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Policy and Procedure Name:
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Travel Reimbursement
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Policy #:
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CP-20-01
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Code/Rule Reference:
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O.A.C. 4123-3-09; O.A.C 4123-6-40; ORC 4123.52
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Effective Date:
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10/07/2021
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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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History:
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Previous versions of this policy are available upon
request
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Travel Reimbursement Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
IV. POLICY
A. Travel Reimbursement-
General Policy Statement
B. Review
C. Preauthorization
D. Reimbursement of Travel
Expenses
E. Obtaining Reimbursement
F. Pre-Payment and
Overpayment of Travel Expenses
V. PROCEDURE
A. Standard Claim File
Documentation
B. Claims Services Staff
and MCO Responsibilities
C. Travel Reimbursement
Requests for Medical Examinations
D. Travel Reimbursement
Requests Due to Medical Treatment
E. Travel Reimbursement Requests
As Part of Vocational Rehabilitation Services
F. Pre-Authorization for
Travel Expenses
G. Payment for Transport by
Ambulance or Ambulette for Non-Emergency Travel
H. Travel for the Fifteen
Thousand Dollar Medical Only (15K) Program Claims
I. Calculating and
Approving Reimbursement
J. Denial of Travel
Reimbursement
K. Pre-payment of Travel
Expenses
L. Overpayment of Travel
Expenses
M. Issues Regarding Travel
The purpose of this policy and procedure is to ensure
consistent and efficient reimbursement to the injured worker (IW) for allowable
travel expenses.
This policy and procedure applies to managed care
organization (MCO) staff and BWC staff.
None
It is the policy of BWC to
reimburse an IW for medically necessary, reasonable, and appropriate travel
expenses, as detailed in the policy and procedure below.
1. MCO and
BWC staff shall review travel expenses prior to reimbursement to ensure medical
necessity and appropriateness.
2. MCO and
BWC staff shall discuss travel expense requests, and the MCO shall provide BWC
staff with documentation of its efforts to inform and assist the IW regarding
travel.
1. The
following types of travel expenses must be pre-authorized by BWC to be
reimbursable:
a. Lodging;
b. Travel in
excess of 400 miles round trip from IW’s residence;
c. Companion
travel; and
d. Travel by taxicabs,
bus, train, non-emergent air transport, or other special transportation.
2. The MCO
may pre-authorize and reimburse medically necessary transportation by ambulance
or ambulette.
1. BWC
Reimbursement of Travel Expenses
a. It is the
policy of BWC to reimburse an IW for reasonable and necessary travel expenses,
upon the filing of a proper request, when the:
i. IW
is required by BWC or the Ohio Industrial Commission (IC) to undergo a medical
examination that is more than 45 miles round trip from the IW’s residence;
ii. MCO has
approved medical treatment, including a service contained in an approved
vocational rehabilitation plan, that cannot be obtained within 45 miles or less
round trip from the IW’s residence; or
iii. IW’s allowed
conditions require the use of taxicab or other special transportation for
purposes of obtaining treatment or attending an examination because of an
allowed injury or occupational disease, and the taxicab or other special
transportation has been pre-authorized (no minimum mileage requirements are
necessary in this circumstance).
b. BWC shall
publish reimbursement rates on the Injured Worker
Reimbursement Rates for Travel Expenses (C-60A), which also details the
criteria for reimbursement of travel expenses.
2. Employer
Reimbursement of Travel Expenses
a. The
employer is responsible for reimbursing the IW for travel expenses when the
travel is related to a request for a medical examination by a physician of the
employer’s choice.
b. Reimbursement
by the employer of travel expenses under this provision shall not:
i. Require
an order of BWC or the IC, unless there is a dispute; and
ii. Be subject
to the minimum mileage requirement applicable to travel expenses reimbursed by
BWC.
3. Self-Insuring
Employer Reimbursement of Travel Expenses
a. The
self-insuring employer is generally responsible for reimbursement of travel
expenses if related to a self-insured claim.
b. BWC is
responsible for the reimbursement of travel expenses in a self-insured claim
only if the the travel is for an:
i. Exam
to determine percentage permanent partial disability; or
ii. Appointment
related to the provision of a prosthetic device.
4. IC-Scheduled
Examinations- When the IC schedules an examination, the associated travel is
reimbursed by:
a. BWC for
state-fund claims; and
b. The
self-insuring employer for self-insured claims.
