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OhioBWC - Basics:  Provider Enrollment and Certification

Provider Enrollment and Certification

BWC/HPP-Certification
With the exception of providers rendering services for state-fund claims with dates of injury prior to Oct. 20, 1993, emergencies, initial visits or otherwise defined by Ohio Administrative Code (OAC) 4123-6-12, medical providers must be BWC-certified to participate in the Health Partnership Program (HPP). Certification is based on licensing, certification and accreditation requirements necessary to provide services, as well as other minimum credentials based on provider type. All providers must:

  1. Have a current license to practice, as applicable;
  2. Meet other general certification requirements for the specific provider type;
  3. Possess a current and valid Drug Enforcement Agency (DEA) registration, unless not required by the providerís discipline and scope of practice;
  4. Have no previous termination from participation in Medicare, Medicaid or the Ohio workersí compensation system;
  5. Have no felony convictions in any jurisdiction, under a federal-controlled substance act or for an act involving dishonesty, fraud or misrepresentation;
  6. Provide proof of adequate, current professional malpractice and liability insurance.

When these requirements are met, providers must complete a Provider Agreement to participate in the HPP.

BWC-Certified Provider
A BWC-certified provider is a credentialed provider who signs a provider agreement with BWC and has agreed to be medically managed by an employerís MCO.

Click here to view a list of provider types and their requirements.

Enrollment
To be eligible for reimbursement, medical providers must be enrolled with BWC as a certified provider. (There are exceptions to this requirement, which are services rendered in state-fund claims with dates of injury prior to Oct. 20, 1993; emergencies; initial visits; or other circumstances defined by Ohio Administrative Code (OAC) 4123-6-12.) To become enrolled as a BWC-certified provider, complete and submit an Application for Provider Enrollment (MEDCO-13) along with all required documentation specified on the form. BWC reviews this information to ensure that minimum certification criteria is met, including all relevant licensing, certification and accreditation requirements, as well as any credentials based on provider type. If all criteria are met and a Provider Agreement is signed, BWC certifies the provider.

Non-BWC Certified Provider
A non-BWC certified provider is a medical provider who is not approved by BWC for participation in the Health Partnership Program and has not signed a provider agreement with BWC.

Provider Agreement
This is an agreement that a medical provider must complete, sign and submit to the Bureau of Workersí Compensation in order to become a BWC-certified provider.

Provider Enrollment
To be eligible for reimbursement, medical providers must be enrolled with BWC as a certified provider. (Exceptions to this requirement are services rendered in state-fund claims with dates of injury prior to Oct. 20, 1993; emergencies; initial visits; or other circumstances defined by Ohio Administrative Code (OAC) 4123-6-12.) To become enrolled as a BWC-certified provider, complete and submit an Application for Provider Enrollment (MEDCO-13) along with all required documentation specified on the form. BWC reviews this information to ensure that minimum certification criteria is met, including all relevant licensing, certification and accreditation requirements, as well as any credentials based on provider type. If all criteria are met and a Provider Agreement is signed, BWC certifies the provider.

Provider Type
A providerís type is a standardized description and associated two-digit code identifying a medical providerís specialty (i.e., audiologist - 04), nature of business (i.e., air ambulance - 01) or nature of facility (i.e., general acute hospital - 34).

Provider/Physician of Record
Although provider of record is commonly used to identify the physician directing care in an injured workerís claim, the term can be somewhat misleading. Under Ohio workersí compensation rules, provider is defined as not only physicians, but also all other medical professionals (i.e., pharmacists, massage therapists, durable medical suppliers, etc.). Although an injured worker can receive services from more than one provider (i.e., treating providers), a physician of record is responsible for assuring that timely, appropriate care is being requested and delivered. A claim may only have one physician of record. A physician of record must be a medical doctor, a doctor of osteopathic medicine, a doctor of mechanotherapy, a doctor of chiropractic, a doctor of podiatry, a doctor of dental surgery or licensed psychologist. A physician of record is commonly referred to as a POR.

Provider Number
All providers enrolled with BWC as certified providers are assigned an 11-digit identification number, which is comprised of a nine-digit number and a two-digit suffix. The nine-digit number is either the providerís federal tax identification number or Social Security number, while the two-digit suffix identifies the provider type (i.e., general practitioner, ambulatory surgical center, audiologist, etc.). When billing, providers must include servicing and pay-to provider numbers on their bills. A servicing provider is the provider that actually renders a particular service to an injured worker. A pay-to provider is an individual doctor, group or facility that will receive direct reimbursement for the services rendered.



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