|OhioBWC - Basics: Medical provider questions and answers (Q&A)|
Medical provider questions and answers (Q&A)
1Q: What form is used for additional allowances?
1A: Physicians of record (POR) and treating physicians may request that an additional diagnosis be added to a claim by completing the Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) and noting the requested diagnosis in Section 6 of the form.
2Q: How long does it take for an additional condition to be added?
2A: Between five and 28 days of the receipt of the recommendation, BWC will notify the provider, managed care organization (MCO) and all parties of the decision in writing.
3Q: Can the provider appeal the decision if the International Classification of Diseases (ICD) code be disallowed?
3A: By law, providers are not parties to the claim; therefore, they cannot appeal the decision regarding additional allowances to the MCO, BWC or the Industrial Commission of Ohio (IC). The injured worker, employer or their authorized representatives must initiate appeals.
4Q: What information is needed along with the C-9?
4A: Supporting medical documentation, including clinical examination and diagnostic test findings are important documentation to include with the C-9. Additionally, a current treatment plan, ICD locations/sites and a causality statement indicating how the mechanism of injury resulted in requested diagnosis must also be included.
5Q: Where can I find a list of invalid ICD codes?
5A: You can obtain BWC's invalid ICD codes online, or request a hard copy by calling 1-800-644-6292 and following the options.
6Q: Are V codes allowed in claims?
6A: BWC accepts V codes for the principal diagnosis on both inpatient and outpatient bills. However, they are not considered as legal diagnosis allowances in claims.
|Alternative dispute resolution (ADR)||Top|
1Q: What is ADR?
1A: ADR stands for Alternative Dispute Resolution, which is a means of resolving disputes over medical issues that arise between the managed care organization (MCO), BWC, employer, injured worker and/or provider without litigation.
2Q: What types of issues are disputed in ADR?
2A: Only medical treatment/service issues are disputed in ADR. It does not address claim reactivation, fee schedule or bill payment issues.
3Q: Who initiates an ADR medical dispute?
3A: ADR disputes may be filed by providers, employers and their representatives, and injured workers and their representatives only at level one.
4Q: Can ADR be initiated on a claim that is in pending status?
4A: ADR disputes may only be filed on allowed claims, not on claims that are in either a pending or disallowed status.
5Q: Can an ADR dispute be filed on a self-insured claim?
5A: The ADR process is for state-fund claims only. Qualified Health Plans (QHPs) have their own ADR process.
6Q: How much time do we have to file an appeal to the MCO after we receive a treatment denial?
6A: Appeals must be filed within 14 days of receipt of the MCO's initial written determination.
7Q: Can the appeal to the MCO be initiated by telephone?
7A: No, the appeal must be in writing and must be signed by the appellant. It may be faxed or mailed to the MCO.
8Q: What can I do if medical billing disputes or customer service issues are a problem?
8A: First, attempt to speak with the MCO on billing and customer service issues. If you are unable to resolve the issue, contact provider relations at 1-800-OHIOBWC, and follow the options, or send your inquiry via e-mail to Feedback.Medical@bwc.state.oh.us.
9Q: Is there a BWC form available to file an ADR appeal?
9A: The ADR appeal to the Request to Appeal MCO Medical Treatment/Service Decision (C-11) is available from BWC forms and publications. Call 1-800-OHIOBWC and follow the options, or click here to download the C-11.
10Q: Must a C-11 form be used to file an ADR appeal?
10A: No, but the appeal must be filed in writing and signed by the provider or his/her authorized representative.
11Q: How many levels of appeal are there at the MCO level?
11A: There is only one level of appeal at the MCO level.
12Q: What is the MCO's deadline to make a decision on the appeal?
12A: The MCO has 21 days from written receipt of a dispute to make a decision regarding the appeal.
13Q: If I disagree with the BWC order, what is my next step?
13A: If an appeal is filed against the BWC order, the file is forwarded to the IC to process the next level. By law, MCOs and providers are not parties to the claim; therefore, they cannot appeal any BWC order, including those regarding medical issues.
