure Claims Without Physical Injury for All Workers Not Covered
Under R.C. 4123.026
1. If the IW
incurred an exposure with no physical injury, claims services staff shall deny
the claim due to no physical injury, using an Initial Denial Order:
a. Select
“SB223 Denial” as the First Denial Reason; and
b. Under
“SB223 Reasons”, select the insert, “Not SB223 Exposed but no disease” (This
will provide language on the order indicating that the IW’s employer may be
required to pay for diagnostic testing and treatment).
2. Example:
a. A FROI is
filed by a nurse alleging a work-related exposure to blood (blood smeared on
the IW’s hand while treating a patient).
b. A smear of
blood on the hand by itself does not constitute a physical injury and
documentation does not indicate that the IW has any physical injury related to
the incident causing the blood smear.
c. Claims
services staff denies the claim because there is no physical injury.
1. If evidence
does not support that the IW suffered an exposure or a physical injury, claims
services staff shall deny the claim due to lack of physical injury; and
2. Send an Initial
Denial Order.
1. Claims
services staff shall consider an application for the contraction of an occupational
disease after exposure consistent with the Occupational
Disease Claims policy, either as:
a. An
additional allowance to a related allowed claim; or
b. A new
claim, if the related claim was not allowed (or there was no other related
claim).
2. Examples:
a. Additional
Allowance
i. The
IW files a claim for exposure to blood and a needle stick.
ii. The
claim is allowed due to the physical injury of the needle stick.
iii. Medical
treatment is approved for the needle stick and for diagnostic testing and
preventive treatment for the exposure.
iv. The IW later
develops hepatitis B (an occupational disease) related to the exposure.
v. The
IW files for an additional allowance in the existing allowed claim for the
occupational disease contracted from the exposure.
b. New Claim
i. The
IW files a claim for exposure to blood or other body fluid, but there is no
physical injury.
ii. The
claim meets the criteria of R.C. 4123.026.
iii. The claim
is disallowed due to no physical injury, but the IW is reimbursed for
diagnostic testing and preventive treatment for the exposure, consistent with
standards of medical care.
iv. The IW later is
found to have contracted an occupational disease related to the exposure.
v. The
IW files a new claim for occupational disease, which is processed consistent
with the Occupational
Disease Claims policy.