for Physicians & Providers HPP Reference Guide€¦ · HPP GUIDE.fh11 8/14/07 7:19 AM Page 1...

HPP GUIDE.fh11 8/14/07 7:19 AM

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HPP Reference Guidefor Physicians & Providers

2007/2008

CD-106Revised August 2007

Total copies printed: 5000Unit cost:


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Table of contentsForeword..................................................................2Ohiobwc.com...........................................................3Provider certification ................................................4Reporting injuries .....................................................5Outpatient medication..............................................7Pharmacy billing .......................................................8Medical management ..............................................9Billing and reimbursement .......................................17Appendix ..................................................................20

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AppendixBWC Provider Fee Schedule

The BWC Provider Fee Schedule is available online atohiobwc.com. You may download a copy by clicking onMedical Providers, then Forms. You may also access aninteractive version of the form by clicking on MedicalProviders, Look-ups, and then Fee schedule look-up. BWCupdates both versions on its Web site as changes occur.

BWC is examining medical payment methodologies toput a structure in place in 2007 that reflects the interestsof Ohio’s injured workers and employers withoutcompromising fair and equitable reimbursements toproviders. Look for additional information about the bureau’s2007 provider fee schedule in BWC Provider Update07-4, scheduled for release in late November 2006.


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ForewordThe Health Partnership Program (HPP) is the Ohio Bureauof Workers’ Compensation’s (BWC’s) program formanaging workers’ compensation health care for injuredworkers employed by state-fund employers. It is mandatedby the Ohio legislature under House Bill 107. BWCemployees, business leaders, labor representatives andhealth-care providers designed HPP.

BWC and private-sector managed care organizations(MCOs) certified to participate in HPP work together tohelp manage workers’ compensation claims andcoordinate medical services with an emphasis on returninginjured workers to work safely and efficiently. BWC andthe MCOs’ shared goal is to provide the best servicepossible for employers and injured workers. This includesforging relationships with doctors and medical providers,rewarding employers who run safe workplaces andopening new opportunities for injured worker.

Return to work — A key factor in return-to-work successis HPP’s focus on quality. While a certain medicalprocedure may incur a higher up-front cost, the impacton a more timely and safe return to work often offsetsthat cost. An injured worker’s physician and MCO willwork together to determine the optimal return-to-workdate for full or modified duty based on the injury and typeof work.

Often times, going back to work mid-week allows injuredworkers more time to readjust to their original job demandswithout being worn out by a full work week. It alsoimproves the chances of injured workers remaining atwork. For employers, the benefits include reducing thecost of replacing injured workers and the total cost of theclaim. In addition, it results in lower employer reserves,helping to prevent a medical-only claim from becominga lost-time claim.

Presumptive authorization — This process allows aphysician to provide basic treatment for the most commonwork-related injuries up to 60 days from the date of injury.

Vocational rehabilitation services — The longer aninjured worker is off work the more difficult it becomesfor that worker to return to work. MCOs work with injuredworkers, employers and medical providers with the goalof promoting an early and safe return to work. Vocationalrehabilitation services help return the injured worker tothe original job whenever possible, or to a different job

with the same employer. If that is not possible theseservices help the injured worker secure a similar jobwith another company or a different job with a differentemployer.

Remain at work — A workplace injury does not haveto result in a long absence. Managed by the employer’sMCO, the remain-at-work program provides injuredworkers with rehabilitation services that help reduce oreliminate the number of days they are off work andkeeps medical-only claims from becoming lost-timeclaims.

Transitional work — Studies have shown the likelihoodof injured workers returning to work after six months is50 percent. This figure drops to 25 percent after oneyear and almost zero after two years off the job. Atransitional work program uses real job duties toaccommodate injured workers’ medical restrictions fora specified time period to gradually return them to theiroriginal jobs.

These five initiatives focus on ensuring injured workersreceive the right services at the right time, thus, avoidinglong debilitating periods off work. Your role is vital duringthis period. While providing your specialized skills, youhave the opportunity to reinforce return-to-workexpectations and encourage injured workers to activelyfacilitate their recovery and return to the job.

The American Academy of Orthopedic Surgeons andthe American Association of Orthopedic Surgeons believesafe, early return-to-work programs are in the patients’best interest. Return to light-duty, part-time or modified-duty programs are important in preventing the onset ofpsychological and other behavior patterns that get in theway of injured workers successfully returning to workand to normal lives.

As a critical player in the HPP design, providers mustunderstand the basis and goals of return-to-workstrategies and optimal return-to-work expectations forinjured workers. It also is important to understand theroles BWC and MCOs play in this partnership.

BWC is responsible for:

• Making claim determinations and allowances;• Paying compensation;• Educating injured workers, employers and providers

about HPP;• MCO oversight.

Billing and reimbursement flow

MCO denies the bill within

seven days.

MCO approves the bill within

seven days.

Bills that are denied as improper

invoices are returned to

providers for correction/

resubmission.

MCO submits bill electronically

to BWC.

BWC receives and validates bill

within seven days.

BWC approves bill.

BWC sends payment to MCO.

Within seven days, MCO sends

payment to provider.

BWC must allow claim.1

Provider submits bill to MCO.2

MCO receives bill.3

BWC does not cover

bills for unapproved

treatment or unrelated

conditions.

2 19

Bills that are denied are

returned to MCO for

correction/resubmission.


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number assigned but as an alternate and additionalidentifier that providers can use in Ohio workers’compensation billing.

BWC is not a covered entity under HIPAA and will continueto accept bills containing only BWC legacy (or current)numbers as well as bills containing both the legacy andthe NPI.

BWC is making changes to effectively add provider NPIdata into its provider enrollment and eligibility database,then to crosswalk the NPI received on invoices to theBWC Provider ID. This approach permits BWC to continueto process bills in a way that is accurate and consistentwith laws, rules and policies governing the payment ofworkers’ compensation medical benefits.

Billing tips

Do:• Submit bills to the appropriate MCO;• Submit bills according to BWC format;• Use the BWC issued 11-digit servicing provider number

in box 25 on the CMS 1500 or box 11 on the C-19;• Bill the actual diagnosis(es) treated;• Submit documentation in cases where services billed

do not correspond to treatment that was requested and approved or if needed to support services rendered;

• Follow form completion guidelines in chapter 4 ofthe BRM;

• Attempt to resolve outstanding billing issues with thespecific MCO;

• A grievance conference can be scheduled with the MCO over medical billing disputes with additional appeal to BWC if needed. This is not applicable to disputes over BWC’s fee schedule rates.

Don’t:• Submit bills with the FROI;• Bill the injured worker for the balance, or ask for

co-payment;• Request payment from the injured worker for

reimbursable covered services;• Unbundle services.

MCOs are responsible for:

• Reporting claims;• Assisting injured workers in securing appropriate

medical treatment from an approved, BWC-certified provider;

• Medical case management, including reviewing treatment requests and making treatment decisions;

• The first level of dispute resolution;• Bill review and payment;• Educating and assisting employers and providers

regarding return-to-work initiatives.

Ohiobwc.comOhiobwc.com is BWC’s e-business service. It allowsthe bureau to use technology to provide its customerswith consistent, customized, streamlined service 24hours a day, seven days a week.

Log on to ohiobwc.com and find out how fast, efficientand easy it is to have all of your workers’ compensationinformation and services at your fingertips.• BWC Library — Take a guided tour to learn more about

processes and policies. Get answers to frequently asked questions and definitions for workers’compensation terms in the provider glossary.

• Medical bill payment look-up — Providers can viewmedical bill payment information. You can alsocustomize bill searches to verify BWC received yourbills from the MCO and made provider paymentsto MCOs.

• Billing and reimbursement — Access and download the online Provider Billing & Reimbursement Manual(BRM). You can also view or print reimbursementpolicies/procedures and quarterly updates. The bureauissues a quarterly newsletter titled BWC ProviderUpdate to notify providers about updates to the BRM.All providers on Web site look-up receive the newsletter.The current and previous three editions of thenewsletter also appear online.

• Claim documents — Providers who meet BWC’ssecurity criteria can access Claim documents,a repository of imaged documents from individualclaim files.

Additionally, with ohiobwc.com, providers can:

• View basic claims information, including InternationalClassification of Diseases, Ninth revision (ICD-9)codes, claim status, date of injury, accident descriptionand the assigned MCO;

• Verify BWC-certified providers through the BWC provider look-up;

• Determine an employer’s MCO with BWCEmployer/MCO look-up;

• View the BWC Provider Fee Schedule;• Download BWC forms, including the First Report of

an Injury, Occupational Disease or Death (FROI), Physician’s Request for Authorization of Medical Services or Recommendation for Additional Conditionsfor Industrial Injury or Occupational Disease (C-9) andRequest for Temporary Total Compensation (C-84). Then, users can print these forms, complete and submit them via mail, fax or in person;

• File the FROI electronically allowing a claim numberto be asigned immediately;

• Download BWC Diagnosis Determination Guidelines,a reference guide, to provide criteria for diagnosis determination/coding decisions between BWC and MCOs for the most frequently used diagnosis/ICD-9 codes;

• Look up an injured worker’s claim history by Social Security number;

• File a Physician’s Report of Work Ability (MEDCO-14),which lists an injured worker’s restrictions but also says what he or she is medically able to do.

Remember, to ensure confidentiality, you must createa primary account before accessing injured workerinformation. You can create secondary users from thisaccount so each of your employees can have individualpasswords.

A new service offering, Group provider relationshipadministration, now available on ohiobwc.com makesaccessing claim information easier for physician of record(POR) provider types associated with group practices.

Group provider relationship administration gives PORprovider types with e-accounts the ability to delegateor revoke their e-account privileges to a group providertype (provider type 12). POR provider types may notdelegate e-account privileges to any other provider types.

Provider groups with multiple POR provider types willfind this new offering helpful. Once each POR providertype delegates e-account privileges to a group, anyperson logged on under that group provider number canaccess the same information as the POR provider type.

For more information about provider services, or forhelp creating a BWC provider e-account (user ID andpassword), call 1-800-OHIOBWC, and listen to theoptions. You also can e-mail the provider relationsdepartment at [email protected].

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Billing andreimbursementThere are various methods for submitting bills, and it isthe provider’s responsibility to ensure he or she bills theappropriate party.

An electronic transmission in the ASCX12 837 format isthe preferred method of submitting bills to the properMCO. You can find implementation documentation forthe 837 on BWC’s Web site, ohiobwc.com.

You also can find addresses to submit hard-copy bills toMCOs in the MCO Directory on ohiobwc.com.

Follow the guidelines in chapter four of the BRM whensubmitting bills to MCOs. You may also view anddownload the BRM from ohiobwc.com. If youcannot access the BRM online, call 1-800-OHIOBWC,and listen to the options, or e-mail your request [email protected].

To ensure consistent billing processes and to maintainquality customer service, all BWC-certified MCOs acceptthe following national and BWC billing forms:• American Dental Association (ADA) dental form;• Centers for Medicare & Medicaid Services CMS 1500;• Uniform Billing (UB 92 and UB-04);• Service Invoice (C-19).

Please do not bill the injured worker or the employer forstate-fund claims.

When billing BWC or MCOs for services, you must codethe service according to the guidelines in the BRM.

Self-insured claims are not part of HPP. Self-insuringemployers will continue to pay for their employees’workers’ compensation benefits. Please send medicalbills directly to the self-insuring employer.

ICD-9-CM

BWC groups ICD-9-CM codes into numeric sets. It definesan ICD-9 group as an injury or condition similar in nature,and/or one involving the same body part, and can containone or more ICD-9 codes. All codes in that group areinterchangeable, and BWC can use them for allowanceand reimbursement purposes.

MCOs and BWC may accept valid V diagnosis codes onbills. You may not use E codes except as other diagnosis

codes or admitting diagnosis codes on hospital bills.The bureau does not recognize these codes for allowanceor reimbursement purposes.

Important: Do not bill using an invalid ICD-9 code. Yourbill will not be paid.

You can order copies of BWC’s ICD-9 groups and invalidICD-9 codes by either calling 1-800-OHIOBWC andlistening to the options or downloading this informationfrom ohiobwc.com.

MCOs determine medical reimbursment eligibility in aworkers’ compensation claim for specific, allowedconditions. That’s why ICD-9 diagnosis codes are requiredto identify medical conditions providers treat.

The provider must bill the diagnosis code for the conditionhe or she treats. Even if you know BWC has not allowedthe condition in the claim formally, the MCO has thediscretion and responsibility to coordinate treatmentand decide whether to pay.

Always follow acceptable ICD-9 coding principles. BWCrecognizes the current version of the ICD-9-CM. If youhave any questions about the claim status, includingdiagnosis information, contact the MCO managing theclaim or log on to ohiobwc.com.

Billing time frames

Within seven days, the MCO must either return the billto the provider, if information is invalid, or edit and pricethe bill. Bills that are denied as improper invoices arereturned to the providers for correction/resubmission.

If the MCO approves a bill, it sends the bill to BWC,which validates the pricing and claim status. BWC sendspayment and remittance advice via electronic fundstransfer to the MCO. Within seven days of receivingpayment from BWC, the MCO pays the provider.

By following this flow, you can expect speed, accuracyand fairness in receiving reimbursement for treatmentof injured workers.

NPI - National Provider Identifier

BWC is in compliance with the ability to recognize billsreceived with a provider NPI number. We request thateach provider also submit their BWC legacy ( or current)number along with their NPI on bills and must send theirNPI to provider enrollment first. (See pg. 5) BWC doesnot view NPI as a replacement of the BWC provider

E-business revolutionizes how BWC does business, but it does not replace people with technology. Customerswho prefer dealing with a person have the option of doingso. And since the system frees BWC employees frommany time-consuming tasks, it allows us to provide moreefficient customer service.

Provider communications

For ongoing provider communications, BWC publishesquarterly updates to the BRM. To obtain a BRM Update,BWC Law Book or BWC Rule Book, call 1-800-OHIOBWCand listen to the options, or e-mail your request [email protected].

