OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:	Additional Allowance
Policy #:	CP-01-03
Code/Rule Reference:	OAC 4123-3-15 and 4123-3-16
Industrial Commission (IC) Resolution/Memo	IC R97-1-06 Requirement on Physicians Reports
Effective Date:	04/14/2021
Approved:	Ann M. Shannon, Chief of Claims Policy and Support
Origin:	Claims Policy
Supersedes:	Policy # CP-01-03, effective 01/01/14 and Procedure # CP-01-03.PR 1, effective 05/06/19
History:	Previous versions of this policy are available upon request

Table of Contents

II. APPLICABILITY

III. DEFINITIONS

Causal Relationship

Medical Evidence

IV. POLICY

A. Additional Allowance Recommendations and Requests

B. Additional Allowances of Psychological or Psychiatric Conditions

V. PROCEDURE: C-86 ADDITIONAL ALLOWANCE REQUESTS

A. General Claim Note and Documentation Requirements

B. Initial Actions

C. Assessing the C-86 and Medical Evidence

D. Requesting a Medical Review

E. Requests for Multiple Conditions

F. Contacting the Employer

G. C-86 Allowance, NOR to the IC, and Dismissal

H. Updating Conditions in the Claims Management System

I. Additional Allowance Request(s) Received Prior to the Final Initial Determination

VI. PROCEDURE: C-9 ADDITIONAL ALLOWANCE RECOMMENDATIONS

A. General Claim Note and Documentation Requirements

B. C-9 Receipt: Initial MCO Actions

C. Assessing the C-9 and Medical Evidence

D. Contacting the IW or IW Representative

E. Requesting a Medical Review

F. Decision

G. Additional Allowance Recommendation(s) Received Prior to the Final Initial Determination

I. POLICY PURPOSE

The purpose of this policy is to ensure that conditions allowed in a claim subsequent to the initial allowance are supported by medical evidence and meet other legal requirements.

II. APPLICABILITY

This policy applies to BWC claims services staff and managed care organizations (MCOs).

III. DEFINITIONS

Causal Relationship: A medical and legal concept used to establish whether an injury or condition is compensable.

A medical concept describing a relationship between the injury or condition and the industrial accident or occupational disease; and
A legal concept that establishes a relationship between the injured worker’s employment and the industrial accident or occupational disease.

Medical Evidence: Relevant information that may prove or disprove whether a requested condition is medically supported in a claim; one criterion that BWC must consider when determining compensability of a claim or allowance of a condition.

IV. POLICY

A. Additional Allowance Recommendations and Requests

1. It is the policy of BWC to additionally allow a condition in a claim following a thorough investigation to ensure that the condition is supported by medical evidence and is causally related to the original injury.

2. In general, additional allowances may be:

a. Recommended by a provider on a Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) (see exception below in IV.B.1); or

b. Requested by the injured worker (IW) or IW representative on a Motion (C-86).

3. Upon receipt of a C-9 recommending or a C-86 requesting the additional allowance of a condition(s) in a claim, BWC may, at its discretion seek independent medical verification of the conditions being requested by either:

a. Obtaining a physician file review (PFR); or

b. Requiring that the IW attend an independent medical examination (IME).

4. An additional allowance is not required to be added to the claim for purposes of treatment that could otherwise be paid under the following policies:

a. Miller Case Criteria;

b. Health Behavioral Assessment and Intervention (HBAI) (found in BWC’s Billing and Reimbursement Manual (BRM));

c. Opioid Use Disorder Treatment Coverage (found in the BRM); or

d. Payment for Treatment of Services Related to Concussion Injuries (found in the BRM).

B. Additional Allowances of Psychological or Psychiatric Conditions

1. BWC will not address a recommendation for the additional allowance of a psychological or psychiatric condition on a C-9.

2. Prior to considering the additional allowance of a psychological or psychiatric condition, BWC requires that a C-86 be filed with a declaration statement signed and dated by the IW.

3. For additional information regarding the handling of claims with psychological or psychiatric conditions, refer to the Psychiatric Conditions policy and procedure.

V. PROCEDURE: C-86 ADDITIONAL ALLOWANCE REQUESTS

A. General Claim Note and Documentation Requirements

1. BWC staff will refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim notes and documentation requirements; and

2. Must follow any other specific instructions for claim notes and documentation included in this procedure.

B. Initial Actions

1. When BWC receives a C-86 requesting the allowance of an additional condition, the C-86 must be indexed into the claim and will populate to the list of work items belonging to the claim’s services staff member assigned to the claim.

