OhioBWC - Provider - Service:  NewClaims

Prescription billing for new claims

BWC expects pharmacy providers to submit bills for new injuries online through BWC's pharmacy benefit manager (PBM), even before the injured worker has a BWC claim number. They should use the injured worker's Social Security number and date of injury.
Note: Pharmacy providers should not submit any portion of a bill for a medication used to treat a work-related injury to a private health insurance carrier.
The PBM will inform the pharmacist that this is a new claim and will return the amount BWC would reimburse for the prescription. The pharmacist can elect to collect this amount from the newly injured worker or choose to accept assignment.

If the pharmacist wishes to accept assignment, the pharmacist must reverse the initial billing and re-submit the bill to the PBM with the prior authorization number 999000000.
Note: When the pharmacist accepts assignment for initial prescriptions in new claims, there is an additional dispensing fee reimbursed when the BWC claim is allowed.
In these cases, the injured worker does not have to pay, and the PBM will automatically reimburse the pharmacy once BWC allows the claim.

If a pharmacy does not accept assignment, the injured worker is asked to pay the BWC fee schedule amount for the prescribed medication at the point of sale. The PBM will automatically reimburse the injured worker once BWC allows the claim.

In either case, if BWC disallows the claim, the bill becomes the injured worker's responsibility. The use of the Outpatient Medication Invoice (C-17) for injured worker's outpatient medication reimbursement should be rare and limited to special circumstances.