For a complete listing of MCO contact information, seethe MCO contact tables in the BRM, or go online toohiobwc.com. BWC will incorporate any revisions to thislist in future BRM Updates and online at ohiobwc.com.

Provider certificationIn HPP, there are three provider categories:

1. BWC-certified provider — A provider BWC has approved for participation in HPP and who signs a BWC provider agreement;

2. MCO panel provider — A BWC-certified provider included within a BWC-certified MCO provider network;

3. Non-BWC-certified provider — A provider BWChas enrolled only for participation in HPP and who has not signed, or been required to sign, a provider agreement with BWC.

With the exception of the following circumstances,

you must be a BWC-certified provider to receive

reimbursement for your services:

• Ongoing treatment of an injured worker with date of injury before Oct. 20, 1993, that began prior to HPP.The injured worker may continue treatment with anon-certified physician. However, an MCO willmanage the care;

• Emergency treatment;• Initial treatment. Non-BWC-certified providers must

have a BWC provider number to receive reimbursementfor these services. If the injured worker changesphysicians, he or she must select a BWC-certifiedprovider or the injured worker will be responsible forpayment;

• Specific provider types listed on Application for ProviderEnrollment Non-Certification (MEDCO 13A).

BWC certification is an ongoing process to accept newproviders in the system. The first step to becomingBWC certified is to complete the Application for ProviderEnrollment and Certification (MEDCO-13). Providersmust also complete the required Declaration RegardingMaterial Assistance/Nonassistance to a TerroristOrganization for Government Business and FundingContracts as required by Ohio Revised Code 2909.33.This form is attached to the MEDCO-13 and should becompleted after viewing the U.S. Department of StateTerrorist Exclusion List located at:http://www.homelandsecurity.ohio.gov/dma_terrorist/terrorist_exclusion_list.pdf

To obtain an application, call 1-800-OHIOBWC, andlisten to the options, or download the application fromohiobwc.com.

If you meet the enrollment and credentialing criteria andsign the provider agreement, BWC will certify you toparticipate in the HPP.

Option 4 To report fraudOption 7 Repeat menuOption 9 Spanish optionOption 0 Customer contact center

1-800-OHIOBWC options

Option 1Injured worker

information

Option 2Employer

information

Option 3Medical andpharmacyproviders

1 Automated information

2 Forms and publications

0 Customer contact centerrepresentative


2 Safety services

3 Self-insured information




2 Pharmacy benefits


4 Drug history review

0 Provider Relations callcenter representative

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C-84 — The POR must complete specific sections of thisform and sign it to indicate the injured worker is unableto work. After the injured worker completes part I of theform, send the C-84 to BWC.

Requesting additional allowances

Periodically, either the treatment of or nature of an injuredworker’s disability may require BWC to add additionalconditions to the claim. For example, BWC may allow aclaim for a lumbar sprain/strain, but additional diagnosisand treatment reveal a herniated nucleus pulposus is theunderlying cause of the injured worker’s disability. Bylaw, BWC must add this condition and pay compensationto the injured worker, and reimburse providers for theirservices.

The proactive allowance policy establishes guidelines forprocessing physician recommendations for additionalallowances. It also provides for better coordination andcommunication between BWC, MCOs and providers onthe result of the bureau’s proactive allowanceconsideration.

BWC’s proactive pursuit of additional allowances providesthe physician an opportunity to deliver services to aninjured worker earlier, resulting in appropriate quality careand the potential for earlier return to work. The policy’sprimary focus is to improve delivery of services, reducelost work days and improve treatment outcomes.

For BWC to consider a proactive allowance request,please forward the following medical data to the assignedMCO. The MCO will ensure the following information isgathered from the physician and submitted to BWC:• Supporting medical documentation, including clinical

examination and diagnostic test findings;• Current treatment plan;• ICD-9 diagnosis code for requested diagnosis (include

specific diagnosis description, e.g.; 722.10 Lumbar HNP, L4-L5 and identify if primary ICD-9);

• ICD-9 location (right, left or bilateral) when applicable;• ICD-9 site (digits, teeth or body part) when applicable;• A causality statement indicating how the mechanism

of injury resulted in requested diagnosis (i.e., is the diagnosis causally related to the industrial accident?).

BWC will consider the physician’s recommendation ofan additional condition(s) when he or she completes anddates the C-9 and/or medical evidence within one yearfrom the date of injury, and the evidence clearly supportsthe condition. The medical documentation, mechanismof injury and time sequence must be defined clearly andsupport the additional allowance recommendation.

BWC will not consider proactively allowing psychiatricor chronic conditions that may be the result of naturaldeterioration or degenerative processes. These includeconditions such as, but not limited to, the following:arthritis, spinal stenosis, spondylolisthesis, degenerativedisc disease or aggravation of a pre-existing conditionor disease; less specific diagnosis of disorders, such asmyalgias, arthalgias or reflex sympathetic dystrophy.

In five to 28 days from the receipt of the recommendation,BWC will either allow the condition or notify the injuredworker or his or her legal representative to request thecondition in writing. BWC also will provide an update tothe physician who recommended the additional allowanceand to the MCO regarding what action the bureau istaking on the proactive allowance.

BWC will not pursue proactive allowance and will alwaysnotify injured workers or their legal representatives to requestthe condition in writing when any of the following occurs:• Any party in the claim, including the injured worker/

employer representative, disagrees with the allowance of the condition(s);

• Psychiatric, degenerative or pre-existing conditions are found;

• The evidence does not clearly establish causality;• It is determined a BWC physician review/exam is

needed.

If the C-9 and/or medical evidence date exceeds oneyear from the date of injury, BWC may still considerproactive allowance if the evidence clearly supports thecondition and causal relationship is established.

Important: Providers may not complete a Motion(C-86) requesting BWC allow an additional condition onthe claim or advise an injured worker to file one.

By law, providers are not parties to the claim; therefore,they cannot appeal decisions regarding additionalallowances to the MCO, BWC or IC. Injured workers,employers or their authorized representatives mustinitiate appeals.

When you sign BWC’s provider agreement, you agree to:

• Comply with Ohio’s workers’ compensation laws andrules;

• Maintain malpractice coverage;• Practice in a managed care environment and comply

with utilization review determinations;• Bill only for services and items performed or provided

and medically necessary, cost-effective and related to the claim or allowed condition;

• Inform the injured worker of his or her liability for payment for non-covered services prior to delivery;

• Charge no more than the usual fee billed to non-industrial patients for the same service;

• Accept reimbursement and not divide/unbundle charges into separate procedure codes when a singleprocedure code is more appropriate;

• Not bill the injured worker or employer for balances.Injured workers are not required to contribute a co-payment and do not have to meet deductibles.

Provider enrollment data

To ensure you receive timely payment for approvedmedical treatments and other information, you mustkeep your provider enrollment information up-to-date.BWC and MCOs use this information regularly to processbills and make payments.

To change provider enrollment data, tax identificationnumbers and group affiliations, complete the Requestto Change Provider Information (MEDCO-12) or submitthe changes in writing on letterhead to: Ohio Bureau ofWorkers’ Compensation, Provider Enrollment Unit, P.O.Box 182031, Columbus, OH 43218-2031. You also mayfax your changes to (614) 621-1333.

When requesting a change to provider enrollment data,tax identification numbers and group affiliations, providethe following information in writing:• Provider name and number;• Effective date;• Telephone number;• Signature of individual assigned to the specific provider

number.

If you’re submitting address changes, please specify:• Physical locations;• Pay-to address;• Correspondence address.

You also must request in writing changes to taxidentification numbers and group affiliations. Pleasespecify when the changes will become effective.BWC plans to recertify providers on a biennial basis.

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Providers wishing to incorporate the use of their NPIinto their Ohio workers’ compensation billing must makesure they have provided their information with verificationto BWC provider enrollment in the BWC provider relationsdepartment. Providers wishing to use NPI in billingshould submit a copy of their NPI confirmation receivedfrom the Enumerator (Fox Systems Inc) to the fax oraddress below.

Ohio BWC Provider Enrollment:Fax: (614) 621-1333

Or mail to:Ohio Provider EnrollmentP.O. Box 182031Columbus, OH 43218-2031

Reporting injuriesProviders must report a worker’s injury to BWC or theappropriate MCO within 24 hours or within one businessday of the initial treatment or visit. Since 24-hour reportingis a legal and contractual requirement, non-compliancecan result in punitive action, such as loss of BWCcertification, removal from an MCO’s panel or both.

Reporting an injury within 24 hours has a number ofadvantages, such as helping BWC expedite the claimsprocess. Generally, the sooner you report a claim, thesooner BWC can allow it. If BWC does not allow a claim,the bureau doesn’t issue payments for either the injuredworker’s compensation or medical bills.

BWC encourages providers to file the FROI online atohiobwc.com. When you file the FROI online, you willreceive a claim number immediately. You also may callthe employer’s MCO, or complete and fax the FROI tothe MCO’s toll-free number found in the MCO Directoryon ohiobwc.com. If you do not know the MCO assignedto the employer, ask the injured worker or employer.You also can check the Employer/MCO look-up featureon ohiobwc.com.

MCOs must transmit 70 percent of the injury reportsto BWC electronically within three business days afterreceiving notice of an injury. MCOs must transmit 100percent of these reports within five business days. TheMCOs rely heavily on providers to supply importantmedical information including BWC-required dataelements and may contact you to gather any additionalrequired information.


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often before BWC assigns a claim number, they sendsome documents to the wrong MCO or directly toBWC. In some cases, documents are lost. This oftenresults in misunderstandings for all involved, delayingthe overall process.

BWC’s medical repository system reduces duplicaterequests from BWC and MCOs to providers for medicaldocumentation. It also coordinates faxes coming fromproviders so MCO and BWC documents are synchronized.

The medical repository process is transparent to providers.Through an automated call-forwarding process, a medicalrepository stores electronic copies of faxed documentsfor viewing by BWC and MCO staff. Each MCO can onlysee documents associated with claims assigned to it.

Providers should continue to fax documents to MCOs.Please refer to the MCO contact information in the MCODirectory on BWC’s Web site, ohiobwc.com, to obtainthe correct toll-free fax number for each MCO.

Send only one fax to the MCO. Do not send a duplicateto BWC. If you receive a request for documentation thatyou faxed to the MCO, ask the requester to check themedical repository first.

Include a fax cover sheet for each injured worker. Also,include the injured worker’s name, Social Security numberor claim number on each page of the fax. Timelysubmission of these medical documents provides MCOsand BWC with important information and minimizes thepossibility of delayed claim authorizations.

A list of BWC forms indexed by the bureau appearsbelow. You will notice the C-9 is not one of thedocuments BWC indexes because an MCO must reviewand either approve or deny information on that formbefore forwarding it to the bureau.

BWC cannot recognize providers NPI’s on any forms.BWC is working to change this, but currently can onlyrecognize this number for billing if it has previouslyreceived this information from the provider (See pg. 5).

Paperwork parameters

With HPP, BWC stresses the importance of focusingon issues and actions involved in the claim. Forms,however, are still necessary as we work together toprovide injured workers with the services they need.Forms you will most likely use include:

FROI — The provider may report the injury by completingand sending this form to the MCO. However, thepreferred method to file the FROI is online atohiobwc.com;

C-9 — The POR or treating physician uses this form tosubmit a treatment request or recommendation foradditional condition to the MCO prior to initiating anynon-emergency treatment;

MEDCO-14 — Form used by physicians for work abilities;

Change of Physician (C-23) — The injured worker mustsign this form and indicate the physician to which he orshe wishes to change and the reason. Send the C-23to the MCO;

BWC forms indexed in the medical repositoryDocument type Description Rationale

C-140 Wage loss application Includes medical restrictions outlined by physicianC-23 Change of physician notice Includes physician informationC-63 Additional information request A V3 letter asking for additional medical informationC-84 Physician’s supplemental report This is a statement of medical disabilityC-85A Application to reactivate claim Form has medical information attachedC-86 Motion Request for additional medical conditionsC-92 Determination of % PP disability Determination of percentage of medical disability

– medical information is attachedC-92A Increase in % of PP disability Determination of percentage of medical disability

– medical information is attachedC-92EXA C92/C92A exams Determination of percentage of medical disability

– medical information is attachedFROI First report of injury Main medical claim formMED Medical documents Medical information that does not fit in the

stated categoriesMEDCO-14 Physician’s Return-to-Work Report Form used by physicians for work restrictionsMEDCO-21 Physician review Forms used by physicians for medical assessment

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Claims flow chart

Injured worker seeks medical treatment.

BWC allows or denies claim.

Allowed claimsMedical management begins. Injured worker continuestreatment from a BWC-certified health-care provider.

MCO and doctor focus on quality health-care servicesgeared to early and safe return to work.

Contested issuesIn contested compensation claims, the IndustrialCommission of Ohio (IC) hears the dispute.

In medical disputes, the MCO and BWC offer a jointlevel of alternative dispute resolution before going tothe IC. (Not on allowed issues.)

Health-care provider files claim online or

with the MCO.

BWC issues claim number and

investigation begins. If you file online, you

will receive a claim number immediately.

What happens after you report an injury?

After receiving an injury report — from you, the injuredworker or employer — the MCO electronically transmitsimportant information about the injury to BWC.

Upon receiving initial notification of an injury, BWCautomatically assigns a claim number to the reportedinjury. If you file the claim online, you will receive a claimnumber immediately. The injured worker and employerwill receive written notice of the claim number. If theMCO received the provider number and submitted it toBWC, the provider who reported the injury also willreceive written notice from the bureau.

Remember, assigning a claim number is the first step inthe initial determination process. It does not mean BWC

has allowed the claim and will pay medical bills. BWC willreimburse providers for the injured worker’s treatment onlywhen it allows the claim and its related medical conditions.If BWC disallows the claim, BWC or the MCO will not paybills for treatments provided to the injured worker.