14Q: Who receives copies of the BWC Order issued through ADR?
14A: The injured worker, employer, his or her representative and the MCO involved in the dispute receive a copy of the BWC Order. The BWC ADR department also sends a copy to the POR.
15Q: If a provider disagrees with BWC's ADR decision, can he/she file an appeal with the Industrial Commission (IC)?
15A: By law, providers are not parties to the claim; therefore they cannot appeal any BWC order, including those regarding medical issues. However, an appeal at the IC level may be filed by the injured worker, employer or their representatives.
16Q: Where should I call for more information about the ADR process or for information on any unresolved dispute at the BWC level?
16A: Call the ADR Unit at (614) 752-4468 for further information.
|Authorization of services||Top|
1Q: How do providers request authorization for non-emergency medical services?
1A: Complete and submit the C-9 form to the MCO managing the case. The MCO will respond within three business days.
2Q: How do providers request authorization if they have already treated the injured worker?
2A: Complete and submit the C-9 form to the MCO managing the case. The MCO will respond to retroactive requests for authorization within 30 days of receipt.
3Q: Do TENS units that are under $250 require authorization?
3A: TENS units require authorization because the purchase price of a TENS unit is greater than $250.
4Q: Do basic X-rays need prior authorization?
4A: Basic X-rays do not need prior authorization.
5Q: Do consultations need prior authorization?
5A: Only psychological and chronic pain program consultations require prior authorization.
6Q: Do consultations performed in the hospital require prior authorization?
6A: Only psychological and chronic pain management consultations require prior authorization. Other types of consultations do not.
7Q: Why do providers need to submit a C-9 when prior authorization is not required?
7A: Providers are required to communicate their treatment plans to the appropriate MCO. You can facilitate open communication by submitting a C-9 to the MCO along with medical documentation.
8Q: The presumptive authorization policy applies to soft tissue and musculoskeletal injuries. What does this mean?
8A: Soft tissue and musculoskeletal injuries are sprains, strains, superficial injuries and contusions, as defined in the International Classification of Diseases book.
9Q: For presumptive authorization, does treatment have to be rendered within the first 60 days after the date of injury or within 60 days from the first treatment?
9A: The presumptive approval guidelines apply to services provided within 60 days of the date of injury.
10Q: Are there time frames for addressing the C-9?
10A: To be compliant, the MCO must respond to the physician within three business days. If the MCO is unable to make a decision within three business days due to the need for additional information and the physician is notified, the MCO must send a Request for Additional Medical Documentation for C-9 (C-9-A). The MCO then has five business days from the date additional information is received to make a subsequent decision.
11Q: What happens if the C-9 is not responded to in three days or five days for additional information?
11A: In instances when the C-9 is not responded to in three days or five days and the provider initiates treatment, the MCO will provide concurrent and retro review. If it is found that treatment is not necessary, the MCO will notify all parties to advise that treatment will be discontinued. Charges for services rendered will be paid.
12Q: Do the C-9 time frames apply to self-insuring employers?
12A: The C-9 time frames do not apply to self-insuring (SI) employers. SI employers have 10 days to respond to the C-9.
13Q: Are there outpatient medications that require prior authorization (PA) from BWC?
13A: Yes. Beginning March 1, 2004, prescribers must submit a prior authorization request for medications that appear on the PA drug list.
1Q: How are medical bills paid?
1A: Medical bills must be submitted to the managed care organization (MCO) that medically manages the claim; the MCO will review, price and submit the bills to BWC. BWC further reviews the bills and remits payment to the MCO, which in turn reimburses the provider.
2Q: The bill was denied as it was past the two-year filing limit but I filed it timely, what should I do?
2A: You must submit proof of timely submission, such as an explanation of benefits (EOB) or MCO date-stamped copy of the bill, to the MCO. If the bill is otherwise payable, the MCO will submit a request for adjustment to BWC. The MCO will usually be able to have the original bill adjusted but in some cases may need to submit a new bill.