2. Upon receipt of the C-86, claims services staff must:

a. Immediately create a legal case in the claims management system with an additional allowance issue (including when a request for reactivation is filed with an additional allowance).

b. Review the claim to determine if:

i. The statute of limitations for the claim has expired.

a) If it has expired, generate the appropriate “Out of Statute of Limitations Letter,” depending on whether the claim is lost time or medical only.

b) For more information regarding the statute of limitations, refer to the:

i) “Statutory Life of a Claim Chart” under Tips and Tools on the Additional Allowance policy page on Claims Online Resources (COR); and

ii) Jurisdiction (Statute of Limitations, Statutory Life of a Claim) policy and procedure.

ii. The request is a moot issue (e.g., claim is disallowed, settled, or the condition is already allowed or denied), or the claim has been suspended. If so, notify the parties to the claim that the request cannot be addressed by sending the “Additional Allowance Combination Letter.”

iii. A Settlement Agreement and Application for Approval of Settlement Agreement (C-240) or an Application for Compensation for Permanent Total Disability (IC-2) has been filed in the claim.

a) If a C-240 or IC-2 is on file, but the respective process is not complete, suspend the C-86.

b) The C-86 may then be processed if the claim is not settled.

c) Regardless of the IC’s decision to allow or deny Permanent Total Disability (PTD), claims services staff must process the request for additional allowance once the IC decision regarding PTD becomes final.

C. Assessing the C-86 and Medical Evidence

1. Upon receipt of a request for an additional allowance, claims services staff must verify that the:

a. Request includes:

i. A clear narrative description of each of the requested condition(s), including location, level, etc. when applicable;

ii. A causality statement; and

iii. Specific evidence to support each of the requested condition(s). Claims services staff must verify the appropriateness of the submitted medical evidence through:

a) The use of the “Workbook - MEDD Resource Guide” on COR;

b) Staffing;

c) Applicable BWC policies and procedures; or

d) Other medical resources.

b. Requested condition(s) is not a symptom. If a symptom is requested:

i. Claims services staff must attempt to clarify with the filing party what condition is causing the symptom(s) listed on the request.

ii. Claims services staff may also discuss with the filing party the possibility of withdrawing the request completely or withdrawing only the requested symptom if other conditions are requested.

iii. Claims services staff may dismiss the request if contact with the filing party is unsuccessful.

c. C-86 includes the signature of the IW or IW representative.

2. If any of the abovementioned required information is not available or is unclear, claims services staff must make reasonable attempts to obtain the necessary information from the IW or IW representative.

a. If the request is missing medical evidence, including a causality statement, claims services staff must make reasonable attempts to obtain the specific medical evidence required for the allowance of the requested conditions (e.g., x-ray to support the presence of a fracture).

b. If the C-86 is missing a signature or is signed by someone other than the IW or IW representative, verbal agreement by the IW or IW representative to the filing of the C-86 is insufficient. Claims services staff must make reasonable attempts to contact the IW or IW representative and obtain a properly signed C-86.

c. For all other missing or unclear information, a new C-86 is not needed if claims services staff obtains verbal clarification. For example:

i. A request is filed for allowance of a herniated disc, but the specific level is not listed.

ii. Claims services staff contacts the filing party and is informed that the level is L4-5.

iii. A new request stating the appropriate level is not needed but claims services staff must enter a note in the claim to reflect the clarified information.

d. When attempting to obtain missing information, claims services staff must:

i. Detail all contacts and contact attempts in claim notes; and

ii. Contact the IW representative only, unless:

a) The IW has expressed that they would like to be included;

b) The representative is not responding to the contact attempts; or

c) The IW does not have a representative.

3. Upon receipt of sufficient medical evidence, or after reasonable attempts to obtain it, claims services staff will continue considering the allowance of the requested condition(s). Claims services staff must:

a. Enter the ICD code of each condition to be considered into the claims management system;

b. Evaluate the requested condition(s) using the “Workbook - MEDD Resource Guide”; and

c. If a medical review is warranted, request one (see the Requesting a Medical Review section of this procedure immediately below for guidance on when a medical review is appropriate and how to request one).

4. If none of the information detailed above is received following reasonable attempts to obtain it, a medical review is not necessary. Claims services staff must dismiss the C-86 via “BWC Miscellaneous Order”, as detailed in the C-86 Allowance, NOR to the IC, and Dismissal section of this procedure.