The MCO will work with BWC to resolve medical andlegal issues, assist in an early claim determination andfacilitate the injured worker’s timely and safe return towork. The MCO may ask you to supply additional medicalinformation to help substantiate the claim or clarify medicalissues related to the workers’ compensation injury. TheMCO will transmit this information to BWC.

Questions of diagnosis and causal relationship are medicalissues that require your opinion before BWC can resolvethem. The bureau must obtain evidence from a physicianwho has examined or treated the employee for the condition.BWC will allow a claim only for a work-related injury.

The provider must report the proper diagnosis for whichthe injured worker is being treated. BWC only pays forinjuries causally related to a workplace accident. Causalrelationship is a medical determination based on reviewof the accident description and injury mechanism.

Injured worker information

• Name* • Telephone number*• Gender* • Social Security number*• Address* • Date of birth*• Marital status • Occupation*

Employer information (The injured worker‘s employer)• Employer name*• Employer address*• Employer telephone number*

Injury information

• Type of injury (accident, occupational disease or death)*• Date of injury (date of death, if applicable)*• Will injury likely result in more than seven days

off work? (yes or no)*• Accident description (detailed account of how

accident happened)*• Date of initial treatment• Date last worked and returned to work (estimated

return to work if exact date is unknown)• ICD-9 diagnosis codes (specific diagnosis description,

including primary ICD-9)• ICD-9 location (right, left, bilateral)• ICD-9 site (digits or teeth)• Injury description (body part injured); for example,

first joint of left index finger)*• Is diagnosis causally related to this industrial

accident? (yes or no)*

Provider information

• Initial treating provider name and BWC provider number (may be a hospital or physician).*

• Name of POR and BWC provider number. (If the MCO receives the BWC provider number and transmits it to BWC, the bureau will send the provider a letter indicating the claim status andthe allowed conditions.)*

Provide the data elements listed below

to MCOs when you report a new injury.

* Indicates data elements required to report an injury within the 24-hour deadline.You must provide the remaining data elements to the MCO no later than fivecalendar days from the initial treatment if not available at the time of the first report.


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BWC’s ADR unit handles the second-level disputeresolution process and keeps the customer service teaminformed of progress and outcomes.

If a disagreement still exists after BWC’s second levelof review, the injured worker, employer or theirrepresentatives may file an appeal with the IC. The ICwill hear the medical dispute only if the parties haveexhausted both levels of ADR.

Effective April 1, 2007, per SB7 and new OAC 4123-6-16 (F) the ADR process shall not be used to resolvedisputes concerning medical services rendered that havebeen approved through standard treatment guidelines,pathways, or presumptive authorization guidelines.

Medical documentation

Providers who treat Ohio’s injured workers assume anobligation to submit initial and subsequent reports to theMCO on behalf of the injured worker. Providers mustsupply supporting medical documentation to MCOs atthe time of the treatment request and reports on outcomesof treatment.

Providers also assume an obligation to provide andcomplete forms required by BWC or the self-insuringemployer. Providers may not charge for completingrequired forms or for submitting necessary documentation.However, providers may charge a fee for copies of medicalrecords if the provider had previously filed copies withBWC or the MCO, or with the self-insuring employer inself-insured claims, and BWC had provided access tosuch medical records electronically. The provider willbase his or her fee on the actual cost of furnishing suchcopies, not to exceed 25 cents per page.

In some instances, it is necessary for the provider toupdate the MCO throughout the delivery of care duringthe treatment period. Such instances include:• Injured worker non-compliance with treatment or

missed appointments;• Negative/lack of response to treatment;• Changes in outcome or goals of treatment;• Diagnostic testing results;• Specialist/consultation results;• Hospital discharge summaries;• Emergency room reports, operative reports or other

situations that indicate a need to alter a treatment plan/plan of care or concurrently monitor the patient’scare. In such situations, the provider must submit theupdate to the MCO within five days of delivery of service or request by MCO.

By filing a claim for workers’ compensation benefits,the injured worker gives BWC or anyone working forthe bureau permission to access information related tothe claim. Consequently, submitting medical reports toeither BWC or an MCO does not require a release ofinformation signed by the injured worker.

The Health Insurance Portability and Accountability Act(HIPAA) privacy and electronic transactions regulationsdo not directly apply to BWC and the MCOs. BWC andthe MCOs do not qualify as covered entities underHIPAA regulations.

The provider can release information to BWC or an MCO(or to a self-insuring employer or Qualified Health Planin a self-insured claim) if the provider is treating an injuredworker and is:• Requesting authorization for treatment;• Requesting payment for treatment already rendered;• Providing information with regard to the allowance

of a workers’ compensation claim, or the allowanceof an additional condition in an existing claim.

MCOs are required to integrate their case managementand bill payment systems so they will not requireproviders to attach medical documentation to bills forpreviously approved treatment on a regular basis.However, providers must submit medical documentationin cases where services billed do not correspond torequested and approved treatment, or if the MCO needsinformation to show what services were provided.

For example, for a period not to exceed 60 days followingthe date of injury, physicians have presumptive approvalfor providing E/M and consultation services when treatingsoft tissue and musculoskeletal injuries for allowedconditions in allowed claims. Although physicians mayrender the E/M service without prior authorization, theymust submit documentation to support the componentsof the E/M service. To justify payment for the servicereported, the documentation must be specific indescribing the provided service.

Medical repository

Providing medical reports to the MCO within 24 hourshas a number of advantages, including helping BWCexpedite claim processing. In most cases, the soonerthe MCO sends the initial medical documentation tothe customer service team, the sooner BWC can allowthe claim.

Since providers often transmit many of these medicalreports and other documents early in the claims process,

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By providing a specific diagnosis to the MCO at the timeof the first report of an injury or soon thereafter, BWCcan more quickly consider the diagnosis for allowance.

Once BWC considers the documentation, it makes adecision. BWC makes a decision by applying Ohio lawand the evidence presented; thus, decisions are impartialand objective.

Once BWC makes the decision, BWC’s customer serviceteam must issue a BWC order, which is a written legalnotice to the injured worker, employer and theirrepresentatives. BWC electronically sends the claim ormedical condition allowance or denial to the MCO.

If the MCO received the provider number and submittedit to BWC, the bureau will send the provider a letterindicating the claim status and allowed conditions.

BWC’s goal is to make claim determinations within 15days of the initial notification of injury, 13 days earlierthan the law requires. This means the injured worker willreceive entitled benefits, and BWC will reimburse youfor services more quickly.

A 14-day appeal period may follow this determination. Ifthe injured worker and employer agree, and both waivethe appeal period, BWC formally allows the claim. BWCmay now pay medical benefits and compensation.

If either the injured worker or the employer appealsBWC’s determination, the IC will conduct a hearing. TheIC’s district hearing officer will hear the appeal within 45days and will issue an order within seven days.

Even when a claim has become inactive (13 monthssince last treatment date), injured workers, employersand providers can still contact the MCO to request medicalservices. To ensure appropriate payment for servicesrendered to an injured worker, providers should makesure a claim is active before scheduling services. Findout if a claim is active by looking up the claim’s statusand diagnosis information on ohiobwc.com or bycontacting the assigned MCO.

Auto adjudication

Auto adjudication is the electronic review of informationreceived on a FROI. Based on complex, pre-establishedcriteria, auto adjudication automatically allows or approveslow-severity claims, and sends notices to injured workersand their employers — all with little or no manualprocessing. Generally, the sooner BWC allows a claim,the sooner it will pay medical bills.

Along with the BWC order, injured workers andemployers receive a contact letter that includesnotification information about the claim, such as theclaim number, the name of the MCO and the assignedmedical claims specialist. Injured workers and employersstill have the right to appeal BWC decisions on auto-adjudicated claims. Auto adjudication improves servicedelivery for injured workers and employers by providingBWC’s medical claims specialists with additional timeto perform more thorough claims investigation andreviews on more complicated, higher-severity claims.

Outpatient medicationPharmacy benefits manager (PBM)

ACS State Healthcare is BWC’s pharmacy benefitsmanager (PBM). ACS processes outpatient medicationbills for state-fund, Black Lung and Marine IndustrialFund claims. The PBM is a single source for acceptingand adjudicating prescription drug information, and isseparate from the MCOs. This program does not applyto claims managed by self-insured employers. Referquestions related to self–insured claims to the injuredworker’s employer.

As part of its responsibilities, ACS:• Performs online, point-of-service adjudication of

outpatient medication bills with prescription information transmitted electronically between a pharmacy and ACS;

• Maintains an adequate pharmacy network;• Maintains a prior authorization system for certain

outpatient medications, which BWC identifies;• Edits prescribed medications for injured workers.

Prior authorization process

BWC’s Outpatient Medication Prior AuthorizationProgram processes requests for medications not typicallyused for treating industrial injuries or occupationaldiseases. The program also processes requests formedications on BWC’s non-preferred drug list.

Non-preferred medication

BWC requires prior authorization for medications on thenon-preferred drug list. The preferred drug programimpacts only three drug classes of medications:• Analgesics: Non-steroidal inflammatory drugs and

COX-2s;• Analgesics: Opioids;• Skeletal muscle relaxants.


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As a provider, you may help the MCO coordinate thevocational rehabilitation plan to provide for the safetransition of the injured worker back to the workplace.You may also help identify when the injured workerneeds specialized services or assistance in changingjobs. Contact the MCO about specific remain-at-workor return-to-work services. Anyone may refer an injuredworker for vocational rehabilitation services. To makea referral, contact the injured worker’s MCO or one ofBWC’s customer service offices.

Alternative dispute resolution (ADR)

ADR facilitates the resolution of disputes in medicalissues that arise between the MCO, BWC, employer,injured worker and/or provider, without litigation. ADRaffords due process regarding conflicts in medicaltreatment issues, but does not include fee schedulegrievances. Implementation of HPP allowed providersto initiate medical disputes involving workers’compensation claims for the first time. Providers initiatinga medical dispute should contact the MCO directly.Providers must initiate ADR within 14 calendar days ofwritten notification of MCO determination.

ADR can address issues that include, but are not limited to:• Quality assurance;• Utilization review;• Determination that a service is or is not covered;• Treatment/service necessity;• Issues involving health-care providers.

MCOs must have a medical dispute-resolution processthat includes one level of review. BWC provides a secondlevel of review for disputes not resolved at the MCOlevel. The MCO’s dispute resolution process must:• Contain a peer review conducted by an individual(s)

licensed pursuant to the same section of the Ohio Revised Code as the health-care provider requestingthe disputed issue;

• Be completed within 21 calendar days of written receipt of notice of a dispute, or within 30 calendar days if the MCO schedules an independent medicalexamination. MCOs must notify concerned parties and their representatives in writing of the dispute-resolution decision at the conclusion of the process.

If the injured worker, employer or provider disagreeswith the MCO’s decision, he or she may request asecond level of dispute resolution within seven calendardays of receiving the MCO’s written notice. The MCOmust refer the dispute to BWC for an independentreview within seven days of written notice of the request.

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To obtain authorization of medications on the non-preferreddrug list, the prescribing physician must complete aRequest for Prior Authorization of Non-PreferredMedication (MEDCO-32) and fax it to ACS at (866) 213-6066. To obtain a MEDCO-32, log on to ohiobwc.com,select Medical Providers, then Forms, or call 1-800-OHIOBWC, and listen to the options. To acquire the non-preferred drug list, access ohiobwc.com and selectMedical Providers, then Services, or call ACS StateHealthcare at 1-800-OHIOBWC, and listen to the options.

Medications not typically used

for industrial injuries or diseases

Prior authorization is required for medications not typicallyassociated with the treatment of either industrial injuriesor occupational diseases, regardless of the date of injury.

The PBM processes prior authorization requests. Theprescribing physician must complete the Request forPrior Authorization of Medication Form (MEDCO-31) anddocument the relationship between the prescribed drugand the allowed condition(s) in an injured worker’s claim.To access BWC’s Non-Preferred Drug Prior AuthorizationRequired List, log on to ohiobwc.com and select MedicalProviders, then Pharmacy prior authorization, or call ACSState Healthcare at 1-800-OHIOBWC, and listen to theoptions.

Generic and brand-name drugs

BWC no longer reimburses for brand-name drugs whenequivalent generic versions are widely available. If aphysician prescribes a brand-name drug, BWC will requirethe injured worker to pay the difference in cost betweenthat medication and the maximum allowable cost for itsgeneric equivalent. Alternatively, the physician may allowthe pharmacy to dispense a generic equivalent or mayprescribe a different drug that is available to the injuredworker at no cost.

BWC preferred drug list

Log on to ohiobwc.com and select Medical Providers,then Pharmacy prior authorization, or call 1-800-OHIOBWC, and listen to the options to access BWC’spreferred drug list.

Other drug coverage issues

• Compounded medications — BWC does not reimburse providers for compounded medications purchased at a pharmacy through the PBM. Contact the MCOs to determine if compound medications prescribed for injured workers are reimbursable.

• Ketorolac tablets — Ketorolac tablets have a quantitylimit of 20 tablets or a five-day supply (whichever is fewer) as a one-time prescription for the duration ofthe claim.

Pharmacy billingSubmitting drug bills for a new claim

Pharmacy providers submit electronic bills for newinjuries online through the bureau’s PBM even beforethe injured worker has a BWC claim number by usinghis or her Social Security number and date of injury. ThePBM will inform the pharmacist that this is a new claimand notify the pharmacist of the amount BWC willreimburse for the prescription if the claim is allowed.The amount is usually indicated in the co-payment areaon the prescription receipt.

The pharmacist can elect to collect this amount from theinjured worker or choose to accept assignment. Thismeans the pharmacist does not change the injured workerup front because he or she expects to receive directpayment from BWC. If the pharmacist wants to acceptassignment, he or she should reverse the previouslysubmitted bill, and then submit the bill to ACS with theprior authorization code of 999000000. The injuredworker’s co-pay field will default to $0.00, and the PBMwill automatically reimburse the pharmacy the feeschedule amount for the prescription, plus an additionaldispensing fee of $2.50 once BWC allows the claim.

