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Policy and Procedure Name:
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PSYCHIATRIC CONDITIONS
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Policy #:
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CP-16-01
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Code/Rule/Case Law Reference:
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R.C. 4123.01
and 4123.53
O.A.C.4123-3-08,
4123-3-09, 4123-3-16 and 4123-5-18
Armstrong v. John R. Jurgensen Co., Slip Opinion
No. 2013-Ohio-2237
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Effective Date:
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12/10/2021
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Approved:
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Ann M. Shannon, Chief of Claims Policy & Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-16-01, effective 02/07/2020
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History:
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Previous versions of this policy are available upon
request.
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Psychiatric Conditions
Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
IV. POLICY
A. Requirements for Allowance
of Psychiatric Conditions in a Claim
B. Initial Determination
Request for a Psychiatric Condition(s)
C. Additional Allowance
Request for a Psychiatric Condition(s)
D. Approval and Reimbursement
for Psychiatric Evaluation and Treatment
E. Provider Types Allowed to
Deliver Psychiatric Services in a Claim
F. Psychiatric Conditions
and Self-Insured Claims
V. PROCEDURES
A. Standard Claim File
Documentation
B. Requests for Initial
Determination and Additional Allowance of Psychiatric Condition(s)
C. Submission of Medical
Documentation to Support a Psychiatric Condition(s)
D. IME and Physician File
Review
E. Notice of Referral (NOR)
The purpose of this policy is to ensure BWC appropriately
allows psychiatric conditions in accordance with the law and rules.
This policy applies to BWC claims services staff.
Forced sexual conduct: Sexual conduct in which the
injured worker was forced by threat of physical harm to engage or participate.
Injury: For purposes of this policy, includes
psychiatric conditions when the injured worker’s psychiatric conditions have
arisen from an injury or occupational disease sustained by that injured worker,
or where the injured worker’s psychiatric conditions have arisen from forced
sexual conduct.
Sexual conduct: For purposes of this policy, vaginal
intercourse between a male and female; anal intercourse, fellatio, and
cunnilingus between persons regardless of gender; and, without privilege to do
so, the insertion, however slight, of any part of the body or any instrument,
apparatus, or other object into the vaginal or anal cavity of another. Penetration,
however slight, is sufficient to complete vaginal or anal intercourse.
A. Requirements for
Allowance of Psychiatric Conditions in a Claim
1. It is the policy
of BWC that a psychiatric condition(s) shall only be considered for allowance
in a claim when the claim includes:
a. A physical
injury; or
b. Forced sexual
conduct. A claim arising out of forced sexual conduct is the only instance
where the law allows for the initial determination of a claim with psychiatric,
emotional or stress conditions absent a physical injury.
2. Requests for the
allowance of a psychiatric condition(s) without an allowed physical injury or
forced sexual conduct shall be denied.
3. Requests for
allowance of a psychiatric condition(s) must be accompanied by supporting
medical documentation, including a detailed medical report. The medical report
must:
a. Be submitted by
a provider listed in Section IV.E.1(a)-(d)
of this policy;
b. Include the
following:
i. The
specific psychiatric condition(s) diagnosis with narrative description and the
appropriate diagnosis code;
ii. Causation
statement;
iii. The psychiatric
findings;
iv. Detailed explanation
of the causal relationship of the diagnosed psychiatric condition(s) to the
work-related injury or occupational disease; and
v. Information
that is clearly reasoned and rationalized.
c. Verify that
the psychiatric condition(s) arose from an injury or occupational disease
sustained by the IW or forced sexual conduct; and
d. Address each
psychiatric condition(s) requested.
4. Requests for an allowance
of a psychiatric condition(s) will not be based on a medical report from an Advanced
Practice Registered Nurse (APRN) or Advanced Practice Nurse (APN).
1. An injured
worker (IW) may request an initial determination for a psychiatric condition(s)
on a First
Report of an Injury, Occupational Disease or Death (FROI-1) concurrent
with the request for a physical injury, or as a result of forced sexual
conduct.
a. The IW must sign
and date the FROI-1 application requesting a psychiatric condition(s); and
b. BWC does not
require an IW declaration statement for a psychiatric condition(s) filed for an
initial determination request.