5. Travel
Reimbursement Requests Due to an Approved Vocational Rehabilitation Plan
a. When
travel expenses are authorized as part of an approved vocational rehabilitation
assessment plan, comprehensive vocational rehabilitation plan, or job retention
plan, BWC shall pay travel reimbursement.
b. Vocational
services that may be eligible for travel reimbursement include, but are not
limited to:
i. Training;
ii. Job
simulation;
iii. Job search
outside the IW’s community.
c. Any
travel reimbursement requests related to an approved vocational rehabilitation
plan are subject to the requirements of the procedures below.
1. To obtain
reimbursement for travel expenses, the IW must complete and submit to the party
responsible for payment an Injured Worker
Statement for Reimbursement of Travel Expense (C-60), or an equivalent
documented travel expense request.
2. Travel
expenses must be submitted within two years of the IW’s date of travel.
1. BWC may,
at its sole discretion, assist an IW by pre-paying allowable lodging and transportation
expenses, such as airplane or railroad fares.
2. BWC shall
collect any overpayment of travel expenses to the IW.
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 responsibilities include:
a. Reviewing
the C-60 or equivalent to determine if it contains complete and accurate
information;
b. Requesting
IW information or supporting documents (e.g., receipts, when applicable) that
are missing or require clarification;
c. Determining
if the travel expense request is medically necessary and reasonable under the
requirements of these procedures; and
d. Processing
requests for travel expenses within seven calendar days upon receipt of the
C-60 or equivalent, or within 14 calendar days if additional information or
clarification was requested.
2. MCO
Responsibilities- Education & Notice to the IW
a. The MCO
shall make the following efforts to minimize unnecessary or unreasonable travel
expenses:
i. The
MCO shall provide written notice to the IW regarding travel reimbursement. The
written notice shall use the following language: “Travel for medical treatment
in excess of 45 miles round trip from your residence may be eligible for
expense reimbursement. Any travel expenses related to this treatment request
must meet the requirements of Ohio Administrative Code rule 4123-6-40 to be
reimbursed, and may require pre-authorization. For more information, please
contact your CSS at {contact info here}.”
ii. When
an IW requests treatment, the MCO shall contact the provider and/or IW to
attempt to determine who is providing the service, where treatment will occur,
and whether it will require travel in excess of 45 miles round trip from the
IW’s residence.
iii. If the provider
or IW informs the MCO that treatment will require travel in excess of 45 miles
round trip from the IW’s residence, the MCO shall:
a) Evaluate
BWC’s certified provider list to determine whether there are treatment
alternatives that either eliminate or minimize the amount the IW must travel.
b) If no BWC
certified provider is available, evaluate whether there are non-certified
providers willing to enroll with BWC that can provide necessary services that
either eliminate or minimize the amount the IW must travel.
c) Provide
assistance to the IW in locating treatment options that are closer to home.
iv. If
alternate treatment options all require travel in excess of 45 miles round trip
from the IW’s residence, the MCO shall work with the IW to minimize the amount
of travel, in a manner that is reasonable and necessary.
b. The MCO
shall provide written documentation to the BWC claim file of its effort to
educate and inform individual IWs when travel expense requests are made (e.g.
entering a claim note).
1. If the
IW’s travel is for a BWC-ordered or authorized exam (including ADR) for a
state-fund claim, claims services staff shall:
a. Verify the
IW attended the exam;
b. Verify the
required mileage was met;
c. Review
appropriateness of other expense requests (e.g. meals, tolls, parking, etc.);
and
d. Grant the
travel reimbursement request if all requirements are met.
2. If the IW
travels for an IC-ordered exam, the IC shall review travel expense requests for
appropriateness and upload the C-60 or equivalent to the claim file:
a. For a
self-insured claim, the IC will send the employer a cover letter and the
approved C-60 or equivalent for payment.
b. For a
state-fund claim, the IC will send the approved C-60 or equivalent to BWC Benefits
Payable for payment.
3. If BWC
receives a C-60 or equivalent for a medical examination scheduled or requested
by a state-fund employer, claims services staff shall:
a. Return the
request to the IW; and
b. Advise the
IW that the request must be submitted to the state-fund employer for
reimbursement.