If a pharmacy does not accept assignment, the injuredworker must pay the BWC fee schedule amount for theprescribed medication at the point of sale. The PBM willreimburse the injured worker once BWC allows theclaim. If BWC disallows the claim, the bill becomes theinjured worker’s responsibility. Pharmacy providersshould not submit any portion of a bill for a medicationused to treat a work-related injury to a private health-insurance carrier.

Submitting bills in an existing claim

When billing for a prescription in an existing claim, thepharmacist should transmit at least two of the followingthree items, along with the other billing information, tothe PBM:• BWC claim number;• Social Security number;• Date of injury.

The PBM verifies the information, processes the bill andsends the pharmacist an appropriate message basedon the claim’s status and allowed conditions.

Case-management plans

The MCO case-management plan is an essential tool inmanaging a claim’s allowed conditions. The case managerdevelops the plan in collaboration with the injured worker,members of the health-care team and employer,if applicable. The plan represents a mutual commitmentto the primary goal of return to work or resolution ofthe claim.

The plan identifies:• Short- and long-term goals;• Time frames for response to referrals, follow-up

and evaluation;• Resources to be used;• Collaborative approaches to be used;• Criteria for case closure;• Anticipated case results.

Rehabilitation programs

Vocational rehabilitation helps injured workers safelyreturn to work or maintain employment throughindividually tailored services. These services focus onhelping the injured worker return to the previous jobwhenever possible. If that is not possible, the casemanager may use other strategies to help the injuredworker return to appropriate work. By initiating servicesas soon as the injured worker can participate, thevocational outcome is more likely to be successful. Byproviding a structured plan for an early and safe returnto work, the injured worker can avoid long debilitatingperiods off work.

MCOs will work directly with the medical provider, injuredworker and employer to find creative ways to allow theinjured worker to remain at work or return to work. MCOswill coordinate these interventions, which may include:• Modifying the work tasks or providing assistive tools

and equipment;• Developing supervised programs, which allow the

injured worker to gradually increase hours or work loads;

• Coordinating transitional work programs that provideprogressive work-site therapy;

• Providing skills enhancement for the injured worker,if needed;

• Locating appropriate employment for the injured worker in a different type of work, if needed.


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BWC pays all bills according to its fee schedule. Therefore,when the injured worker has paid for the prescription infull (i.e., an amount greater than the fee schedule) andthen seeks reimbursement, the injured worker isresponsible for the difference between the amount paidand the amount reimbursed. It is in the best interest ofthe injured worker for the pharmacy to submit the bill(s)for outpatient medication to ACS State Healthcareelectronically.

Denied claims

BWC will not pay for any medication for disallowedclaims, or those involving self-insuring or other employersparticipating in the $5,000 Medical-Only Program. Thisprogram will expand to $15,000 for injuries suffered afterSept. 10, 2007. Paying for such medication is either thepatient’s responsibility or the employer’s.

Forms

• Request for Prior Authorization of Medication (MEDCO-31) — The prescribing physician uses thisform to request prior authorization for medicationsnot typically used for industrial injuries or occupationaldiseases.

• Request for Prior Authorization of Non-Preferred Medication (MEDCO-32) — The prescribing physicianuses this form to request prior authorization for medications on BWC’s non-preferred drug list. Somemedications in the following categories require priorauthorization: non-steroidal anti-inflammatory drugs (NSAIDS) including Cox-2 inhibitors, skeletal musclerelaxants and opioid analgesics.

• Outpatient Medication Invoice (C-17) — Injured workers should use the C-17 form to get reimbursedfor prescribed outpatient medication only. Injured workers can obtain all the information needed to complete the C-17 form at their pharmacy.

• Service Invoice (C-19) or CMS 1500 — MCOs determine reimbursement eligibility for the followingservices that may be obtained in a pharmacy: durablemedical equipment; disposable medical supplies; andhome infusion therapy. Contact the MCO for specificrequirements for the use of the C-19 and CMS 1500.

Outpatient medication contacts

• ACS State Healthcare — BWC’s PBM is prepared to answer inquiries regarding the Outpatient Medication Prior Authorization Program and point-of-service billing for outpatient medications. To contactACS, call 1-800-OHIOBWC, and listen to the options.

• BWC pharmacy consultant — Providers may send questions or comments about outpatient drug benefits, the Outpatient Medication Prior Authorization

Program or other related matters to BWC’s pharmacyconsultant at [email protected] or by mail to:

Pharmacy ConsultantOhio Bureau of Workers’ CompensationMedical Services30 W. Spring St., 23rd floor, Columbus, OH 43215-2256.

Medical managementMCO treatment authorization

MCOs use nationally recognized treatment guidelinesto evaluate the necessity and/or effectiveness ofmedical care. They also use these guidelines to com-municate with and educate providers in all decisioncorrespondence. Many MCOs use the Work Loss DataInstitute’s Official Disability Guidelines (ODG), and Mercy,Guidelines for Chiropractic Quality Assurance and PracticeParameters.

BWC and MCOs extensively use the ODG, which provideevidence-based treatment guidelines. The ODG do notreplace the treatment guidelines MCOs use; but becauseODG is a Web-based tool, BWC and MCO staff caneasily search and find pertinent information necessaryto everyday issues in claims and medical casemanagement. BWC staff uses the guidelines in the ADRprocess.

Ohio providers can take advantage of the BWCnegotiated price by ordering the guidelines throughwww.WorkLossData.com, or by calling ODG’s toll-freenumber (800) 488-5548. When ordering online, type“Ohio BWC price” in the free text field under “How didyou find out about ODG?” to obtain the negotiated pricefor your subscription.

Presumptive authorization guidelines

BWC has established a program giving providerspresumptive authorization to provide specific medicalservices without waiting for prior authorization from theMCO. For a period not to exceed 60 days following thedate of injury, physicians have presumptive authorizationto provide the following services when treating soft-tissue and musculoskeletal injuries for allowed conditionsin allowed claims:• A maximum of 10 physical medicine visits per injured

worker claim, which may include any combination ofosteopathic manipulative treatment, chiropractic manipulative treatment, and physical medicine and rehabilitation services performed by a provider whosescope of practice includes these procedures, including,

Return-to-work initiatives

One of the things that sets HPP apart from traditionalmanaged-care programs is the emphasis on return towork. Most injured workers return to work without anyassistance, but some require more medical care, resultingin longer recovery and time away from work. Some alsorequire intensive return-to-work and vocational servicesto return to productive employment.

The optimal return-to-work date is an outcomemeasurement which measures success and establishesan optimal return-to-work date at the individual level. Forexample, BWC expects a construction worker who breaksa leg to be off work longer than an office worker withthe same injury because of the way the injury relates tohis or her job.

BWC recognizes these differences and plans the bestcourse for the individual worker. The optimal return-to-work date assists BWC and MCOs in working with theemployer, injured worker and physician to set return-to-work expectations.

As a critical player in the HPP design, providers mustunderstand the basis and goals of the return-to-workstrategy and optimal return-to-work date. In addition,providers need to manage follow-up office visits andtreatment plans with the optimal return-to-work date inmind, enabling injured workers to work (with restrictions,if necessary) as soon as medically feasible.

BWC’s expanded return-to-work program includes severalprograms to ensure injured workers return to work assoon as medically feasible.

Transitional work programs

BWC encourages employers to develop transitional workprograms and will continue to assist organizations increating their own programs. Developed in conjunctionwith the employer, collective bargaining agent (whereapplicable), POR and rehabilitation professionals,transitional work programs are one of the most effectiveways to help injured workers progressively perform realjob tasks and remain working.

These programs are well received by workers who wantto protect their employability or ability to work, and byemployers who want to maintain an experienced workforce and reduce disability-related costs.

The overall company program is developed by speciallyaccredited rehabilitation case managers or occupationalor physical therapists with experience in developingtransitional work programs. An occupational or physicaltherapist provides on-site therapy to the injured workerat the employer’s work site.

Remain-at-work services

BWC offers remain-at-work services to injured workerswith medical-only claims to keep them from becominglost-time claims. Prior to this initiative, injured workerscould only receive these types of services if they wereoff work for eight or more days. A field vocationalrehabilitation case manager may coordinate theseservices, which the MCO manages and which BWCcharges to the employer’s risk.

Physician’s Report of Work Ability (MEDCO-14)

The physician must complete this standard form at everyre-evaluation visit when the injured worker is under workrestrictions or when the injured worker is temporarilytotally disabled. Similar to forms MCOs or physicianoffices use, it provides a permanent record for thephysician’s file. The two-part form allows injured workersto receive a copy for their records. After faxing a copyto the MCO, the MCO will inform employers of theirinjured workers’ restrictions and explore work siteadaptations/modifications.

This form reduces the need for phone calls requestinginformation from several parties regarding the injuredworker’s return-to-work progress. It also providesimportant information to injured workers about theirrecovery and work limitations. Injured workers haveimmediate information they can share with their directsupervisor upon returning to the job. In addition,employers will be informed and see the progress of allinjured workers from the beginning of treatment untilthey are back on the job, and can assist in successfulreturn-to-work practices.


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Service Requirement

Physical medicine services, including chiropractic/ Prior authorization (PA)osteopathic manipulative treatment and acupuncture

Consultations - psychological/chronic pain program only PA

Chronic pain program including pre-admission evaluation PAand treatment

Dental PA

Diagnostic testing PA (except basic X-rays, which do not require PA)

Durable medical equipment (DME) PA if the purchase price > $250, PA for all DME rental

Home/auto/van modifications PA required from BWC

Home health agency services PA

All inpatient and outpatient services and ambulatory PA except for emergency services.* Emergencysurgery services inpatient hospitalization may be through the emergency

department or by direct admission

In-home physician services PA after first visit

Injections PA

Non-emergency ambulance services PA

Orthotic and prosthetic devices and/or repair PA > $250

Skilled nursing facility (SNF)/Extended care facility (ECF) PA

TENS and NMES units PA, both rental and purchase

TENS and NMES monthly supplies PA for a maximum of six months per authorization

Vision /hearing services PA > $100

Vocational rehabilitation - All vocational rehabilitation PAservices, in or out of plan

Standardized prior authorization table

10 11

but not limited to, doctor of chiropractic, doctor of osteopathic medicine, doctor of allopathic medicine, physical therapist, occupational therapist, athletic traineror massage therapist;

• Diagnostic studies, including X-rays, CAT scans, MRIscans and EMG/NCV;

• Up to three soft tissue or joint injections involving thejoints of the extremities (shoulder including acromioclavicular, elbow, wrist, finger, hip, knee, ankleand foot, including toes) and up to three trigger-pointinjections. Injections of the paraspinal region, includingepidural injections, facet injections, and sacroiliac injections are not included in the presumptive approvalguidelines;

• Evaluation and Management (E/M) services and consultation services.

The following criteria must be met prior to initiatingany or all of the aforementioned services:• The provider will file the FROI with BWC or the MCO;• The provider will complete and file the C-9 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 services beingrendered are medically necessary for the claim allowance;

• The provider will notify the MCO within 24 hours of treatment if the injured worker will be off work for more than two calendar days.


Except for emergency care, services listed in the MCOstandardized prior authorization table on page 11, requireprior authorization if they do not fall within the presumptiveapproval parameters. Providers must submit a C-9 toindicate services for which they are requesting formalauthorization.

Treatment request approval guidelines

To help the MCO consider authorization and expeditemedical bill payments, BWC implemented the followingguidelines:

1. The POR or treating physician submits the treatmentrequest to the appropriate MCO prior to initiating anynon-emergency treatment. The C-9 is the preferred submission method; however, you may use any otherphysician-generated document, provided the substitutesupporting document contains, at a minimum, data elements on the C-9;

2. The MCO must respond to the physician in writing within three business days with a decision regarding

the proposed treatment request. The MCO will authorize or deny a provider’s retroactive treatmentrequest within 30 calendar days from receipt, or willkeep the request pending;

3. The MCO must fax the authorized, denied or pendingtreatment request to the physician within the requiredthree business days. If faxing is not feasible, the MCOis required to call the physician to communicate thedecision and follow up in writing via mail or e-mail;

4. If the MCO cannot make a decision within three business days due to the need for additional information, the MCO must notify the physician. In addition, the MCO will send a Request for AdditionalMedical Documentation (C-9-A) to the provider. TheMCO has five business days from the date it receivesadditional information to make a subsequent decision.The MCO may deny the treatment request if the physician does not provide the MCO with requesteddocumentation within 10 business days. The MCO must notify the physician by fax or telephone of thesubsequent decision and follow up via mail;

5. If the MCO cannot make a decision within three business days due to the need for a medical review,the MCO must notify the physician. The medical review must take place and a decision made within the five-business-day period. Again, the MCO must notify the physician of the subsequent decision by fax or telephone, and follow up in writing via mail;

6. A treatment request will be considered approved andthe provider may initiate treatments when all of thesecriteria are met:• The MCO fails to communicate a decision to the

physician within three business days of receipt ofan original treatment request or within five businessdays if the request is pending;

• The physician has documented the treatment request completely and correctly on a C-9 or otheracceptable document;

• The physician has proof of submission to the appropriate MCO;

• Treatment is for the allowed conditions;• The claim is in a payable status;

7. In instances when the MCO does not respond to theC-9 within three business days and the provider initiates treatment, the MCO will provide concurrentand retro review. If the MCO finds the treatment is not medically necessary for the allowed conditions in the claim, it will notify all parties that charges for additional treatment will not be paid. Charges for services previously rendered will be paid;

8. If the claim is inactive, the claim reactivation processmay take up to 44 business days to complete. TheMCO will have a maximum of 16 business days torespond to the treatment request and refer the claimreactivation issue to BWC. BWC will have a maximumof 28 business days to complete the causalityinvestigation and issue a BWC order.

Under BWC’s direction, the MCOs have been workingwith physicians to more effectively manage injuredworker claims.

MCO’s send noncompliance notices to providerssubmitting retro C-9s without just cause, as listed in thebilling and reimbursement manual. These are reportedto BWC for monthly review and administrative action.Medical documentation noncompliance issues arereported on a case-by-case basis.

