OhioBWC - Basics:  Proactive Allowance

Proactive Allowance

BWC’s proactive allowance policy allows our customer service specialists to initiate the allowance of additional conditions to a claim. This process can begin when a recommendation for an additional condition is submitted to BWC by the injured worker’s managed care organization (MCO). The MCO’s recommendation is based on evidence submitted by the injured worker’s provider of record (POR).

The key advantage of proactive allowance is that the POR or other medical provider can expedite the delivery of services to an injured worker, resulting in the delivery of timely, appropriate care and the potential for an earlier return-to-work. Providers initiate the proactive allowance process by submitting a Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) and any associated medical evidence to the MCO. Ideally, proactive allowance requests should be received within one year from the date of injury (DOI); however, requests exceeding one year from the DOI are considered if the medical evidence clearly supports the condition and a causal relationship is established. Clearly, the injured worker’s POR plays a critical role in the proactive allowance process. To assist BWC with making a proactive allowance decision, the physician should provide this information to the MCO:

  • Supporting medical documentation, including clinical examination and diagnostic test findings;
  • A current treatment plan;
  • ICD-9 diagnosis codes for all requested conditions;
  • ICD-9 location (i.e., left, right, bilateral), when appropriate;
  • ICD-9 site (i.e., digits, teeth or body part), when appropriate;
  • A causality statement indicating how the mechanism of injury resulted in the requested diagnosis (i.e., Is the diagnosis causally related to the industrial accident?).