D. Requesting a Medical Review

1. Claims services staff will request a medical review if:

a. The condition is not included in the “Workbook - MEDD Resource Guide”; or

b. Claims services staff:

i. Needs assistance determining causality; or

ii. Feels that a medical review is necessary.

2. Prior to referring the claim, claims services staff must:

a. Ensure that:

i. They have utilized all available resources to identify any appropriate medical documentation that would be needed to determine allowance of the conditions (e.g., online research for conditions not listed in the “Workbook - MEDD Resource Guide”); and

ii. All necessary medical evidence has been received.

b. Follow the “SOP Medical Referral Note Guidelines”; and

c. Document the following information in claim notes:

i. The type of application the request was submitted on;

ii. Date the application was received;

iii. The condition(s) being requested (narrative), including level and location, when applicable;

iv. Previous claims if the IW has any;

v. Suspect intervening injury and a corresponding Insurance Services Office (ISO) report if it exists;

vi. Their rationale for sending the referral for medical review;

vii. Titles and indexing dates of supporting medical evidence, including causality statement; and

viii. Any other pertinent information.

3. Claims services staff must create a “Nurse-AA” case event, which will in turn create a work item for a Medical Services Specialist (MSS).

4. Refer to the Independent Medical Examinations (IMEs) and Physician File Reviews (PFRs) policy and procedure for more information regarding IMEs and PFRs.

E. Requests for Multiple Conditions

1. If one or more requested condition(s) is fully supported by sufficient medical evidence, but there is insufficient medical evidence to support the other condition(s) (even after reasonable attempts by claims services staff to obtain sufficient evidence), or an IME or PFR report states that there is insufficient evidence to support the other condition(s):

a. Claims services staff must contact the IW or IW representative to determine if they prefer that:

i. The entire request be referred to the Ohio Industrial Commission (IC); or

ii. The conditions in the request be bifurcated to:

a) Allow the condition(s) that is supported by sufficient medical evidence; and

b) Dismiss the condition(s) for which there is insufficient medical evidence.

b. The IW or IW representative may respond either verbally or in writing.

2. If the IW or IW representative:

a. Agrees to bifurcate the request, claims services staff will move forward with processing the claim by contacting the employer, as detailed in the Contacting the Employer section of this procedure below.

b. Disagrees with bifurcating the request or does not respond, claims services staff must prepare a Notice of Referral (NOR) to the IC following the Notice of Referral to the Industrial Commission policy and procedure.

3. Example:

a. A claim is allowed for back sprain.

b. BWC receives a request for allowance of right knee sprain and herniated disc at L5-S1.

c. A treatment request for the right knee has been submitted to the MCO.

d. The PFR supports allowance of the right knee sprain, but does not support allowance of the herniated disc.

e. Claims services staff contacts the IW or IW representative to determine if they would like to dismiss the request for herniated disc (the condition that is not supported).

f. The IW or IW representative agrees to dismiss the request for herniated disc, which allows claims services staff to move forward with allowance of the right knee sprain and allows the MCO to consider the associated treatment.

g. Claims services staff issues a “BWC Subsequent Order” that addresses the allowance of the right knee sprain (the condition that is supported by sufficient medical evidence), and includes language dismissing the request for the herniated disc.

F. Contacting the Employer

1. Contact with the employer regarding the request is not necessary if:

a. BWC’s decision is to dismiss the request; or

b. BWC recommends the request be denied. The employer will receive the NOR to the IC and will have an opportunity to submit information at the hearing.

2. If BWC’s decision is to allow the request (in its entirety or in part), claims services staff must contact the employer (or employer representative) to obtain agreement regarding allowance of the conditions and answer any questions the employer may have regarding the request:

a. By phone, unless the employer has requested to be contacted by an alternative method (e.g., e-mail); and

b. Directly, unless the employer has indicated that contact should be directed to the employer’s representative.

G. C-86 Allowance, NOR to the IC, and Dismissal

1. Allowance

a. Claims services staff must issue a “BWC Subsequent Order” to allow the requested condition(s).

b. Allowance of the requested condition(s) is appropriate when:

i. BWC agrees with the allowance of the condition(s); and

ii. The employer:

a) Agreed with allowance of the condition(s); or

b) Did not provide a response when contacted regarding allowance of the condition(s).