2. It is the policy
of BWC to treat an initial determination requesting a psychiatric condition(s)
as a result of forced sexual conduct the same as any other claim for an initial
determination.
C. Additional Allowance
Request for a Psychiatric Condition(s)
1. BWC must receive
an additional allowance request for a psychiatric condition(s) on a Motion (C-86).
2. For each motion
submitted, BWC must also receive a signed and dated declaration statement from
the IW.
a. The
declaration may either be included on the C-86 or in a separate letter.
b. If submitted in
a separate letter, the declaration should read as mandated by rule, "I am
aware that this motion is being filed to request that the bureau or commission
recognize my emotional problem, nervous condition, or psychiatric disability as
being a result of the injury for which this claim is allowed."
3. BWC will not
process requests for a psychiatric condition(s) recommended by a treating
physician on a Physician's Request for Medical Service or Recommendation for
Additional Conditions for Industrial Injury or Occupational Disease (C-9)
without the IW’s C-86 and declaration statement.
- BWC may approve and/or reimburse for psychiatric
evaluations and/or treatment when an IW’s:
1. Psychiatric
condition is:
a. Allowed in the
claim; or
b. Allowed in the
claim and the IW or provider previously paid for an examination performed to
provide evidence to support the Motion (C-86);
2. Psychiatric
independent medical examination (IME) is scheduled by BWC for BWC purposes;
3. Evaluation is
part of an authorized pre-admission evaluation for an approved chronic pain
program;
4. Evaluation
and/or treatment is part of an:
a. Approved
vocational rehabilitation treatment plan;
b. Authorized
chronic pain program; or
c. Authorized
detoxification or substance abuse program.
5. Claim is
categorized as catastrophic; if so, the IW is entitled to ten visits without a
psychological allowance.
E. Provider Types
Allowed to Deliver Psychiatric Services in a Claim
1. The following
provider types may submit a medical report accompanying a request for an
allowance of a psychiatric condition(s):
a.
Medical Doctors (M.D.);
b. Doctors of
Osteopathic Medicine (D.O.);
c. Licensed
psychiatric specialists;
d. Clinical
psychologists;
e. Licensed Professional
Clinical Counselors (LPCC); or
f. Licensed
Independent Social Workers (LISW).
2. The following
provider types may request and provide psychiatric treatment to IWs independent
of a psychiatrist or psychologist, but may not certify periods of disability or
sign any forms used for compensation (e.g., MEDCO-14):
a. Licensed
Independent Social Workers (LISW); and
b. Licensed
Professional Clinical Counselors (LPCC).
3. The following
provider types may request and provide psychiatric treatment to IWs, certify
periods of disability based on psychiatric allowance(s), and sign forms used
for compensation:
a. Medical Doctors
(M.D.);
b. Doctors of
Osteopathic Medicine (D.O.); and
c. Psychologists.
1. It is the policy
of BWC not to schedule exams for psychiatric condition(s) requested in
self-insured claims unless the Ohio Industrial Commission (IC) orders such an
exam.
2. If an exam is
ordered, the self-insured employer is responsible for the cost of the psychiatric
condition(s) independent medical examination scheduled at the request of the IC
by BWC.
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. BWC shall
evaluate initial and additional allowance requests for a psychiatric
condition(s) in a claim to ensure the condition(s) arises from:
a. An injury or
occupational disease sustained by the injured worker. The requested
psychological condition must be causally related to the allowed physical
condition(s) and not the mechanism of injury; or
b. Forced sexual
conduct.
2. Initial
Determination
a.