* Per Ohio Administrative Code 4123-6-01 (0)Note: PA not required for transitional work on-site therapy services provided by an OT or PT that fall under thepresumptive authorization guidelines. Occupational rehabilitation (work hardening) requires CARF accreditation.

HPP GUIDE.fh11 8/14/07 7:19 AM Page 11

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Service Requirement

Physical medicine services, including chiropractic/ Prior authorization (PA)osteopathic manipulative treatment and acupuncture

Consultations - psychological/chronic pain program only PA

Chronic pain program including pre-admission evaluation PAand treatment

Dental PA

Diagnostic testing PA (except basic X-rays, which do not require PA)

Durable medical equipment (DME) PA if the purchase price > $250, PA for all DME rental

Home/auto/van modifications PA required from BWC

Home health agency services PA

All inpatient and outpatient services and ambulatory PA except for emergency services.* Emergencysurgery services inpatient hospitalization may be through the emergency

department or by direct admission

In-home physician services PA after first visit

Injections PA

Non-emergency ambulance services PA

Orthotic and prosthetic devices and/or repair PA > $250

Skilled nursing facility (SNF)/Extended care facility (ECF) PA

TENS and NMES units PA, both rental and purchase

TENS and NMES monthly supplies PA for a maximum of six months per authorization

Vision /hearing services PA > $100

Vocational rehabilitation - All vocational rehabilitation PAservices, in or out of plan


10 11

but not limited to, doctor of chiropractic, doctor of osteopathic medicine, doctor of allopathic medicine, physical therapist, occupational therapist, athletic traineror massage therapist;

• Diagnostic studies, including X-rays, CAT scans, MRIscans and EMG/NCV;

• Up to three soft tissue or joint injections involving thejoints of the extremities (shoulder including acromioclavicular, elbow, wrist, finger, hip, knee, ankleand foot, including toes) and up to three trigger-pointinjections. Injections of the paraspinal region, includingepidural injections, facet injections, and sacroiliac injections are not included in the presumptive approvalguidelines;

• Evaluation and Management (E/M) services and consultation services.

The following criteria must be met prior to initiatingany or all of the aforementioned services:• The provider will file the FROI with BWC or the MCO;• The provider will complete and file the C-9 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 services beingrendered are medically necessary for the claim allowance;

• The provider will notify the MCO within 24 hours of treatment if the injured worker will be off work for more than two calendar days.


Except for emergency care, services listed in the MCOstandardized prior authorization table on page 11, requireprior authorization if they do not fall within the presumptiveapproval parameters. Providers must submit a C-9 toindicate services for which they are requesting formalauthorization.

Treatment request approval guidelines

To help the MCO consider authorization and expeditemedical bill payments, BWC implemented the followingguidelines:

1. The POR or treating physician submits the treatmentrequest to the appropriate MCO prior to initiating anynon-emergency treatment. The C-9 is the preferred submission method; however, you may use any otherphysician-generated document, provided the substitutesupporting document contains, at a minimum, data elements on the C-9;

2. The MCO must respond to the physician in writing within three business days with a decision regarding

the proposed treatment request. The MCO will authorize or deny a provider’s retroactive treatmentrequest within 30 calendar days from receipt, or willkeep the request pending;

3. The MCO must fax the authorized, denied or pendingtreatment request to the physician within the requiredthree business days. If faxing is not feasible, the MCOis required to call the physician to communicate thedecision and follow up in writing via mail or e-mail;

4. If the MCO cannot make a decision within three business days due to the need for additional information, the MCO must notify the physician. In addition, the MCO will send a Request for AdditionalMedical Documentation (C-9-A) to the provider. TheMCO has five business days from the date it receivesadditional information to make a subsequent decision.The MCO may deny the treatment request if the physician does not provide the MCO with requesteddocumentation within 10 business days. The MCO must notify the physician by fax or telephone of thesubsequent decision and follow up via mail;

5. If the MCO cannot make a decision within three business days due to the need for a medical review,the MCO must notify the physician. The medical review must take place and a decision made within the five-business-day period. Again, the MCO must notify the physician of the subsequent decision by fax or telephone, and follow up in writing via mail;

6. A treatment request will be considered approved andthe provider may initiate treatments when all of thesecriteria are met:• The MCO fails to communicate a decision to the

physician within three business days of receipt ofan original treatment request or within five businessdays if the request is pending;

• The physician has documented the treatment request completely and correctly on a C-9 or otheracceptable document;

• The physician has proof of submission to the appropriate MCO;

• Treatment is for the allowed conditions;• The claim is in a payable status;

7. In instances when the MCO does not respond to theC-9 within three business days and the provider initiates treatment, the MCO will provide concurrentand retro review. If the MCO finds the treatment is not medically necessary for the allowed conditions in the claim, it will notify all parties that charges for additional treatment will not be paid. Charges for services previously rendered will be paid;

8. If the claim is inactive, the claim reactivation processmay take up to 44 business days to complete. TheMCO will have a maximum of 16 business days torespond to the treatment request and refer the claimreactivation issue to BWC. BWC will have a maximumof 28 business days to complete the causalityinvestigation and issue a BWC order.

Under BWC’s direction, the MCOs have been workingwith physicians to more effectively manage injuredworker claims.

MCO’s send noncompliance notices to providerssubmitting retro C-9s without just cause, as listed in thebilling and reimbursement manual. These are reportedto BWC for monthly review and administrative action.Medical documentation noncompliance issues arereported on a case-by-case basis.

* Per Ohio Administrative Code 4123-6-01 (0)Note: PA not required for transitional work on-site therapy services provided by an OT or PT that fall under thepresumptive authorization guidelines. Occupational rehabilitation (work hardening) requires CARF accreditation.


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BWC pays all bills according to its fee schedule. Therefore,when the injured worker has paid for the prescription infull (i.e., an amount greater than the fee schedule) andthen seeks reimbursement, the injured worker isresponsible for the difference between the amount paidand the amount reimbursed. It is in the best interest ofthe injured worker for the pharmacy to submit the bill(s)for outpatient medication to ACS State Healthcareelectronically.

Denied claims

BWC will not pay for any medication for disallowedclaims, or those involving self-insuring or other employersparticipating in the $5,000 Medical-Only Program. Thisprogram will expand to $15,000 for injuries suffered afterSept. 10, 2007. Paying for such medication is either thepatient’s responsibility or the employer’s.

Forms

• Request for Prior Authorization of Medication (MEDCO-31) — The prescribing physician uses thisform to request prior authorization for medicationsnot typically used for industrial injuries or occupationaldiseases.

• Request for Prior Authorization of Non-Preferred Medication (MEDCO-32) — The prescribing physicianuses this form to request prior authorization for medications on BWC’s non-preferred drug list. Somemedications in the following categories require priorauthorization: non-steroidal anti-inflammatory drugs (NSAIDS) including Cox-2 inhibitors, skeletal musclerelaxants and opioid analgesics.

• Outpatient Medication Invoice (C-17) — Injured workers should use the C-17 form to get reimbursedfor prescribed outpatient medication only. Injured workers can obtain all the information needed to complete the C-17 form at their pharmacy.

• Service Invoice (C-19) or CMS 1500 — MCOs determine reimbursement eligibility for the followingservices that may be obtained in a pharmacy: durablemedical equipment; disposable medical supplies; andhome infusion therapy. Contact the MCO for specificrequirements for the use of the C-19 and CMS 1500.

Outpatient medication contacts

• ACS State Healthcare — BWC’s PBM is prepared to answer inquiries regarding the Outpatient Medication Prior Authorization Program and point-of-service billing for outpatient medications. To contactACS, call 1-800-OHIOBWC, and listen to the options.

• BWC pharmacy consultant — Providers may send questions or comments about outpatient drug benefits, the Outpatient Medication Prior Authorization

Program or other related matters to BWC’s pharmacyconsultant at [email protected] or by mail to:

Pharmacy ConsultantOhio Bureau of Workers’ CompensationMedical Services30 W. Spring St., 23rd floor, Columbus, OH 43215-2256.

Medical managementMCO treatment authorization

MCOs use nationally recognized treatment guidelinesto evaluate the necessity and/or effectiveness ofmedical care. They also use these guidelines to com-municate with and educate providers in all decisioncorrespondence. Many MCOs use the Work Loss DataInstitute’s Official Disability Guidelines (ODG), and Mercy,Guidelines for Chiropractic Quality Assurance and PracticeParameters.

BWC and MCOs extensively use the ODG, which provideevidence-based treatment guidelines. The ODG do notreplace the treatment guidelines MCOs use; but becauseODG is a Web-based tool, BWC and MCO staff caneasily search and find pertinent information necessaryto everyday issues in claims and medical casemanagement. BWC staff uses the guidelines in the ADRprocess.

Ohio providers can take advantage of the BWCnegotiated price by ordering the guidelines throughwww.WorkLossData.com, or by calling ODG’s toll-freenumber (800) 488-5548. When ordering online, type“Ohio BWC price” in the free text field under “How didyou find out about ODG?” to obtain the negotiated pricefor your subscription.

Presumptive authorization guidelines

BWC has established a program giving providerspresumptive authorization to provide specific medicalservices without waiting for prior authorization from theMCO. For a period not to exceed 60 days following thedate of injury, physicians have presumptive authorizationto provide the following services when treating soft-tissue and musculoskeletal injuries for allowed conditionsin allowed claims:• A maximum of 10 physical medicine visits per injured

worker claim, which may include any combination ofosteopathic manipulative treatment, chiropractic manipulative treatment, and physical medicine and rehabilitation services performed by a provider whosescope of practice includes these procedures, including,

Return-to-work initiatives

One of the things that sets HPP apart from traditionalmanaged-care programs is the emphasis on return towork. Most injured workers return to work without anyassistance, but some require more medical care, resultingin longer recovery and time away from work. Some alsorequire intensive return-to-work and vocational servicesto return to productive employment.

The optimal return-to-work date is an outcomemeasurement which measures success and establishesan optimal return-to-work date at the individual level. Forexample, BWC expects a construction worker who breaksa leg to be off work longer than an office worker withthe same injury because of the way the injury relates tohis or her job.

BWC recognizes these differences and plans the bestcourse for the individual worker. The optimal return-to-work date assists BWC and MCOs in working with theemployer, injured worker and physician to set return-to-work expectations.

As a critical player in the HPP design, providers mustunderstand the basis and goals of the return-to-workstrategy and optimal return-to-work date. In addition,providers need to manage follow-up office visits andtreatment plans with the optimal return-to-work date inmind, enabling injured workers to work (with restrictions,if necessary) as soon as medically feasible.

BWC’s expanded return-to-work program includes severalprograms to ensure injured workers return to work assoon as medically feasible.

Transitional work programs

BWC encourages employers to develop transitional workprograms and will continue to assist organizations increating their own programs. Developed in conjunctionwith the employer, collective bargaining agent (whereapplicable), POR and rehabilitation professionals,transitional work programs are one of the most effectiveways to help injured workers progressively perform realjob tasks and remain working.

These programs are well received by workers who wantto protect their employability or ability to work, and byemployers who want to maintain an experienced workforce and reduce disability-related costs.

The overall company program is developed by speciallyaccredited rehabilitation case managers or occupationalor physical therapists with experience in developingtransitional work programs. An occupational or physicaltherapist provides on-site therapy to the injured workerat the employer’s work site.

Remain-at-work services

BWC offers remain-at-work services to injured workerswith medical-only claims to keep them from becominglost-time claims. Prior to this initiative, injured workerscould only receive these types of services if they wereoff work for eight or more days. A field vocationalrehabilitation case manager may coordinate theseservices, which the MCO manages and which BWCcharges to the employer’s risk.

Physician’s Report of Work Ability (MEDCO-14)

The physician must complete this standard form at everyre-evaluation visit when the injured worker is under workrestrictions or when the injured worker is temporarilytotally disabled. Similar to forms MCOs or physicianoffices use, it provides a permanent record for thephysician’s file. The two-part form allows injured workersto receive a copy for their records. After faxing a copyto the MCO, the MCO will inform employers of theirinjured workers’ restrictions and explore work siteadaptations/modifications.

This form reduces the need for phone calls requestinginformation from several parties regarding the injuredworker’s return-to-work progress. It also providesimportant information to injured workers about theirrecovery and work limitations. Injured workers haveimmediate information they can share with their directsupervisor upon returning to the job. In addition,employers will be informed and see the progress of allinjured workers from the beginning of treatment untilthey are back on the job, and can assist in successfulreturn-to-work practices.


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As a provider, you may help the MCO coordinate thevocational rehabilitation plan to provide for the safetransition of the injured worker back to the workplace.You may also help identify when the injured workerneeds specialized services or assistance in changingjobs. Contact the MCO about specific remain-at-workor return-to-work services. Anyone may refer an injuredworker for vocational rehabilitation services. To makea referral, contact the injured worker’s MCO or one ofBWC’s customer service offices.

Alternative dispute resolution (ADR)

ADR facilitates the resolution of disputes in medicalissues that arise between the MCO, BWC, employer,injured worker and/or provider, without litigation. ADRaffords due process regarding conflicts in medicaltreatment issues, but does not include fee schedulegrievances. Implementation of HPP allowed providersto initiate medical disputes involving workers’compensation claims for the first time. Providers initiatinga medical dispute should contact the MCO directly.Providers must initiate ADR within 14 calendar days ofwritten notification of MCO determination.

ADR can address issues that include, but are not limited to:• Quality assurance;• Utilization review;• Determination that a service is or is not covered;• Treatment/service necessity;• Issues involving health-care providers.

MCOs must have a medical dispute-resolution processthat includes one level of review. BWC provides a secondlevel of review for disputes not resolved at the MCOlevel. The MCO’s dispute resolution process must:• Contain a peer review conducted by an individual(s)

licensed pursuant to the same section of the Ohio Revised Code as the health-care provider requestingthe disputed issue;

• Be completed within 21 calendar days of written receipt of notice of a dispute, or within 30 calendar days if the MCO schedules an independent medicalexamination. MCOs must notify concerned parties and their representatives in writing of the dispute-resolution decision at the conclusion of the process.