4. If BWC receives
a C-60 or equivalent and the IW is employed by a self-insuring employer:
a. Claims
services staff shall:
i. Return
the request to the IW; and
ii. Advise
the IW that the request must be submitted to the self-insuring employer for
reimbursement, unless the travel is for:
a) An exam
prior to a determination for percentage permanent partial disability; or
b) The
provision of a prosthetic device pursuant to the Artificial
Appliance Requests policy.
b. If the
travel reimbursement request is related to V.C.4.a.ii immediately above, claims
services staff shall review the request for appropriateness of payment.
5. In the
event an IW is medically unable to self-transport to a BWC-scheduled exam due
to the allowed condition(s) in a claim, the minimum mileage requirement will be
waived.
Example: The IW’s
allowed conditions are two broken legs. The IW does not have personal access to
transportation that accomodates a wheelchair. In this case, BWC would pay for
round trip travel to the exam, regardless of the distance.
D. Travel
Reimbursement Requests Due to Medical Treatment
1.
When the provider or IW informs the MCO that requested medical treatment
would require the IW to travel more than 45 miles roundtrip from the IW’s
residence, the MCO:
a. Shall identify
whether there is a closer provider of the service, utilizing the hierarchy of
distance (i.e., a provider in the following order of preference: within the
local community, regional community, statewide community, or contiguous states where
services can be obtained);
b. May may
need to investigate to determine the location of the rendering provider or
medical treatment facility in order to determine if the IW will need to travel
for medical treatment; and
c. Shall
document all actions taken in claim notes.
2. If
equivalent medical treatment can be obtained closer to the IW’s residence, the
MCO shall:
a. Discuss its
recommendations regarding closer treatment options with the treating physician
and the IW before authorizing treatment and document this discussion in claim
notes; and
b. Inform the
IW that travel expenses will not be reimbursed should the IW choose medical
treatment that requires travel. If the treating physician and IW do not agree
to move the treatment to a closer facility, the MCO shall also document this
information in claim notes.
3. If the MCO
has determined that treatment necessary for the IW’s allowed condition is
required and cannot be obtained 45 miles or less round trip from the IW’s
residence, the MCO shall notify BWC and BWC shall proceed with its review under
V.I of this procedure.
4. The MCO
shall advise the IW to contact BWC for more information regarding requirements
and procedures for obtaining reimbursement of travel expenses.
1. The DMC
shall review all requests for travel reimbursement when travel is being
requested as part of vocational rehabilitation services.
2. For
appeals of travel reimbursement requests associated with vocational rehabilitation,
please see the Disputes
Regarding Vocational Rehabilitation Decisions policy and
procedures.
3. The DMC shall
staff any issues with the BWC Rehab Policy Unit.
1. The MCO and
claims service staff shall work together to inform and assist the IW when
pre-authorization for travel expenses is necessary.
2. The MCO
shall review the medical treatment to determine if closer treatment options are
available as outlined in Section V.D.
above.
3. If closer
treatment options are not available and requested treatment has been determined
to be medically necessary, claims services staff shall contact
the IW to:
a. Provide
information regarding pre-authorization requirements; and
b. Obtain
information on which type of travel expenses the IW anticipates incurring and
additional details regarding lodging and special transportation (e.g., selected
hotel and mode of transportation).
4. If the
pre-authorization request is for travel reimbursement for special transport
(e.g. taxicab, bus, train, or air), claims services staff shall:
a. Discuss
with the MCO to determine if there is a medical necessity for special
transportation due to the allowed conditions in the claim;
b. Review to
determine whether the type of transportation expenses requested are a reasonable
means of transportation for the IW.
5. If the IW
submits a valid request for travel reimbursement for special transport due to
medical necessity, there is no minimum mileage requirement.
6. Upon
receipt of the request for pre-authorization of travel expenses, claims
services staff shall:
a. Review MCO
notes to verify need for travel;
b. Confirm
that the travel expenses requested are reasonable;
c. If
necessary, contact the IW via phone in an attempt to resolve any questions or
problems related to the pre-authorized travel reimbursement request; e-authorized
or not;
d. Prepare
written approval or denial of pre-authorization for travel expenses;
e. Send a
letter to the IW notifying the IW of BWC’s decision regarding the
pre-authorization of travel expenses; and
i. Example
of approval letter (click
here).
ii. Example
of denial letter (click
here).
f. Document
the decision in a claim note.