In order to correctly process an initial determination request for a psychiatric
condition(s), claims services staff shall follow the:
i. Initial
Claim Determination policy and procedures; and
ii. Guidelines
specified immediately below.
b. Claims services
staff shall process a First
Report of an Injury, Occupational Disease or Death (FROI-1) requesting
an initial determination of a psychiatric condition(s).
i. If the
FROI-1 is signed and dated by the injured worker, claims services staff shall:
a) Refer to the ICD
Modification policy and procedure for steps to request a modification
when adding a psychiatric condition(s) to the claims management system when the
initial determination is only for a psychiatric condition(s); and
b) Once claims
services staff completes the investigation and the ICD code is added in the
claims management system, claims services staff shall publish the initial
determination decision on a BWC order. Refer to the Orders,
Waivers, Appeals and Hearings policy and procedures. For an initial
determination request, claims services staff shall issue an:
i) “Initial
Allowance Order” or
ii) “Initial
Denial Order.”
ii. If the
FROI-1 is not signed and dated by the IW, claims services staff shall:
a) Attempt to
obtain the IW’s signature on the FROI-1 during the 28-day determination period;
and
b) If, at the end
of the 28-day determination period, the signed FROI-1 has not been received and
cannot be obtained and:
i) The
only condition requested is psychiatric, claims services staff shall dismiss
the claim by Miscellaneous Order.
ii) Both
physical and psychiatric conditions are being requested, claims services staff
shall issue an order allowing the physical condition(s) as appropriate and
neither allowing nor disallowing the psychiatric condition(s), specifically
noting in the order that the psychiatric condition(s) can be addressed upon
receipt of appropriate evidence.
iii) If neither the
physical or psychiatric conditions are appropriate, the claim shall be
dismissed.
c. Claims
services staff shall not require a declaration statement for a psychiatric
condition(s) as part of an initial determination request.
3. Additional
Allowance
a. In order to
correctly process an additional allowance request for psychiatric condition(s),
claims services staff shall follow the:
i. Additional
Allowance policy and procedures; and
ii. Guidelines
specified immediately below.
b. Claims services staff
shall ensure that any request for an additional allowance for a psychiatric
condition(s) is:
i. Submitted
on a Motion
(C-86) and not on a C-9;
ii. Accompanied
by sufficient medical evidence as outlined in Section V.C of this procedure; and
iii. Accompanied
by a declaration, as outlined in Section IV.C of this policy.
c. If the documentation
and evidence is sufficient to allow the motion in its entirety, claims services
staff shall staff the claim with their supervisor and issue the additional
allowance decision on a BWC Order.
d. If the motion
is not accompanied by a declaration statement, claims services staff shall:
i. Request
the declaration statement from the IW.
a) Claims services
staff may make this request verbally or in writing.
b) If
the request is made in writing, claims services staff shall use the
“Psychiatric Declaration Statement Letter” located on COR and copy the
correspondence to all parties in the claim.
ii. If the
declaration statement is not received within 14 days of BWC’s request, claims
services staff shall complete a Notice of Referral (NOR) to the IC and
recommend dismissal of the motion, referring to Section V.E
of this procedure for the NOR language.
C. Submission of Medical Documentation
to Support a Psychiatric Condition(s)
1.
Claims services staff shall ensure that the IW has submitted medical
evidence to support each requested psychiatric condition(s).
2. Medical evidence
must meet the criteria laid out in Section IV.A.3(a)-(d) of this policy. If the
medical evidence for a psychiatric condition(s) only partially meets or does
not meet the criteria:
a. Claims services
staff shall request additional medical evidence to support the initial determination
or additional allowance request. Claims services staff may make this request
verbally or in writing. If the request is made in writing, claims services
staff shall copy the correspondence to all parties in the claim.
b. If, after 14
days, additional medical evidence was requested but not received, claims
services staff shall continue processing the claim.
i. If
the request is for an initial determination, claims services staff shall
determine if a physician file review or IME is necessary.
ii. If the
request is for an additional allowance, claims services staff shall determine
whether:
a) A physician file
review or IME is necessary; or
b) The claim should
be referred to the IC with a recommendation for dismissal, referring to Section
V.E of this
procedure for the NOR language.
c. Claims
services staff shall review claims with a BWC attorney as needed.
D.
IME and Physician File Review
1. Claims services
staff shall schedule an IME or PFR if there are outstanding issues, a conflict,
or dispute with the evidence regarding the request for a psychiatric
condition(s).
2. Claims services
staff may request a psychiatric IME or physician file review to receive a medical
opinion on the following:
a. The presence of
a psychiatric condition(s) in a claim as an initial determination or an
additional allowance request;
b. The necessity
and appropriateness of psychiatric treatment; and
c. The extent
of a psychiatric disability.