If the injured worker, employer or provider disagreeswith the MCO’s decision, he or she may request asecond level of dispute resolution within seven calendardays of receiving the MCO’s written notice. The MCOmust refer the dispute to BWC for an independentreview within seven days of written notice of the request.

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To obtain authorization of medications on the non-preferreddrug list, the prescribing physician must complete aRequest for Prior Authorization of Non-PreferredMedication (MEDCO-32) and fax it to ACS at (866) 213-6066. To obtain a MEDCO-32, log on to ohiobwc.com,select Medical Providers, then Forms, or call 1-800-OHIOBWC, and listen to the options. To acquire the non-preferred drug list, access ohiobwc.com and selectMedical Providers, then Services, or call ACS StateHealthcare at 1-800-OHIOBWC, and listen to the options.

Medications not typically used

for industrial injuries or diseases

Prior authorization is required for medications not typicallyassociated with the treatment of either industrial injuriesor occupational diseases, regardless of the date of injury.

The PBM processes prior authorization requests. Theprescribing physician must complete the Request forPrior Authorization of Medication Form (MEDCO-31) anddocument the relationship between the prescribed drugand the allowed condition(s) in an injured worker’s claim.To access BWC’s Non-Preferred Drug Prior AuthorizationRequired List, log on to ohiobwc.com and select MedicalProviders, then Pharmacy prior authorization, or call ACSState Healthcare at 1-800-OHIOBWC, and listen to theoptions.

Generic and brand-name drugs

BWC no longer reimburses for brand-name drugs whenequivalent generic versions are widely available. If aphysician prescribes a brand-name drug, BWC will requirethe injured worker to pay the difference in cost betweenthat medication and the maximum allowable cost for itsgeneric equivalent. Alternatively, the physician may allowthe pharmacy to dispense a generic equivalent or mayprescribe a different drug that is available to the injuredworker at no cost.

BWC preferred drug list

Log on to ohiobwc.com and select Medical Providers,then Pharmacy prior authorization, or call 1-800-OHIOBWC, and listen to the options to access BWC’spreferred drug list.

Other drug coverage issues

• Compounded medications — BWC does not reimburse providers for compounded medications purchased at a pharmacy through the PBM. Contact the MCOs to determine if compound medications prescribed for injured workers are reimbursable.

• Ketorolac tablets — Ketorolac tablets have a quantitylimit of 20 tablets or a five-day supply (whichever is fewer) as a one-time prescription for the duration ofthe claim.

Pharmacy billingSubmitting drug bills for a new claim

Pharmacy providers submit electronic bills for newinjuries online through the bureau’s PBM even beforethe injured worker has a BWC claim number by usinghis or her Social Security number and date of injury. ThePBM will inform the pharmacist that this is a new claimand notify the pharmacist of the amount BWC willreimburse for the prescription if the claim is allowed.The amount is usually indicated in the co-payment areaon the prescription receipt.

The pharmacist can elect to collect this amount from theinjured worker or choose to accept assignment. Thismeans the pharmacist does not change the injured workerup front because he or she expects to receive directpayment from BWC. If the pharmacist wants to acceptassignment, he or she should reverse the previouslysubmitted bill, and then submit the bill to ACS with theprior authorization code of 999000000. The injuredworker’s co-pay field will default to $0.00, and the PBMwill automatically reimburse the pharmacy the feeschedule amount for the prescription, plus an additionaldispensing fee of $2.50 once BWC allows the claim.

If a pharmacy does not accept assignment, the injuredworker must pay the BWC fee schedule amount for theprescribed medication at the point of sale. The PBM willreimburse the injured worker once BWC allows theclaim. If BWC disallows the claim, the bill becomes theinjured worker’s responsibility. Pharmacy providersshould not submit any portion of a bill for a medicationused to treat a work-related injury to a private health-insurance carrier.

Submitting bills in an existing claim

When billing for a prescription in an existing claim, thepharmacist should transmit at least two of the followingthree items, along with the other billing information, tothe PBM:• BWC claim number;• Social Security number;• Date of injury.

The PBM verifies the information, processes the bill andsends the pharmacist an appropriate message basedon the claim’s status and allowed conditions.

Case-management plans

The MCO case-management plan is an essential tool inmanaging a claim’s allowed conditions. The case managerdevelops the plan in collaboration with the injured worker,members of the health-care team and employer,if applicable. The plan represents a mutual commitmentto the primary goal of return to work or resolution ofthe claim.

The plan identifies:• Short- and long-term goals;• Time frames for response to referrals, follow-up

and evaluation;• Resources to be used;• Collaborative approaches to be used;• Criteria for case closure;• Anticipated case results.

Rehabilitation programs

Vocational rehabilitation helps injured workers safelyreturn to work or maintain employment throughindividually tailored services. These services focus onhelping the injured worker return to the previous jobwhenever possible. If that is not possible, the casemanager may use other strategies to help the injuredworker return to appropriate work. By initiating servicesas soon as the injured worker can participate, thevocational outcome is more likely to be successful. Byproviding a structured plan for an early and safe returnto work, the injured worker can avoid long debilitatingperiods off work.

MCOs will work directly with the medical provider, injuredworker and employer to find creative ways to allow theinjured worker to remain at work or return to work. MCOswill coordinate these interventions, which may include:• Modifying the work tasks or providing assistive tools

and equipment;• Developing supervised programs, which allow the

injured worker to gradually increase hours or work loads;

• Coordinating transitional work programs that provideprogressive work-site therapy;

• Providing skills enhancement for the injured worker,if needed;

• Locating appropriate employment for the injured worker in a different type of work, if needed.


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BWC’s ADR unit handles the second-level disputeresolution process and keeps the customer service teaminformed of progress and outcomes.

If a disagreement still exists after BWC’s second levelof review, the injured worker, employer or theirrepresentatives may file an appeal with the IC. The ICwill hear the medical dispute only if the parties haveexhausted both levels of ADR.

Effective April 1, 2007, per SB7 and new OAC 4123-6-16 (F) the ADR process shall not be used to resolvedisputes concerning medical services rendered that havebeen approved through standard treatment guidelines,pathways, or presumptive authorization guidelines.

Medical documentation

Providers who treat Ohio’s injured workers assume anobligation to submit initial and subsequent reports to theMCO on behalf of the injured worker. Providers mustsupply supporting medical documentation to MCOs atthe time of the treatment request and reports on outcomesof treatment.

Providers also assume an obligation to provide andcomplete forms required by BWC or the self-insuringemployer. Providers may not charge for completingrequired forms or for submitting necessary documentation.However, providers may charge a fee for copies of medicalrecords if the provider had previously filed copies withBWC or the MCO, or with the self-insuring employer inself-insured claims, and BWC had provided access tosuch medical records electronically. The provider willbase his or her fee on the actual cost of furnishing suchcopies, not to exceed 25 cents per page.

In some instances, it is necessary for the provider toupdate the MCO throughout the delivery of care duringthe treatment period. Such instances include:• Injured worker non-compliance with treatment or

missed appointments;• Negative/lack of response to treatment;• Changes in outcome or goals of treatment;• Diagnostic testing results;• Specialist/consultation results;• Hospital discharge summaries;• Emergency room reports, operative reports or other

situations that indicate a need to alter a treatment plan/plan of care or concurrently monitor the patient’scare. In such situations, the provider must submit theupdate to the MCO within five days of delivery of service or request by MCO.

By filing a claim for workers’ compensation benefits,the injured worker gives BWC or anyone working forthe bureau permission to access information related tothe claim. Consequently, submitting medical reports toeither BWC or an MCO does not require a release ofinformation signed by the injured worker.

The Health Insurance Portability and Accountability Act(HIPAA) privacy and electronic transactions regulationsdo not directly apply to BWC and the MCOs. BWC andthe MCOs do not qualify as covered entities underHIPAA regulations.

The provider can release information to BWC or an MCO(or to a self-insuring employer or Qualified Health Planin a self-insured claim) if the provider is treating an injuredworker and is:• Requesting authorization for treatment;• Requesting payment for treatment already rendered;• Providing information with regard to the allowance

of a workers’ compensation claim, or the allowanceof an additional condition in an existing claim.

MCOs are required to integrate their case managementand bill payment systems so they will not requireproviders to attach medical documentation to bills forpreviously approved treatment on a regular basis.However, providers must submit medical documentationin cases where services billed do not correspond torequested and approved treatment, or if the MCO needsinformation to show what services were provided.

For example, for a period not to exceed 60 days followingthe date of injury, physicians have presumptive approvalfor providing E/M and consultation services when treatingsoft tissue and musculoskeletal injuries for allowedconditions in allowed claims. Although physicians mayrender the E/M service without prior authorization, theymust submit documentation to support the componentsof the E/M service. To justify payment for the servicereported, the documentation must be specific indescribing the provided service.

Medical repository

Providing medical reports to the MCO within 24 hourshas a number of advantages, including helping BWCexpedite claim processing. In most cases, the soonerthe MCO sends the initial medical documentation tothe customer service team, the sooner BWC can allowthe claim.

Since providers often transmit many of these medicalreports and other documents early in the claims process,

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By providing a specific diagnosis to the MCO at the timeof the first report of an injury or soon thereafter, BWCcan more quickly consider the diagnosis for allowance.

Once BWC considers the documentation, it makes adecision. BWC makes a decision by applying Ohio lawand the evidence presented; thus, decisions are impartialand objective.

Once BWC makes the decision, BWC’s customer serviceteam must issue a BWC order, which is a written legalnotice to the injured worker, employer and theirrepresentatives. BWC electronically sends the claim ormedical condition allowance or denial to the MCO.

If the MCO received the provider number and submittedit to BWC, the bureau will send the provider a letterindicating the claim status and allowed conditions.

BWC’s goal is to make claim determinations within 15days of the initial notification of injury, 13 days earlierthan the law requires. This means the injured worker willreceive entitled benefits, and BWC will reimburse youfor services more quickly.

A 14-day appeal period may follow this determination. Ifthe injured worker and employer agree, and both waivethe appeal period, BWC formally allows the claim. BWCmay now pay medical benefits and compensation.

If either the injured worker or the employer appealsBWC’s determination, the IC will conduct a hearing. TheIC’s district hearing officer will hear the appeal within 45days and will issue an order within seven days.

Even when a claim has become inactive (13 monthssince last treatment date), injured workers, employersand providers can still contact the MCO to request medicalservices. To ensure appropriate payment for servicesrendered to an injured worker, providers should makesure a claim is active before scheduling services. Findout if a claim is active by looking up the claim’s statusand diagnosis information on ohiobwc.com or bycontacting the assigned MCO.

Auto adjudication

Auto adjudication is the electronic review of informationreceived on a FROI. Based on complex, pre-establishedcriteria, auto adjudication automatically allows or approveslow-severity claims, and sends notices to injured workersand their employers — all with little or no manualprocessing. Generally, the sooner BWC allows a claim,the sooner it will pay medical bills.

Along with the BWC order, injured workers andemployers receive a contact letter that includesnotification information about the claim, such as theclaim number, the name of the MCO and the assignedmedical claims specialist. Injured workers and employersstill have the right to appeal BWC decisions on auto-adjudicated claims. Auto adjudication improves servicedelivery for injured workers and employers by providingBWC’s medical claims specialists with additional timeto perform more thorough claims investigation andreviews on more complicated, higher-severity claims.

Outpatient medicationPharmacy benefits manager (PBM)

ACS State Healthcare is BWC’s pharmacy benefitsmanager (PBM). ACS processes outpatient medicationbills for state-fund, Black Lung and Marine IndustrialFund claims. The PBM is a single source for acceptingand adjudicating prescription drug information, and isseparate from the MCOs. This program does not applyto claims managed by self-insured employers. Referquestions related to self–insured claims to the injuredworker’s employer.

As part of its responsibilities, ACS:• Performs online, point-of-service adjudication of

outpatient medication bills with prescription information transmitted electronically between a pharmacy and ACS;

• Maintains an adequate pharmacy network;• Maintains a prior authorization system for certain

outpatient medications, which BWC identifies;• Edits prescribed medications for injured workers.

Prior authorization process

BWC’s Outpatient Medication Prior AuthorizationProgram processes requests for medications not typicallyused for treating industrial injuries or occupationaldiseases. The program also processes requests formedications on BWC’s non-preferred drug list.

Non-preferred medication

BWC requires prior authorization for medications on thenon-preferred drug list. The preferred drug programimpacts only three drug classes of medications:• Analgesics: Non-steroidal inflammatory drugs and

COX-2s;• Analgesics: Opioids;• Skeletal muscle relaxants.

HPP GUIDE.fh11 8/14/07 12:45 PM Page 7

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often before BWC assigns a claim number, they sendsome documents to the wrong MCO or directly toBWC. In some cases, documents are lost. This oftenresults in misunderstandings for all involved, delayingthe overall process.

BWC’s medical repository system reduces duplicaterequests from BWC and MCOs to providers for medicaldocumentation. It also coordinates faxes coming fromproviders so MCO and BWC documents are synchronized.

The medical repository process is transparent to providers.Through an automated call-forwarding process, a medicalrepository stores electronic copies of faxed documentsfor viewing by BWC and MCO staff. Each MCO can onlysee documents associated with claims assigned to it.

Providers should continue to fax documents to MCOs.Please refer to the MCO contact information in the MCODirectory on BWC’s Web site, ohiobwc.com, to obtainthe correct toll-free fax number for each MCO.

Send only one fax to the MCO. Do not send a duplicateto BWC. If you receive a request for documentation thatyou faxed to the MCO, ask the requester to check themedical repository first.

Include a fax cover sheet for each injured worker. Also,include the injured worker’s name, Social Security numberor claim number on each page of the fax. Timelysubmission of these medical documents provides MCOsand BWC with important information and minimizes thepossibility of delayed claim authorizations.