3Q: The bill was denied as the diagnosis is not allowed in the claim, what should I do?
3A: Contact the MCO to discuss whether the claim needs to be amended to add the condition that you are treating to the claim. Depending on the circumstances, the claim may amended or the MCO may authorize payment without amending the claim, or it may be determined that the condition being treated is not related to the workers’ compensation claim.
4Q: The bills are being denied because I am not a BWC-certified provider, what should I do?
4A: To be reimbursed for services rendered to an Ohio injured worker, all providers must be enrolled with BWC. In addition, providers located in Ohio are also required to be BWC-certified to participate in the Health Partnership Program.
5Q: The bill is being denied as there was not prior authorization but I did obtain authorization, what should I do?
5A: Contact the MCO that medically manages the claim to discuss the inappropriate denial. If the MCO intended to deny the bill but used the wrong EOB code, you will have to correct your bill and resubmit. However, if the MCO denied the bill in error, it must correct its mistake and cannot require you to submit a new bill.
6Q: The bill was denied as there was no prior authorization but it was within the 45-day presumptive authorization period, what should I do?
6A: Contact the MCO that medically manages the claim to discuss the inappropriate denial. If the MCO intended to deny the bill but used the wrong EOB code, you will have to correct your bill and resubmit. However, if the MCO denied the bill in error, it must correct its mistake and cannot require you to submit a new bill.
7Q: What do I do if I do not believe that I was reimbursed at the full amount allowed by BWC?
7A: Check the Fee schedule look-up to determine the appropriate reimbursement amount. When utilizing the look up, keep in mind that rates for services performed in a doctor’s office are shown under non-facility. The rates for services performed in any other setting are shown under facility.
8Q: What do I do if the injured worker either does not have a claim number, or has several claim numbers?
8A: Check the injured worker’s Claim history profile, which will give you a list of all claims filed under the injured worker's Social Security number. This profile enables you to see the allowed diagnosis for all of the injured worker’s claims to determine which (if any) claim to submit your bills against or if a new claim must be filed.
9Q: Why was my bill denied for not having either sufficient medical or medical documentation? I already submitted this information with my bill.
9A: Contact the MCO that medically manages the claim to discuss the denial. If the MCO intended to deny the bill but used the wrong EOB code, you will have to correct your bill and resubmit. However, if the MCO denied the bill in error, it must correct its mistake and cannot require you to submit a new bill.
10Q: The claim is listed as self-insured but no MCO is listed. Where should I send the bill?
10A: Self-insuring employers do not participate in the Health Partnership Program (HPP), so there is no MCO for the claim. The bill should go directly to the employer or its third-party administrator. Contact the employer for correct billing information or call 800-OHIOBWC, and press 23.
11Q: Can I bill the injured worker?
11A: BWC discourages but does not forbid providers from billing injured workers, who in turn must seek reimbursement from BWC. However, this process places a burden on the injured worker, who in addition to dealing with his or her health concerns, must then contend with billing forms, procedure codes, etc. Providers considering billing injured workers due to past billing difficulties should e-mail the HPP provider inquiry, or call 1-800-477-2292 for assistance.
1Q: How long does it take for BWC to determine the status of a claim?
1A: After receiving the First Report of Injury (FROI), BWC notifies the injured worker, employer and their authorized representatives that a claim has been filed. Within 28 days of this notice, BWC is legally required to determine the claim. However, BWC makes every effort to render a decision on the claim in advance of this time frame, which has resulted in average claim determination times of 11.1 days from the date the claim is received, and 7.8 days from the date the claim is assigned to a claims service specialist (CSS). Meeting our legal obligations and customer expectations depends on how quickly we receive all evidence related to the claim, particularly medical documentation. Providers assist with meeting these goals by submitting medical information to the injured worker's managed care organization (MCO) when either submitting the FROI, or shortly thereafter.