3. If claims
services staff determine that an IME or physician file review is needed:
a. Claims services
staff:
i. Must
consult with an IMS and MSS for a physician file review referral.
ii. Are not
required to consult an MSS to request an IME for an additional allowance for a
psychiatric condition(s).
b. Claims services
staff shall:
i. Inform
the Disability Evaluator Panel (DEP) physician to review only the psychiatric
condition(s) that is supported by the medical evidence; and
ii. Utilize the
applicable physician file review and IME questions available on Claims On-line
Resources (COR).
c. For claims
requiring IMEs, claims services staff shall schedule the examination with a
psychiatrist or psychologist from the DEP physician list.
4. Upon receipt of
the medical report, claims services staff shall review and evaluate the report
following the:
a. Independent
Medical Exams (IME) and Physician File Reviews (PFR) policy and
procedures; and
b. Guidelines
specified immediately below.
5. Claims services
staff shall review the report to determine if:
a. Special handling
considerations are necessary, such as confidentiality of information included
in the written report;
b. A conflict
exists in the medical evidence, such as the diagnosis and/or the causal
relationship to the allowed condition(s); and
c. The report
recommends the allowance of a psychiatric condition(s) not requested on the
motion.
6. If the condition(s)
is not requested, claims services staff shall not address the condition(s)
unless the IW or his/her legal representative requests allowance of the
psychiatric condition on a motion. For example:
a. The IW requests
allowance of chronic depression in the claim.
b. The IME report
agrees with allowance of chronic depression but also states that organic
psychosis is present.
c. Claims
services staff shall not address the condition “organic psychosis” since the IW
did not request it to be allowed in the claim.
7. Multi-Claim Psychiatric
IME for the Same IW Workflow
a. Claims services
staff shall process a motion for a psychiatric condition(s) allowance for
multiple claims for the same IW.
b. Claims services
staff shall complete a note titled “Multiple Psych Exam Scheduled.”
c. Claims
services staff shall prepare a medical packet for each claim involved.
d. Upon receipt of
a Multiple Psych IME Referral, claims services staff shall:
i. Schedule
the exam in the claims management system exam scheduling window while
completing the following steps:
a) Update the
claims management system exam scheduler window using the most recent claim;
b) Stop the
standard claims management system “Independent Medical Examination Injured
Worker Notice” from being mailed;
c) Complete the IW
notification letter titled “Psych IME IW Notification letter” located on COR;
d) Send a copy of
the letter to all parties in the claim and to the claim via RightFax;
e) Generate
correspondence for the physician notification, including the following
statement: “Please see the Motion (C-86) for the requested condition(s)
in claims (Example: 00-123456 and 99-789654). See the attached
medical packets for all allowed conditions in these claims.”; and
f) Mail
copies of the IW notification letter and exam packet to the DEP physician as
outlined in the exam scheduler-training manual.
e. The DEP
physician shall, as referenced in Document P of the DEP Manual:
i. Write
one IME report addressing each claim separately;
ii. Send the
IME report and service invoice(s) to the claims services staff for review; and
iii. Determine which
claim to assign the code: W1603, Psych Exam, Single Claim; W1604,
Subsequent Claims, same IW, same date of service, each 10-minutes (6 units max
per claim). *Note: DEP physicians shall bill each subsequent claim
on a separate service invoice in 10-minute billing units with W1604.
f. Claims
services staff shall forward the IME report invoice(s) for any claims received
to BWC Medical Billing and Adjustments (MB&A) Department via:
i. Fax 614-621-1398; or
ii. Scan onto
MB&A worklist.
g. MB&A shall
send any questionable IME report invoices to DEP Central Unit to review and
authorize payment as needed.
E.
Notice of Referral (NOR)
1. Claims services
staff shall complete a NOR to the IC, following the Notice
of Referral to the Industrial Commission policy and procedures and
notify a BWC attorney when the hearing is scheduled so they can attend and
request a referral back if necessary when:
a. A declaration
statement is not received within 14 days of BWC’s request.
b. The employer
disagrees with the IW’s request;
c. BWC is
recommending:
i. Denial;
ii. Dismissal;
or
iii. A combination of
allowance/denial/dismissal.