A list of BWC forms indexed by the bureau appearsbelow. You will notice the C-9 is not one of thedocuments BWC indexes because an MCO must reviewand either approve or deny information on that formbefore forwarding it to the bureau.

BWC can only accommodate NPI’s on forms for billing.BWC is working to change this, but currently can onlyrecognize this number for billing if it has previouslyreceived this information from the provider (See pg. 5).

Paperwork parameters

With HPP, BWC stresses the importance of focusingon issues and actions involved in the claim. Forms,however, are still necessary as we work together toprovide injured workers with the services they need.Forms you will most likely use include:

FROI — The provider may report the injury by completingand sending this form to the MCO. However, thepreferred method to file the FROI is online atohiobwc.com;

C-9 — The POR or treating physician uses this form tosubmit a treatment request or recommendation foradditional condition to the MCO prior to initiating anynon-emergency treatment;

MEDCO-14 — Form used by physicians for work abilities;

Change of Physician (C-23) — The injured worker mustsign this form and indicate the physician to which he orshe wishes to change and the reason. Send the C-23to the MCO;

BWC forms indexed in the medical repositoryDocument type Description Rationale

C-140 Wage loss application Includes medical restrictions outlined by physicianC-23 Change of physician notice Includes physician informationC-63 Additional information request A V3 letter asking for additional medical informationC-84 Physician’s supplemental report This is a statement of medical disabilityC-85A Application to reactivate claim Form has medical information attachedC-86 Motion Request for additional medical conditionsC-92 Determination of % PP disability Determination of percentage of medical disability

– medical information is attachedC-92A Increase in % of PP disability Determination of percentage of medical disability

– medical information is attachedC-92EXA C92/C92A exams Determination of percentage of medical disability

– medical information is attachedFROI First report of injury Main medical claim formMED Medical documents Medical information that does not fit in the

stated categoriesMEDCO-14 Physician’s Return-to-Work Report Form used by physicians for work restrictionsMEDCO-21 Physician review Forms used by physicians for medical assessment

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Claims flow chart

Injured worker seeks medical treatment.

BWC allows or denies claim.

Allowed claimsMedical management begins. Injured worker continuestreatment from a BWC-certified health-care provider.

MCO and doctor focus on quality health-care servicesgeared to early and safe return to work.

Contested issuesIn contested compensation claims, the IndustrialCommission of Ohio (IC) hears the dispute.

In medical disputes, the MCO and BWC offer a jointlevel of alternative dispute resolution before going tothe IC. (Not on allowed issues.)

Health-care provider files claim online or

with the MCO.

BWC issues claim number and

investigation begins. If you file online, you

will receive a claim number immediately.

What happens after you report an injury?

After receiving an injury report — from you, the injuredworker or employer — the MCO electronically transmitsimportant information about the injury to BWC.

Upon receiving initial notification of an injury, BWCautomatically assigns a claim number to the reportedinjury. If you file the claim online, you will receive a claimnumber immediately. The injured worker and employerwill receive written notice of the claim number. If theMCO received the provider number and submitted it toBWC, the provider who reported the injury also willreceive written notice from the bureau.

Remember, assigning a claim number is the first step inthe initial determination process. It does not mean BWC

has allowed the claim and will pay medical bills. BWC willreimburse providers for the injured worker’s treatment onlywhen it allows the claim and its related medical conditions.If BWC disallows the claim, BWC or the MCO will not paybills for treatments provided to the injured worker.

The MCO will work with BWC to resolve medical andlegal issues, assist in an early claim determination andfacilitate the injured worker’s timely and safe return towork. The MCO may ask you to supply additional medicalinformation to help substantiate the claim or clarify medicalissues related to the workers’ compensation injury. TheMCO will transmit this information to BWC.

Questions of diagnosis and causal relationship are medicalissues that require your opinion before BWC can resolvethem. The bureau must obtain evidence from a physicianwho has examined or treated the employee for the condition.BWC will allow a claim only for a work-related injury.

The provider must report the proper diagnosis for whichthe injured worker is being treated. BWC only pays forinjuries causally related to a workplace accident. Causalrelationship is a medical determination based on reviewof the accident description and injury mechanism.

Injured worker information

• Name* • Telephone number*• Gender* • Social Security number*• Address* • Date of birth*• Marital status • Occupation*

Employer information (The injured worker‘s employer)• Employer name*• Employer address*• Employer telephone number*

Injury information

• Type of injury (accident, occupational disease or death)*• Date of injury (date of death, if applicable)*• Will injury likely result in more than seven days

off work? (yes or no)*• Accident description (detailed account of how

accident happened)*• Date of initial treatment• Date last worked and returned to work (estimated

return to work if exact date is unknown)• ICD-9 diagnosis codes (specific diagnosis description,

including primary ICD-9)• ICD-9 location (right, left, bilateral)• ICD-9 site (digits or teeth)• Injury description (body part injured); for example,

first joint of left index finger)*• Is diagnosis causally related to this industrial

accident? (yes or no)*

Provider information

• Initial treating provider name and BWC provider number (may be a hospital or physician).*

• Name of POR and BWC provider number. (If the MCO receives the BWC provider number and transmits it to BWC, the bureau will send the provider a letter indicating the claim status andthe allowed conditions.)*

Provide the data elements listed below

to MCOs when you report a new injury.

* Indicates data elements required to report an injury within the 24-hour deadline.You must provide the remaining data elements to the MCO no later than fivecalendar days from the initial treatment if not available at the time of the first report.


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C-84 — The POR must complete specific sections of thisform and sign it to indicate the injured worker is unableto work. After the injured worker completes part I of theform, send the C-84 to BWC.

Requesting additional allowances

Periodically, either the treatment of or nature of an injuredworker’s disability may require BWC to add additionalconditions to the claim. For example, BWC may allow aclaim for a lumbar sprain/strain, but additional diagnosisand treatment reveal a herniated nucleus pulposus is theunderlying cause of the injured worker’s disability. Bylaw, BWC must add this condition and pay compensationto the injured worker, and reimburse providers for theirservices.

The proactive allowance policy establishes guidelines forprocessing physician recommendations for additionalallowances. It also provides for better coordination andcommunication between BWC, MCOs and providers onthe result of the bureau’s proactive allowanceconsideration.

BWC’s proactive pursuit of additional allowances providesthe physician an opportunity to deliver services to aninjured worker earlier, resulting in appropriate quality careand the potential for earlier return to work. The policy’sprimary focus is to improve delivery of services, reducelost work days and improve treatment outcomes.

For BWC to consider a proactive allowance request,please forward the following medical data to the assignedMCO. The MCO will ensure the following information isgathered from the physician and submitted to BWC:• Supporting medical documentation, including clinical

examination and diagnostic test findings;• Current treatment plan;• ICD-9 diagnosis code for requested diagnosis (include

specific diagnosis description, e.g.; 722.10 Lumbar HNP, L4-L5 and identify if primary ICD-9);

• ICD-9 location (right, left or bilateral) when applicable;• ICD-9 site (digits, teeth or body part) when applicable;• A causality statement indicating how the mechanism

of injury resulted in requested diagnosis (i.e., is the diagnosis causally related to the industrial accident?).

BWC will consider the physician’s recommendation ofan additional condition(s) when he or she completes anddates the C-9 and/or medical evidence within one yearfrom the date of injury, and the evidence clearly supportsthe condition. The medical documentation, mechanismof injury and time sequence must be defined clearly andsupport the additional allowance recommendation.

BWC will not consider proactively allowing psychiatricor chronic conditions that may be the result of naturaldeterioration or degenerative processes. These includeconditions such as, but not limited to, the following:arthritis, spinal stenosis, spondylolisthesis, degenerativedisc disease or aggravation of a pre-existing conditionor disease; less specific diagnosis of disorders, such asmyalgias, arthalgias or reflex sympathetic dystrophy.

In five to 28 days from the receipt of the recommendation,BWC will either allow the condition or notify the injuredworker or his or her legal representative to request thecondition in writing. BWC also will provide an update tothe physician who recommended the additional allowanceand to the MCO regarding what action the bureau istaking on the proactive allowance.

BWC will not pursue proactive allowance and will alwaysnotify injured workers or their legal representatives to requestthe condition in writing when any of the following occurs:• Any party in the claim, including the injured worker/

employer representative, disagrees with the allowance of the condition(s);

• Psychiatric, degenerative or pre-existing conditions are found;

• The evidence does not clearly establish causality;• It is determined a BWC physician review/exam is

needed.

If the C-9 and/or medical evidence date exceeds oneyear from the date of injury, BWC may still considerproactive allowance if the evidence clearly supports thecondition and causal relationship is established.

Important: Providers may not complete a Motion(C-86) requesting BWC allow an additional condition onthe claim or advise an injured worker to file one.

By law, providers are not parties to the claim; therefore,they cannot appeal decisions regarding additionalallowances to the MCO, BWC or IC. Injured workers,employers or their authorized representatives mustinitiate appeals.

When you sign BWC’s provider agreement, you agree to:

• Comply with Ohio’s workers’ compensation laws andrules;

• Maintain malpractice coverage;• Practice in a managed care environment and comply

with utilization review determinations;• Bill only for services and items performed or provided

and medically necessary, cost-effective and related to the claim or allowed condition;

• Inform the injured worker of his or her liability for payment for non-covered services prior to delivery;

• Charge no more than the usual fee billed to non-industrial patients for the same service;

• Accept reimbursement and not divide/unbundle charges into separate procedure codes when a singleprocedure code is more appropriate;

• Not bill the injured worker or employer for balances.Injured workers are not required to contribute a co-payment and do not have to meet deductibles.

Provider enrollment data

To ensure you receive timely payment for approvedmedical treatments and other information, you mustkeep your provider enrollment information up-to-date.BWC and MCOs use this information regularly to processbills and make payments.

To change provider enrollment data, tax identificationnumbers and group affiliations, complete the Requestto Change Provider Information (MEDCO-12) or submitthe changes in writing on letterhead to: Ohio Bureau ofWorkers’ Compensation, Provider Enrollment Unit, P.O.Box 182031, Columbus, OH 43218-2031. You also mayfax your changes to (614) 621-1333.

When requesting a change to provider enrollment data,tax identification numbers and group affiliations, providethe following information in writing:• Provider name and number;• Effective date;• Telephone number;• Signature of individual assigned to the specific provider

number.

If you’re submitting address changes, please specify:• Physical locations;• Pay-to address;• Correspondence address.

You also must request in writing changes to taxidentification numbers and group affiliations. Pleasespecify when the changes will become effective.BWC plans to recertify providers on a biennial basis.

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Providers wishing to incorporate the use of their NPIinto their Ohio workers’ compensation billing must makesure they have provided their information with verificationto BWC provider enrollment in the BWC provider relationsdepartment. Providers wishing to use NPI in billingshould submit a copy of their NPI confirmation receivedfrom the Enumerator (Fox Systems Inc) to the fax oraddress below.

Ohio BWC Provider Enrollment:Fax: (614) 621-1333

Or mail to:Ohio Provider EnrollmentP.O. Box 182031Columbus, OH 43218-2031

Reporting injuriesProviders must report a worker’s injury to BWC or theappropriate MCO within 24 hours or within one businessday of the initial treatment or visit. Since 24-hour reportingis a legal and contractual requirement, non-compliancecan result in punitive action, such as loss of BWCcertification, removal from an MCO’s panel or both.

Reporting an injury within 24 hours has a number ofadvantages, such as helping BWC expedite the claimsprocess. Generally, the sooner you report a claim, thesooner BWC can allow it. If BWC does not allow a claim,the bureau doesn’t issue payments for either the injuredworker’s compensation or medical bills.

BWC encourages providers to file the FROI online atohiobwc.com. When you file the FROI online, you willreceive a claim number immediately. You also may callthe employer’s MCO, or complete and fax the FROI tothe MCO’s toll-free number found in the MCO Directoryon ohiobwc.com. If you do not know the MCO assignedto the employer, ask the injured worker or employer.You also can check the Employer/MCO look-up featureon ohiobwc.com.

MCOs must transmit 70 percent of the injury reportsto BWC electronically within three business days afterreceiving notice of an injury. MCOs must transmit 100percent of these reports within five business days. TheMCOs rely heavily on providers to supply importantmedical information including BWC-required dataelements and may contact you to gather any additionalrequired information.


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Billing andreimbursementThere are various methods for submitting bills, and it isthe provider’s responsibility to ensure he or she bills theappropriate party.

An electronic transmission in the ASCX12 837 format isthe preferred method of submitting bills to the properMCO. You can find implementation documentation forthe 837 on BWC’s Web site, ohiobwc.com.

You also can find addresses to submit hard-copy bills toMCOs in the MCO Directory on ohiobwc.com.

Follow the guidelines in chapter four of the BRM whensubmitting bills to MCOs. You may also view anddownload the BRM from ohiobwc.com. If youcannot access the BRM online, call 1-800-OHIOBWC,and listen to the options, or e-mail your request [email protected].

To ensure consistent billing processes and to maintainquality customer service, all BWC-certified MCOs acceptthe following national and BWC billing forms:• American Dental Association (ADA) dental form;• Centers for Medicare & Medicaid Services CMS 1500;• Uniform Billing (UB 92 and UB-04);• Service Invoice (C-19).

Please do not bill the injured worker or the employer forstate-fund claims.

When billing BWC or MCOs for services, you must codethe service according to the guidelines in the BRM.

Self-insured claims are not part of HPP. Self-insuringemployers will continue to pay for their employees’workers’ compensation benefits. Please send medicalbills directly to the self-insuring employer.

ICD-9-CM

BWC groups ICD-9-CM codes into numeric sets. It definesan ICD-9 group as an injury or condition similar in nature,and/or one involving the same body part, and can containone or more ICD-9 codes. All codes in that group areinterchangeable, and BWC can use them for allowanceand reimbursement purposes.

MCOs and BWC may accept valid V diagnosis codes onbills. You may not use E codes except as other diagnosis

codes or admitting diagnosis codes on hospital bills.The bureau does not recognize these codes for allowanceor reimbursement purposes.

