Medical Evidence

Medical documentation from the POR/treating physician supporting the injured worker’s disability due to the allowed work-related injury/disease is required to pay initial and subsequent requests for TT compensation according toRule 4123-6-20(B) .  The physican (back side) C-84/equivalent form is considered sufficient medical evidence to support the disability.  However, a Medco-14 or other supporting documentation may be submitted.

 

If the POR/treating physician authorizes a period of disability prior to the first time the injured worker saw the physician, the CSS should staff with Claims Policy Field Technical Specialist to determine if the period of disability is appropriate.

 

The CSS will contact the POR/treating physician to obtain any information that is missing or needed to make a decision regarding the compensation payment being requested.

 

·         The POR/treating physician will identify if the injured worker was released to return to work or if the POR/treating physician is estimating a return to work date in the future.

 

·         If the POR/treating physician is unable to clarify the periods of disability, the physician’s C-84/equivalent form will be updated to “Processing Error” in application tracking.

 

·         If the physician’s C-84/equivalent form is submitted with less than 8 days of disability and there is no other supporting medical evidence attached indicating lost time, the physician’s C-84/equivalent form is updated to “Processing Error” in application tracking.

 

·         If the injured worker’s C-84/equivalent form is submitted with less than 8 days of disability and the injured worker does not intend to proceed with the request for TT compensation, the injured worker’s C-84/equivalent form is updated to “Withdrawn” in application tracking and a V3 Note is entered.  If the injured worker does intend to proceed with the request for TT compensation, the CSS will refer the issue to the IC for hearing on entitlement to TT compensation.  BWC does not have jurisdiction after the initial allowance decision has been issued.

 

V3 Notes will be updated to document all responses and decisions.

 

 

Initial Payment of TT Compensation without Medical or Injured Worker’s C-84/Equivalent Form

In the processing of initial applications (FROI) in state fund claims, when requesting payment of TT compensation in addition to medical benefits, BWC may approve TT compensation for a period up to 4 weeks without medical documentation if the FROI has been properly completed and signed by both parties, certified by the employer and non controversial according to  Rule 4123-3-09(B)(1)(b) .

 

·         Oftentimes there may be a slight delay between the date of injury and the date the injured worker is able to get an appointment with the POR/treating physician.  When this occurs, TT compensation is payable from the date of injury as long as the FROI is completed and signed by both parties, certified by the employer, non-controversial.  Also, the injured worker must be off work due to the allowed conditions for 14 consecutive days in order to be paid for the first seven days.

 

In certain circumstances, such as catastrophic or for a short closed period of disability within the four weeks (when no conflict exists), payment can be made without the injured worker’s signature.

 

The CSS must verify the period of disability with the injured worker and/or employer during the initial investigation. 

 

In catastrophic claims, payment beyond the first 4 weeks may be considered without the injured worker’s signature.  However, the CSS must staff with the team leader and/or a Claims Policy Field Technical Specialist prior to extending TT compensation beyond the 4 weeks without the injured worker’s signature.

 

If the claim is assigned to Medical Claims at the time the C-84/equivalent form is received, the claim will automatically be reassigned to the appropriate Service Office for investigation and processing.

 

 

Allowed/Non-Allowed Conditions Listed on the Physician’s C-84/Equivalent Form

According to Ohio Supreme Court case Bradley v IC, payment of TT compensation must be based solely on allowed condition(s) in the claim.  The allowed condition(s) cannot combine with non-allowed condition(s) to produce temporary total disability.

 

The CSS will verify all conditions listed on the physician C-84/equivalent form/Medco-14 and/or the attached supporting medical documentation with the claim information for accuracy.

 

If one or several allowed conditions on the physician C-84/equivalent form or medical report are listed along with a condition(s) that are not allowed, the CSS will need to contact the POR/treating physician’s office to verify the following:

 

·         Is/are the allowed condition(s) in the claim preventing this injured worker from returning to work?

·         The allowed condition(s), not the disallowed condition(s), are still prohibiting the injured worker from returning to work and inform the POR/treating physician of the disallowed condition(s).

 

If non-determined condition(s) are listed, the condition(s) must be reviewed for possible proactive allowance or send a motion required letter.  If there is insufficient medical documentation on file, the CSS will request the information from the POR/treating physician’s office. 

 

If clarification cannot be obtained, the issue is referred to the IC.  If the injured worker is currently receiving TT compensation, it will continue until the IC addresses the conflict because BWC does not have jurisdiction to terminate TT compensation in these situations.  However, if the injured worker is requesting a new period of TT compensation, BWC will not begin payment because there is not sufficient evidence to support the new period. 