2. No
declaration statement submitted: When an additional allowance request does
not include a signed and dated declaration statement, and the IW fails to
submit the requested declaration statement, include the following language in
the NOR:
a. Reason/Position:
BWC recommends that the motion be dismissed because there is no signed and
dated declaration statement from the injured worker (IW). A signed and dated
declaration statement was requested from the IW on <<Enter date>>,
but has not been received.
b. Based
on: Ohio law requires a signed and dated declaration statement from the IW
prior to considering the additional allowance of a psychiatric condition(s).
3. No
declaration statement or medical evidence submitted: When an
additional allowance request does not include a signed and dated declaration
statement and no medical evidence is attached, and the IW fails to
submit the requested declaration and medical evidence, include the following
language in the NOR:
a. Reason/Position: BWC
recommends that the motion be dismissed as the injured worker has
not met the burden of proof. A signed declaration statement and medical
evidence supporting the requested condition(s) were requested on <<Enter
date>>, but have not been received.
b. Based
on: Ohio law requires a declaration statement be signed and
submitted by the IW and medical evidence to support the requested condition(s)
from a medical doctor (M.D.), a doctor of osteopathic medicine (D.O.), a licensed
psychiatric specialist, a clinical psychologist, a Licensed Professional
Clinical Counselor (LPCC), or a Licensed Independent Social Worker (LISW) prior
to consideration for the additional allowance of a psychiatric condition(s).
4. No
medical evidence submitted: When an additional allowance
request does not include medical evidence, and the IW fails to submit requested
additional medical evidence, include the following language in the NOR:
a. Reason/Position: BWC
recommends that the motion be dismissed as the injured worker has
not met the burden of proof. No supporting medical evidence has been submitted.
It was requested on <<Enter date>>, but has not been received.
b. Based
on: Ohio law requires medical evidence to support a requested
condition(s) from a medical doctor (M.D.), a doctor of osteopathic medicine
(D.O.), a licensed psychiatric specialist, a clinical psychologist, a Licensed
Professional Clinical Counselor (LPCC), or a Licensed Independent Social Worker
(LISW) prior to consideration for the additional allowance of a psychiatric
condition(s).
5. Medical
evidence submitted from an incorrect provider type: When
an additional allowance request does not include medical evidence from a
correct provider type, including medical doctors (M.D.), doctors
of osteopathic medicine (D.O.), licensed psychiatric specialists, clinical
psychologists, Licensed Professional Clinical Counselors (LPCC), or Licensed
Independent Social Workers (LISW) and the IW fails to submit supporting
evidence from a correct provider type, include the following language in the
NOR:
a. Reason/Position: BWC
recommends that the motion be dismissed as the injured worker has not met the
burden of proof. The supporting medical evidence submitted is
from an incorrect provider type. Evidence from a correct provider type
was requested on <<Enter date>>, but has not been received.
b. Based
on: Ohio law requires medical evidence to support the
requested condition(s) from a medical doctor (M.D.), a doctor of osteopathic
medicine (D.O.), a licensed psychiatric specialist, a clinical psychologist, a
Licensed Professional Clinical Counselor (LPCC), or a Licensed Independent
Social Worker (LISW) prior to consideration for the additional allowance of a
psychiatric condition(s).
6. Medical
evidence does not support requested condition(s): When an
additional allowance request includes medical evidence, but it does not support
the requested condition(s), include the following language in the NOR:
a. Reason/Position: BWC
recommends that the motion be denied as the injured worker (IW)
has not met the burden of proof. The IW has not provided supporting medical
evidence for the requested condition(s). It was requested on <<Enter
date>>, but has not been received.
b. Based
on: Ohio law requires medical evidence to support a requested
condition(s) from a medical doctor (M.D.), a doctor of osteopathic medicine
(D.O.), a licensed psychiatric specialist, a clinical psychologist, a Licensed
Professional Clinical Counselor (LPCC), or a Licensed Independent Social Worker
(LISW) prior to consideration for the additional allowance of a psychiatric
condition(s).