BWC requires prior authorization for non-emergency treatment and services through the submission of a C-9 or its equivalent, to the MCO.
MCO standard prior authorization table
There are specific instances, however, when services are provided within the first 60 days from the date of injury, that physicians have
presumed approval to provide treatment and services for specific work-related injuries – soft tissue and musculoskeletal injuries – the most
common BWC injuries, if specific criteria are met.
Presumptive approval guidelines are meant to further BWC’s goal of expediting early treatment management for allowed conditions in
allowed claims. By eliminating wait time for authorizations, you may immediately schedule diagnostic testing and other procedures covered
under the presumptive approval criteria at the time of the office visit. Quicker treatment means faster recovery, lower disability
costs and injured workers returning to gainful employment.
Presumptive approval criteria (All criteria must be met.)
Treatment is for a soft tissue or musculoskeletal injury (such as sprains, strains, superficial injuries and contusions, per
the International Classification of Diseases (ICD) manual) for allowed conditions in allowed claims and includes only the following treatment(s):
All of the following are completed prior to initiating treatment noted above:
- A maximum of 12 physical medicine visits per injured worker claim which may include any combination of osteopathic
manipulative treatment, chiropractic manipulative treatment, and physical medicine and rehabilitation services performed by
a provider whose scope of practice includes these procedures, including, but not limited to, doctor of chiropractic, doctor
of osteopathic medicine (DO), doctor of allopathic medicine (MD), physical therapist, occupational therapist, athletic trainer
or massage therapist;
- Diagnostic studies, including X-rays, CAT scans, MRI scans and EMG/NCV. Note: Medical necessity for the allowed conditions is always the
driver for services. Surgical diagnostics, such as arthroscopic procedures, are not included unless it is an emergency. (MCO case managers
may advise providers when they identify procedures that do not appear to be medically necessary but as long as a provider follows commonly
accepted treatment guidelines when treating allowed conditions in a claim, the bill will be paid);
- Up to three soft tissue or joint injections involving the joints of the extremities (shoulder including acromioclavicular, elbow, wrist,
finger, hip, knee, ankle and foot including toes) and up to three trigger point injections. Note: Injections of the paraspinal region,
including epidural injections, facet injections, and sacroiliac injections are not included in the presumptive approval guidelines;
- E/M services and consultation services.
- The First Report of Injury (FROI) is filed with the MCO;
- The Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial
Injury or Occupational Disease (C-9) is filed with the MCO. The MCO will notify the provider within three business
days acknowledging receipt of the C-9 and that a review was completed to ensure that services being rendered
are medically necessary for the claim allowance. When the claim or condition for which treatment is being requested
is not yet in an allowed status, the MCO may use disclaimer language notifying the provider that service will not
be paid if the claim is not allowed;
- The MCO is notified within 24 hours of treatment if the injured worker will be off work for more than two calendar days.