G. Payment for
Transport by Ambulance or Ambulette for Non-Emergency Travel
1. If there
is a request for medical treatment but no specific request for special
transportation (e.g. ambulance or ambulette) exists, the MCO may:
a. Review to
determine whether there is a need for special transportation; and
b. Pre-authorize
special transportation if there is an urgent, time-driven need (e.g., IW needs
to be moved by ambulance from a hospital to a step-down facility) without
staffing with claims services staff.
2. When the
MCO determines that special transportation (e.g. ambulance or ambulette) is necessary
and supported by the medical evidence on file, the MCO shall:
a. Document
its efforts to pre-authorize the travel for special transportation by ambulance
or ambulette;
b. Ensure the
transportation provider is eligible to become or is enrolled as a certified
provider;
c. Obtain
a C-9 request retrospectively whenever possible, or document rationale as to
why a C-9 was not obtained; and
d. Arrange
for payment for special transportation as an MCO medical payment.
1. When
claims services staff receives a travel reimbursement request, staff shall
verify if the claim is enrolled in the 15K program.
2. If the
claim is enrolled, claims services staff shall follow the procedures for travel
reimbursement outlined in the $15,000
Medical-Only Program policy.
I. Calculating
and Approving Reimbursement
1. If travel
expenses associated with approved medical treatment in the claim appear necessary,
claims services staff shall determine reasonableness of the travel expenses by calculating
reimbursement in the following manner:
a. Reimbursement
for travel by a personal vehicle shall be at the rate indicated on the C-60A,
per mile, for the date(s) of travel.
i. The
total reimbursement is determined by multiplying the number of miles traveled
by the per mile rate.
ii. Internet
resources may be used as a tool to help determine reasonable and necessary
mileage.
b. Reimbursement
for the reasonable cost for meals shall be at the rates indicated on the C-60A
when the travel:
i. Includes
an overnight stay; or
ii. Totals
more than 12 hours in one day.
c. Pre-authorized
lodging for the IW shall be reimbursed at reasonable actual cost (receipts
required), up to the maximum amount indicated on the C-60A, plus applicable
taxes.
d. Travel by
taxi, train, airplane, bus or other special transportation shall be reimbursed
at actual and necessary cost (receipts required).
e. Miscellaneous
travel expenses, such as tolls and parking, shall be reimbursed at the actual
amount (receipts required).
f.
Approved travel expenses related to pre-authorized companions shall be
reimbursed at the same rates permitted for the IW, except:
i. Claims
services staff shall not reimburse for lodging for the companion unless special
circumstances require the companion to have a separate room; and
ii. Claims
services staff shall only reimburse mileage to the IW.
2. To process
and document the C-60 form, claims services staff shall:
a. Enter the
calculations in the appropriate section of the “Official Use Only” section of
the form;
b. Indicate
the appropriate procedure code(s) to be charged;
c. Check
the “Surplus Fund” box if the travel expenses are related to:
i. A
percentage permanent partial exam for state funded covered claims;
ii. Services
in an approved vocational rehabilitation plan;
iii. A prosthetic
provided to the IW pursuant to the Artificial
Appliance Requests policy; or
iv. A medical exam
for a denied statutory occupational disease. (See the Occupational
Disease Claims policy for further information).
d. Sign,
date, enter their phone number and “A” number where indicated, image a copy of
the C-60 into the claim and, send a copy to the IW with a copy of the C-60A;
and
e. Fax a copy
of the completed C-60 or equivalent to BWC Benefits Payable.
i. Benefits
Payable will notify claims services staff if a C-60 or equivalent is not
completed properly.
ii. Claims
services staff shall be responsible for correcting and resubmitting the C-60 or
equivalent.
3. If the
request for travel reimbursement has not been submitted on a C-60, claims
services staff shall process and document the request noting on the request or
any attached document:
a. Calculations
of reimbursable travel expenses;
b. The
related procedure codes, as designated on the C-60; and
c. Whether
any charges are to be made to the Surplus Fund.
4. If any of
the IW’s travel reimbursement request appears unreasonable or unnecessary, or
is otherwise questionable, claims services staff shall contact the IW in an
attempt to resolve.
Example: Mileage
submitted by IW is 30 miles more than an online resource indicates the trip
would be, using the most direct route. Contact with the IW reveals that there
was an accident causing a detour, resulting in the additional miles.