You can order copies of BWC’s ICD-9 groups and invalidICD-9 codes by either calling 1-800-OHIOBWC andlistening to the options or downloading this informationfrom ohiobwc.com.

MCOs determine medical reimbursment eligibility in aworkers’ compensation claim for specific, allowedconditions. That’s why ICD-9 diagnosis codes are requiredto identify medical conditions providers treat.

The provider must bill the diagnosis code for the conditionhe or she treats. Even if you know BWC has not allowedthe condition in the claim formally, the MCO has thediscretion and responsibility to coordinate treatmentand decide whether to pay.

Always follow acceptable ICD-9 coding principles. BWCrecognizes the current version of the ICD-9-CM. If youhave any questions about the claim status, includingdiagnosis information, contact the MCO managing theclaim or log on to ohiobwc.com.

Billing time frames

Within seven days, the MCO must either return the billto the provider, if information is invalid, or edit and pricethe bill. Bills that are denied as improper invoices arereturned to the providers for correction/resubmission.

If the MCO approves a bill, it sends the bill to BWC,which validates the pricing and claim status. BWC sendspayment and remittance advice via electronic fundstransfer to the MCO. Within seven days of receivingpayment from BWC, the MCO pays the provider.

By following this flow, you can expect speed, accuracyand fairness in receiving reimbursement for treatmentof injured workers.


BWC is in compliance with the ability to recognize billsreceived with a provider NPI number. Please refer toprovider enrollment information on page 5. BWC doesnot view NPI as a replacement of the BWC providernumber assigned but as an alternate and additionalidentifier that providers can use in Ohio workers’compensation billing.

E-business revolutionizes how BWC does business, but it does not replace people with technology. Customerswho prefer dealing with a person have the option of doingso. And since the system frees BWC employees frommany time-consuming tasks, it allows us to provide moreefficient customer service.

Provider communications

For ongoing provider communications, BWC publishesquarterly updates to the BRM. To obtain a BRM Update,BWC Law Book or BWC Rule Book, call 1-800-OHIOBWCand listen to the options, or e-mail your request [email protected].

For a complete listing of MCO contact information, seethe MCO contact tables in the BRM, or go online toohiobwc.com. BWC will incorporate any revisions to thislist in future BRM Updates and online at ohiobwc.com.

Provider certificationIn HPP, there are three provider categories:

1. BWC-certified provider — A provider BWC has approved for participation in HPP and who signs a BWC provider agreement;

2. MCO panel provider — A BWC-certified provider included within a BWC-certified MCO provider network;

3. Non-BWC-certified provider — A provider BWChas enrolled only for participation in HPP and who has not signed, or been required to sign, a provider agreement with BWC.

With the exception of the following circumstances,

you must be a BWC-certified provider to receive

reimbursement for your services:

• Ongoing treatment of an injured worker with date of injury before Oct. 20, 1993, that began prior to HPP.The injured worker may continue treatment with anon-certified physician. However, an MCO willmanage the care;

• Emergency treatment;• Initial treatment. Non-BWC-certified providers must

have a BWC provider number to receive reimbursementfor these services. If the injured worker changesphysicians, he or she must select a BWC-certifiedprovider or the injured worker will be responsible forpayment;

• Specific provider types listed on Application for ProviderEnrollment Non-Certification (MEDCO 13A).

BWC certification is an ongoing process to accept newproviders in the system. The first step to becomingBWC certified is to complete the Application for ProviderEnrollment and Certification (MEDCO-13). Providersmust also complete the required Declaration RegardingMaterial Assistance/Nonassistance to a TerroristOrganization for Government Business and FundingContracts as required by Ohio Revised Code 2909.33.This form is attached to the MEDCO-13 and should becompleted after viewing the U.S. Department of StateTerrorist Exclusion List located at:http://www.homelandsecurity.ohio.gov/dma_terrorist/terrorist_exclusion_list.pdf

To obtain an application, call 1-800-OHIOBWC, andlisten to the options, or download the application fromohiobwc.com.

If you meet the enrollment and credentialing criteria andsign the provider agreement, BWC will certify you toparticipate in the HPP.

Option 4 To report fraudOption 7 Repeat menuOption 9 Spanish optionOption 0 Customer contact center

1-800-OHIOBWC options

Option 1Injured worker

information

Option 2Employer

information

Option 3Medical andpharmacyproviders





2 Safety services

3 Self-insured information




2 Pharmacy benefits


4 Drug history review

0 Provider Relations callcenter representative

4 17


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BWC is not a covered entity under HIPAA and will continueto accept bills containing only BWC legacy (or current)numbers as well as bills containing both the legacy andthe NPI.

BWC is making changes to effectively add provider NPIdata into its provider enrollment and eligibility database,then to crosswalk the NPI received on invoices to theBWC Provider ID. This approach permits BWC to continueto process bills in a way that is accurate and consistentwith laws, rules and policies governing the payment ofworkers’ compensation medical benefits.

Billing tips

Do:• Submit bills to the appropriate MCO;• Submit bills according to BWC format;• Bill the actual diagnosis(es) treated;• Submit documentation in cases where services billed

do not correspond to treatment that was requested and approved or if needed to support services rendered;

• Follow form completion guidelines in chapter 4 ofthe BRM;

• Attempt to resolve outstanding billing issues with thespecific MCO;

• A grievance conference can be scheduled with the MCO over medical billing disputes with additional appeal to BWC if needed. This is not applicable to disputes over BWC’s fee schedule rates.

Don’t:• Submit bills with the FROI;• Bill the injured worker for the balance, or ask for

co-payment;• Request payment from the injured worker for

reimbursable covered services;• Unbundle services.

MCOs are responsible for:

• Reporting claims;• Assisting injured workers in securing appropriate

medical treatment from an approved, BWC-certified provider;

• Medical case management, including reviewing treatment requests and making treatment decisions;

• The first level of dispute resolution;• Bill review and payment;• Educating and assisting employers and providers

regarding return-to-work initiatives.

Ohiobwc.comOhiobwc.com is BWC’s e-business service. It allowsthe bureau to use technology to provide its customerswith consistent, customized, streamlined service 24hours a day, seven days a week.

Log on to ohiobwc.com and find out how fast, efficientand easy it is to have all of your workers’ compensationinformation and services at your fingertips.• BWC Library — Take a guided tour to learn more about

processes and policies. Get answers to frequently asked questions and definitions for workers’compensation terms in the provider glossary.

• Medical bill payment look-up — Providers can viewmedical bill payment information. You can alsocustomize bill searches to verify BWC received yourbills from the MCO and made provider paymentsto MCOs.

• Billing and reimbursement — Access and download the online Provider Billing & Reimbursement Manual(BRM). You can also view or print reimbursementpolicies/procedures and quarterly updates. The bureauissues a quarterly newsletter titled BWC ProviderUpdate to notify providers about updates to the BRM.All providers on Web site look-up receive the newsletter.The current and previous three editions of thenewsletter also appear online.

• Claim documents — Providers who meet BWC’ssecurity criteria can access Claim documents,a repository of imaged documents from individualclaim files.

Additionally, with ohiobwc.com, providers can:

• View basic claims information, including InternationalClassification of Diseases, Ninth revision (ICD-9)codes, claim status, date of injury, accident descriptionand the assigned MCO;

• Verify BWC-certified providers through the BWC provider look-up;

• Determine an employer’s MCO with BWCEmployer/MCO look-up;

• View the BWC Provider Fee Schedule;• Download BWC forms, including the First Report of

an Injury, Occupational Disease or Death (FROI), Physician s Request for Authorization of Medical Services or Recommendation for Additional Conditionsfor Industrial Injury or Occupational Disease (C-9) andRequest for Temporary Total Compensation (C-84). Then, users can print these forms, complete and submit them via mail, fax or in person;

• File the FROI electronically allowing a claim numberto be asigned immediately;

• Download BWC Diagnosis Determination Guidelines,a reference guide, to provide criteria for diagnosis determination/coding decisions between BWC and MCOs for the most frequently used diagnosis/ICD-9 codes;

• Look up an injured worker’s claim history by Social Security number;

• File a Physician s Report of Work Ability (MEDCO-14),which lists an injured worker’s restrictions but also says what he or she is medically able to do.

Remember, to ensure confidentiality, you must createa primary account before accessing injured workerinformation. You can create secondary users from thisaccount so each of your employees can have individualpasswords.

A new service offering, Group provider relationshipadministration, now available on ohiobwc.com makesaccessing claim information easier for physician of record(POR) provider types associated with group practices.

Group provider relationship administration gives PORprovider types with e-accounts the ability to delegateor revoke their e-account privileges to a group providertype (provider type 12). POR provider types may notdelegate e-account privileges to any other provider types.

Provider groups with multiple POR provider types willfind this new offering helpful. Once each POR providertype delegates e-account privileges to a group, anyperson logged on under that group provider number canaccess the same information as the POR provider type.

For more information about provider services, or forhelp creating a BWC provider e-account (user ID andpassword), call 1-800-OHIOBWC, and listen to theoptions. You also can e-mail the provider relationsdepartment at [email protected].

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ForewordThe Health Partnership Program (HPP) is the Ohio Bureauof Workers’ Compensation’s (BWC’s) program formanaging workers’ compensation health care for injuredworkers employed by state-fund employers. It is mandatedby the Ohio legislature under House Bill 107. BWCemployees, business leaders, labor representatives andhealth-care providers designed HPP.

BWC and private-sector managed care organizations(MCOs) certified to participate in HPP work together tohelp manage workers’ compensation claims andcoordinate medical services with an emphasis on returninginjured workers to work safely and efficiently. BWC andthe MCOs’ shared goal is to provide the best servicepossible for employers and injured workers. This includesforging relationships with doctors and medical providers,rewarding employers who run safe workplaces andopening new opportunities for injured worker.

Return to work — A key factor in return-to-work successis HPP’s focus on quality. While a certain medicalprocedure may incur a higher up-front cost, the impacton a more timely and safe return to work often offsetsthat cost. An injured worker’s physician and MCO willwork together to determine the optimal return-to-workdate for full or modified duty based on the injury and typeof work.

Often times, going back to work mid-week allows injuredworkers more time to readjust to their original job demandswithout being worn out by a full work week. It alsoimproves the chances of injured workers remaining atwork. For employers, the benefits include reducing thecost of replacing injured workers and the total cost of theclaim. In addition, it results in lower employer reserves,helping to prevent a medical-only claim from becominga lost-time claim.

Presumptive authorization — This process allows aphysician to provide basic treatment for the most commonwork-related injuries up to 60 days from the date of injury.

Vocational rehabilitation services — The longer aninjured worker is off work the more difficult it becomesfor that worker to return to work. MCOs work with injuredworkers, employers and medical providers with the goalof promoting an early and safe return to work. Vocationalrehabilitation services help return the injured worker tothe original job whenever possible, or to a different job

with the same employer. If that is not possible theseservices help the injured worker secure a similar jobwith another company or a different job with a differentemployer.

Remain at work — A workplace injury does not haveto result in a long absence. Managed by the employer’sMCO, the remain-at-work program provides injuredworkers with rehabilitation services that help reduce oreliminate the number of days they are off work andkeeps medical-only claims from becoming lost-timeclaims.

Transitional work — Studies have shown the likelihoodof injured workers returning to work after six months is50 percent. This figure drops to 25 percent after oneyear and almost zero after two years off the job. Atransitional work program uses real job duties toaccommodate injured workers’ medical restrictions fora specified time period to gradually return them to theiroriginal jobs.

These five initiatives focus on ensuring injured workersreceive the right services at the right time, thus, avoidinglong debilitating periods off work. Your role is vital duringthis period. While providing your specialized skills, youhave the opportunity to reinforce return-to-workexpectations and encourage injured workers to activelyfacilitate their recovery and return to the job.

The American Academy of Orthopedic Surgeons andthe American Association of Orthopedic Surgeons believesafe, early return-to-work programs are in the patients’best interest. Return to light-duty, part-time or modified-duty programs are important in preventing the onset ofpsychological and other behavior patterns that get in theway of injured workers successfully returning to workand to normal lives.

As a critical player in the HPP design, providers mustunderstand the basis and goals of return-to-workstrategies and optimal return-to-work expectations forinjured workers. It also is important to understand theroles BWC and MCOs play in this partnership.

BWC is responsible for:

• Making claim determinations and allowances;• Paying compensation;• Educating injured workers, employers and providers

about HPP;• MCO oversight.

Billing and reimbursement flow

MCO denies the bill within

seven days.

MCO approves the bill within

seven days.

Bills that are denied as improper

invoices are returned to

providers for correction/

resubmission.

MCO submits bill electronically

to BWC.

BWC receives and validates bill

within seven days.

BWC approves bill.

BWC sends payment to MCO.

Within seven days, MCO sends

payment to provider.

BWC must allow claim.1

Provider submits bill to MCO.2

MCO receives bill.3

BWC does not cover

bills for unapproved

treatment or unrelated

conditions.

2 19

Bills that are denied are

returned to MCO for

correction/resubmission.


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Table of contentsForeword..................................................................2Ohiobwc.com...........................................................3Provider certification ................................................4Reporting injuries .....................................................5Outpatient medication..............................................7Pharmacy billing .......................................................8Medical management ..............................................9Billing and reimbursement .......................................17Appendix ..................................................................20

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AppendixBWC Provider Fee Schedule

The BWC Provider Fee Schedule is available online atohiobwc.com. You may download a copy by clicking onMedical Providers, then Forms. You may also access aninteractive version of the form by clicking on MedicalProviders, Look-ups, and then Fee schedule look-up. BWCupdates both versions on its Web site as changes occur.

BWC is examining medical payment methodologies toput a structure in place in 2008 that reflects the interestsof Ohio’s injured workers and employers withoutcompromising fair and equitable reimbursements toproviders. Look for additional information about the bureau’s2008 provider fee schedule in BWC Provider Update07-4, scheduled for release in late November 2007.


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2007/2008

CD-106Revised August 2007

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