2Q: How long does it take to receive a claim number?
2A: After receiving a first report of injury (FROI), the MCO electronically transmits the information about the injury to BWC's system. Upon receiving that initial notification from an MCO, BWC automatically assigns a claim number to the reported injury. If you file your claim online, you will immediately receive a claim number. Otherwise, the injured worker and employer will receive written notice of the claim number. If the provider number was submitted to the MCO, the treating physician or provider who reported the injury also will receive written notice from BWC.
3Q: Why isn't the diagnosis that I put on the FROI the same as what's allowed in the claim?
3A: BWC must have supporting medical documentation to allow a diagnosis in a claim. If the medical documentation does not support the condition that you submitted on the FROI, BWC may allow a diagnosis that the documentation does support. You may want to refer to BWC’s Diagnosis Determination Guidelines which give the subjective and objective physical findings necessary to substantiate the top 30 diagnosis codes used at BWC.
|First Report of Injury (FROI)||Top|
1Q: Who is responsible for filing the FROI?
1A: BWC Rule 4123-6-028 requires providers to report new injured worker claims to the responsible managed care organization (MCO) within 24 hours or one business day of the initial treatment or initial visit.
2Q: What if an injured worker or employer is unable to provide the name of the MCO?
2A: Employer — MCO assignments are available online. If you are unable to access this information, call 1-800-OHIOBWC.
3Q: Are there additional provider time frames after submitting the FROI?
3A: Yes. There are other time frames to be met. Providers play a critical role in providing the MCO pertinent medical documentation and diagnosis information during the initial phase of a new injury.
4Q: What if I can't determine which MCO is responsible for the injured worker's claim?
4A: If you have searched using the Employer/MCO look-up and you have called 1-800-OHIOBWC but still cannot determine which MCO is responsible, you may mail or fax the FROI to the BWC customer service office closest to the injured worker’s home.
5Q: Can the FROI be filed online?
5A: Yes. The FROI can be completed and filed online. File the FROI electronically and you will immediately receive a claim number.
1Q: What medical documents are providers required to submit?
1A: Ohio workers’ compensation rules and policies require providers who are treating injured workers to submit initial and subsequent reports to the managed care organizations MCOs on behalf of injured workers. Providers must supply medical documentation to the MCOs when requesting treatment authorizations or when requested by the MCO, BWC or a self-insuring employer.
2Q: When does a provider need to update the injured worker's MCO?
2A: In some instances, it is necessary for the provider to update the MCO either when making a treatment request or at various points during the treatment of the injured worker. Examples of the circumstances or documents that require updates include:
3Q: Is a signed release of medical information required to provide information to either the injured worker's MCO or BWC?
3A: Under Ohio law, by filing a workers’ compensation claim, the injured worker authorizes the release of all information related to the claim to BWC, the MCO or any of the claim’s parties (i.e., the injured worker, employer and their authorized representatives). Consequently, submitting medical documents does not require a separate release of information.
4Q: Where does BWC maintain all of the documentation submitted by medical providers?
4A: Needless to say, BWC and the MCOs receive and compile a great deal of medical documentation that has been submitted in support of injured worker claims. To help manage this information, BWC electronically stores documentation submitted by providers in our medical repository system. Through an automated process, when a provider faxes documents to the injured worker’s MCO, copies of this information are automatically captured by BWC’s medical repository.
5Q: What information should be included with the medical documentation being faxed to the injured worker's MCO?
5A: To avoid confusion and to assist with matching the medical documents with the correct claim, please separate all information for each injured worker and submit it along with an individual coversheet. On the coversheet, include the injured worker’s name, Social Security number (if possible) and claim number. Also, please include this information on each page of the fax. Following these steps will provide BWC and the MCOs with important information and minimizes the possibility that claim authorizations will be delayed.
6Q: How can I access BWC's medical repository?