 

If the injured worker’s POR/treating physician states that the injured worker is temporarily and totally disabled due to any allowed condition(s) in the claim, the injured worker is entitled to TT compensation.  The CSS will document the POR/treating physician’s response in V3 Notes regarding the conditions that prevent the injured worker from returning to work.

 

Note* The CSS must ensure that the POR/treating physician is listed/added to the Maintenance Provider window on V3.  This will ensure that if/when ICD codes are added to the claim the active physician will receive notice.

 

 

Returned to Work (RTW) Dates Listed on the Physician’s C-84/Equivalent Form

If the estimated or actual returned to work (RTW) date is in the past, the CSS will contact the injured worker, employer, or the authorized representatives to verify the return to work date prior to making the payment.

 

If the estimated or actual RTW date is in the future, the CSS will contact the injured worker, employer, or authorized representatives to verify that the injured worker has not yet returned to work.  The CSS should also inform the parties of the importance of calling BWC immediately if the injured worker returns to work.  This will help to minimize incorrect payments that may occur if the injured worker returns to work before or after the date indicated.

 

·         Temporary total compensation is paid through the day before the actual or estimated return to work (e.g., If the actual or estimated return to work is 5/31/09, TT compensation is paid through 5/30/09).

 

When TT compensation is paid into the future with an estimated RTW date,  the CSS will set a diary at least 2 weeks prior to the end date of the TT compensation to follow up to determine if the injured worker is expected to RTW on the estimated date.  The CSS will follow the workflow for “No C-84” titled Medical Supporting Period of Disability Received without C-84 from IW.  This workflow is located on COR under Temporary Total Disability Workflow and Operational Guidelines.  If the injured worker is not expected to return to work, the CSS will send a C-84 to the injured worker and set another diary to follow-up on the receipt of the C-84/equivalent form.  If it is expected that the injured worker will RTW on the estimated date, a diary is set for the estimated RTW date to remind the CSS to follow up and get an actual RTW date. 

 

The V3 Benefit Plan must be built to match the period of disability indicated by the POR/treating physician on the supporting documentation.

 

If the POR/treating physician indicates that the injured worker is able to return to his/her former position, TT compensation is paid through the day before the date the injured worker was released.  If no date is provided, the CSS will follow up with the POR/treating physician.

 

 

POR/Treating Physician Releases RTW with Restrictions

According to RC 4123.56  if the POR/treating physician has released the injured worker to return to restricted (light) duty, but the employer is not able to accommodate the restrictions, the injured worker may still be entitled to TT compensation until the employer can accommodate or the restrictions are lifted.  The restrictions must prevent the injured worker from performing his/her job duties at the time of the injury.  In some instances, the injured worker may also be entitled to Wage Loss (WL); however, the injured worker cannot be made to apply for WL compensation.  Additional information can be found in the Wage Loss compensation policy located on COR.

 

 

POR/Treating Physician States MMI

If the POR/treating physician indicates that the injured worker has reached maximum medical improvement (MMI), TT compensation will be terminated as of the date listed on the physician C-84/equivalent form. Additional information on MMI is available on COR under Maximum Medical Improvement (MMI).

 

 

POR/Treating Physician Signature on the C-84/Equivalent Form

The POR/treating physician signature is required to pay TT compensation.  A stamped signature, as well as an electronic signature from the POR/treating physician, is acceptable.  Additional information regarding physician signature on medical evidence by provider type is available on COR in the Medical Evidence for Diagnosis (MEDD) policy.  The CSS will discuss with the POR/treating physician the other authorized staff who can sign the physician C-84/equivalent form (POR’s designee, a Provider Assistant (PA) under the POR’s/treating physicians guidance, or a physician in the same group practice, etc).  It is reasonable to assume that the POR’s/treating physician’s designee has some knowledge of the injury, work history, medical history and/or may have examined the injured worker.  The POR/treating physician designee will sign for the POR/treating physician and include his/her own initials on the form.  However, while a PA can sign as a POR designee, he/she cannot sign a physician C-84/equivalent form or certify compensation in his/her own name.  If the physician C-84 is submitted online, the electronic signature must be that of the POR/treating physician.

 

 

BWC Certified/Non-Certified POR/Treating Physician

The POR/treating physician does not have to be BWC certified to complete and sign the physician C-84/equivalent form.  However, payment for treatment/services rendered by a non-certified POR/treating physician is the responsibility of the injured worker.  The POR/treating physician may enroll with BWC in order to be paid and become certified by BWC.

 

If any POR/treating physician does not submit additional medical documentation as requested, it is the responsibility of the injured worker to provide the information.