1. If, after
reviewing the C-60 or other submitted documentation, claims services staff determines
that all or some of the submitted travel expenses do not meet the criteria for
reimbursement, claims services staff shall publish a
miscellaneous order which states:
a. “After a
thorough review of your request for travel reimbursement filed on [date], BWC
has determined that [a portion of] your request does not meet the criteria
listed below:”
b. The
appropriate travel denial reason; and
c. Any
additional explanation needed to explain the basis for the denial and the
following statement: “Therefore, we have denied [a portion of] your request for
travel reimbursement.”
2. If only a
portion of a travel reimbursement request is denied, claims services staff
shall do the following after all administrative appeals are finalized:
a. Strike out
the denied expenses on the C-60;
b. Calculate
the totals for the allowed expenses and indicate the amount of reimbursement;
c. Image
a copy of the amended C-60 into the claim and send a copy to the IW with a copy
of the C-60A; and
d. Fax the
amended C-60 to BWC Benefits Payable.
1. If the IW
requests assistance from BWC to prepay lodging and other transportation
expenses (e.g., hotel, airfare, bus fare), claims services staff shall submit
the request to BWC management (i.e., team leader, supervisor or claims director)
for review and approval as soon as possible prior to travel.
a. The
Pre-Pay Travel (PPT) unit shall be available for consultation via the BWC Pre-Pay
Travel email box.
b. Claims
services staff shall also advise the IW that approval must be granted before
any travel arrangements are made.
2. Claims
services staff and BWC management shall staff the request.
a. If
approved by BWC management, claims services staff, in consultation with the IW,
shall complete the Injured Worker Travel Card Authorization Log (A-53),
located on COR, and submit it to the PPT unit BWC Pre-Pay Travel email box for
final approval or disapproval.
b. Within two
business days of receipt of the A-53, the PPT unit will approve or disapprove
the request and notify claims services staff by email.
i. If
approved, the PPT unit will proceed with making travel arrangements.
ii. If
disapproved, the A-53 will be cancelled and returned to claims services staff.
iii. Claims
services staff shall document the approval or disapproval in the claim notes.
3. To process
the approved A-53:
a. The PPT
unit will:
i. Document
the travel arrangements on the A-53 with the confirmed vendor, dates of travel,
the total cost of travel and the confirmation numbers;
ii. Attach
any itineraries received from the appropriate vendors and fax this information
along with the approved A-53 to claims services staff; and
iii. Maintain
the completed and confirmed copy of the A-53 and fax a copy to BWC Benefits
Payable to be processed.
b. Claims
services staff shall:
i. Image
the A-53 and document the travel approval in the claim notes;
ii. Prepare
a letter of confirmation to send to the IW, which includes the arrangements
made by the PPT unit, any itineraries, and a C-60 or equivalent for any
expenses incurred by the IW that are not prepaid but approved, or otherwise
meet the requirements of these procedures;
iii. Set a work
item for the next business day after the expected return date of the IW’s
travel;
iv. Verify the IW
traveled and kept the appointment per the arrangements confirmed on the A-53
and document the verification in claim notes; and
v. Ensure
that any travel reimbursement request submitted by the IW does not include the
pre-paid travel arrangements.
c. If
claims services staff determines that the prearranged travel was not utilized, claims
services staff shall:
i. Contact
the IW to determine if there are justifiable reasons or circumstances that
prevented the travel; and
ii. Document
the details of the contact in claim notes.
4. If, for
any reason, the IW cancels the arrangements and does not make alternative
arrangements, claims services staff shall notify the PPT unit immediately via
the BWC Pre-Pay Travel email box.
The PPT unit will contact the vendors and cancel the arrangements to avoid fees
or penalties.
a. Upon
receipt of the cancellation notice, the PPT unit shall send a copy of the A-53
with the required cancellation notations, including any fees or penalties to
BWC Benefits Payable;
b. Claims
services staff shall document the travel cancellation in the claim notes; and
c. If
new travel arrangements are made, a new A-53 shall be prepared and processed
consistent with these procedures.
1. If there
is an overpayment of travel expenses, claims services staff shall issue an
order indicating the overpayment and that the overpayment will be collected at
100% from any future approved travel expense reimbursement to the IW.
2. The IW may
also repay the overpayment amount at any time.
1. Claims
services staff shall staff any questions and unusual situations regarding
travel pre-authorization and reimbursement with a BWC attorney as needed.
2. The MCO
shall staff catastrophic and complex injury travel issues with the BWC
catastrophic nurse assigned to the claim.