6A: Providers who are attached to a claim (i.e., associated with an injured worker’s claim) in our computer system as either a physician of record (POR) or a treating physician can access imaged documents in the medical repository. Additionally, the physician must be one of the following provider types: medical doctor, doctor of osteopathy, chiropractor, dentist, psychologist, podiatrist or mechanotherapist/doctor of mechanotherapy. Also, physicians who are enrolled with BWC’s Disability Evaluators' Panel (DEP) can access the medical repository. DEP physicians, however, do not need to be attached to the claim.
7Q: What is DISCWeb and who can use it?
7A: DISCWeb is software that enables users to view all imaged information for an injured worker’s claim. Images are electronic snapshots of all documentation that is received for an injured worker’s claim. Rather than maintaining numerous, paper-based claim files, BWC maintains paperless files that can be referenced via computer and, when necessary, reproduced.
|Pharmacy benefits manager (PBM)||Top|
1Q: How soon after an injury occurs can an injured worker have a prescription filled?
1A: To pay for medical benefits, the injured worker’s claim must be allowed by BWC. However, physicians often write prescriptions for injured workers before a claim has even been filed with BWC; this does not mean that the injured worker has to wait until the claim is allowed to have a prescription filled. In these situations, the pharmacy must be aware of the unique requirements of BWC.
2Q: When filling prescriptions for a newly injured worked, is the BWC claim number required to submit a drug bill electronically to BWC's PBM?
2A: For newly injured workers, the BWC claim number is not required to submit a drug bill electronically to BWC’s PBM. When an injured worker arrives at the pharmacy right after the injury, he/she should be asked for his/her Social Security number and the date of injury. When this data is submitted to the PBM, the pharmacy provider is notified that the injured worker’s claim is new or not yet allowed, and of the amount that will be reimbursed by BWC if the claim is ultimately allowed. This amount appears in most pharmacy systems as the co-payment amount on the pharmacy receipt, and is the amount that the injured worker should be charged for the prescription as it is the amount that will be reimbursed directly to the injured worker when the claim is allowed. This process benefits injured workers because their out-of-pocket expenses are less than what they would pay as a cash customer. This also speeds the reimbursement process as this serves to submit the drug bill at the point-of-service so there are no delays associated with completion of paper invoices, which also saves the pharmacist the time and effort associated with completing reimbursement forms.
3Q: What does accept assignment mean and how does it work?
3A: Another unique program function of the BWC program affords the pharmacy the opportunity to increase the amount it is reimbursed, increase prescription volume and increase customer satisfaction. This is the ability of the pharmacy to accept assignment on new or pending claims. Accepting assignment means that in the cases of new or pending claims instead of asking the injured worker to pay for the allowed amount of the prescription, you provide the medication at no charge to the injured worker. When the claim is allowed, instead of the injured worker being reimbursed, the pharmacy receives payment directly from the PBM. For providing this service to the injured worker, you will be reimbursed an additional $2.50 per allowed prescription.
4Q: What is required to bill for a prescription in an existing claim?
4A: The pharmacist should transmit at least two of the following three items, along with the other billing information, to the PBM:
5Q: An injured worker has returned to the pharmacy stating that we did not submit bills electronically at the time of services. How can this injured worker be reimbursed for prescription costs?
5A: The pharmacist has two options in this case. You can submit the bills electronically to BWC’s PBM, and if the injured worker’s claim is allowed, you will be reimbursed directly by the PBM. You should then reimburse the injured worker the amount paid to you initially for the prescription.
6Q: BWC was paying for an injured worker's prescriptions, but they are now being denied?
6A: There are a number of reasons why a prescription bill may be denied. This includes:
7Q: The PBM will not reimburse for an injured workers’ syringes, dressings or other medical supplies that I submit electronically at the point-of-service. How do I receive reimbursement for these items?
7A: Medical supplies and durable medical equipment (DME) must be billed to the MCO assigned to the claim using Health Care Financing Administration's Common Procedure Coding System (HCPCS codes) on either a HCFA-1500 or BWC's Service Invoice (C-19).
|Provider enrollment and certification||Top|
1Q: What is the difference between enrollment and certification?
1A: Enrollment is the process of entering provider data into BWC’s database. Enrollment information includes the provider’s business names, addresses, specialties, business relationships, etc. Certification is awarded when providers meet or exceed BWC’s minimum credentialing criteria.
2Q: What is a BWC-certified provider?
2A: A BWC-certified provider is a credentialed provider who is approved by BWC for participation in the Health Partnership Program (HPP) and who has signed a provider agreement with BWC.
3Q: How will I know if a doctor is a BWC-certified provider?
3A: You can click here to access BWC's Certified Provider Look-up, or you can contact BWC's provider relations department by calling 1-800-OHIOBWC, and following the options.
4Q: Do I need to be certified to see injured workers?
4A: Per Rule 4123-6-12 for claims with dates of injury on or after Oct. 21, 1993, injured workers must see a BWC-certified provider. For claims with dates of injury prior to Oct. 20, 1993, injured workers may continue to be treated by their physicians of record even if they are not BWC-certified. However, in the case of a claim prior to Oct. 20, 1993, if injured workers change providers, they are required to see one that is BWC-certified.
5Q: How long does the enrollment/certification process take?
5A: Generally, it takes four to six weeks after BWC receives the required information.
6Q: May providers request for an address change over the phone?
6A: All requests for address or tax identification changes must be submitted in writing. You may complete the Request to Change Provider Information (MEDCO-12), and send it to BWC at the address or fax listed on the form.
7Q: If a provider changes from one group practice to another, does his/her provider number change, also?
7A: An individual servicing provider may keep his/her provider number regardless of changes in his/her affiliation with group practices.
8Q: If we have more than one provider location, does each location need to be enrolled and certified?
8A: In these cases, each physical location must be enrolled and certified.
1Q: What is Chapter 4 and how do I obtain it?
1A: Chapter 4 refers to the rehabilitation section of the MCO Policy Reference Guide, which is updated quarterly. It is the primary source of BWC policy information for vocational rehabilitation service delivery. The managed care organizations (MCOs) are contractually obligated to adhere to these guidelines. Your MCO must provide you with these guidelines on a quarterly basis. They may also be obtained from BWC's forms and publications department by calling 1-800-OHIOBWC and following the options.
2Q: As a rehabilitation provider, who should I contact regarding issues related to the injured worker's vocational rehab case?
2A: Each injured worker is assigned a disability management coordinator (DMC) on the customer service team in the injured worker’s local customer service office. DMCs specialize in rehabilitation and their duties include addressing specific questions about the injured worker’s rehab case.
3Q: Policy guidelines say that each vocational rehab plan must identify a specific job goal. Will it suffice to say that the injured worker will be returning to a different job with a different employer?
3A: No. Different job, different employer refers to one level of the return-to-work hierarchy. A job goal identifies a specific occupation (i.e. word processor) or job family (i.e., clerical). All plan services are then directed toward achieving this return-to-work goal. Pre-plan assessments establish this job goal which may change as the rehabilitation plan progresses.
4Q: Can plan services be extended beyond the Average Durations identified in Chapter 4?
4A: Services identified as having an average duration can be extended with appropriate justification of need. Other services are identified as having maximum time frames which cannot be extended.
5Q: Can an injured worker choose which BWC-certified vocational rehabilitation case management provider is assigned to his or her rehab case?
5A: Yes. The injured worker can make this choice. The injured worker must submit that information in writing to the MCO, which will forward the referral on to the specified case manager.
6Q: Since participation in a vocational rehabilitation plan is voluntary, does that mean that the injured worker may choose to not fully participate in plan services?
6A: Participation in vocational rehabilitation is voluntary; however, once a rehabilitation plan is developed and the injured worker agrees to the terms of the plan, he or she must fully cooperate as outlined in the signed Rehabilitation Agreement (RH-1) and Individualized Vocational Rehabilitation Plan (RH-2).