2. Addressing Multiple Conditions

a. If the decision is to allow all requested conditions, claims services staff must follow the directions detailed in Section V.G.1(a-b) immediately above.

b. If one or more requested conditions are supported by sufficient medical evidence, but there is no medical evidence to support the other condition(s) and the IW or IW representative has chosen to bifurcate the request, claims services staff will issue a BWC Order:

i. Allowing the condition(s) that is supported by sufficient medical evidence; and

ii. Dismissing the other(s), using the following language: “IW/IW representative <<verbally dismissed, dismissed in writing>> the following condition(s) <<dismissed conditions>> on <<date of dismissal>> without prejudice.”

3. Waivers

a. If BWC is allowing the condition(s) and both the employer or employer representative and the IW or IW representative submit a signed waiver, claims services staff must immediately update the claims management system.

b. For more information about waivers, refer to the Orders, Waivers, Appeals and Hearings policy and procedure.

4. NOR to the IC

a. Claims services staff must complete a NOR to the IC when:

i. The employer disagrees with allowance of the condition(s); or

ii. BWC recommends denial of any requested condition(s).

b. Before referring the condition(s) to the IC, claims services staff must obtain evidence (e.g. file review or exam) to support BWC’s position on the issue unless no file review or exam is recommended during staffing with a BWC attorney.

5. Dismissal

a. Claims services staff must dismiss the C-86 via “BWC Miscellaneous Order” when:

i. The IW or IW’s authorized representative wishes to withdraw or dismiss the request;

ii. The C-86 is not signed, following reasonable attempts to obtain a signature;

iii. There is no evidence to support the request, following reasonable attempts to obtain evidence; or

iv. The requested action is not clear, following reasonable attempts to clarify the request.

b. For more information regarding the dismissal of a C-86, refer to the Motions policy and procedure.

H. Updating Conditions in the Claims Management System

1. Claims services staff will ensure the condition(s) is updated in the claims management system after making a decision on the request.

2. Specifically, claims services staff will update the condition(s) in the claims management system when any of the following occur:

a. A BWC Order to allow or dismiss the condition(s) is issued;

b. Upon completion of a NOR to the IC;

c. An appeal is filed to a BWC or IC order;

d. All parties to the claim have waived the appeal period; or

e. The appeal period expires.

I. Additional Allowance Request(s) Received Prior to the Final Initial Determination

1. If BWC has not yet published an initial claim decision, the newly requested condition(s) will be included in the initial decision, even though the condition(s) is not listed on the First Report of Injury, Occupational Disease or Death (FROI). The condition(s) is treated as a condition(s) found in the medical evidence (e.g., the condition(s) can be allowed, but cannot be denied because it was not requested by the IW).

2. When a request is filed prior to the initial determination of the claim becoming final (during the appeal period with an appeal filed), the request must be suspended until the claim is fully adjudicated.

a. Claims services staff may call the filing party to notify them that the request has been suspended or send the “Additional Allowance Combination Letter” to notify parties to the claim that the request has been suspended.

b. If the claim is allowed, BWC will consider the condition(s) immediately.

c. If the claim is denied, consideration of the condition(s) is a moot issue. Claims services staff will send the “Additional Allowance Combination Letter” to notify the parties.

3. If an initial claim decision has been issued and a request is filed during the appeal period, but no appeal is filed, the previous order may be vacated with a new decision issued to include the new request. However, it may be appropriate to let the appeal period expire and issue a subsequent decision to facilitate timely payment of compensation and benefits to the IW.

VI. PROCEDURE: C-9 ADDITIONAL ALLOWANCE RECOMMENDATIONS

A. General Claim Note and Documentation Requirements

1. BWC staff will refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note and documentation requirements; and

2. Must follow any other specific instructions for claim notes and documentation included in this procedure.

B. C-9 Receipt: Initial MCO Actions

1. Upon receipt of a C-9 recommending the allowance of an additional condition, the MCO will review and assess the recommendation within three business days of receipt of the C-9 to confirm the following is included:

a. A clear narrative description of each recommended condition(s), including location, level, etc. when applicable, and that the recommended condition is not a:

i. Symptom; or

ii. Generalized condition (e.g., diabetes, obesity, hypertension) that requires treatment, which may be:

a) Addressed through bill payment using explanation of benefits (EOB) 776 instead of considering the condition for additional allowance in the claim; or

b) Considered for payment under the Miller Case Criteria policy.

b. Evidence to support the existence of each recommended condition; and

c. A physician’s causality statement.

2. If any of the information listed immediately above is not available, or information on the C-9 needs clarified, the MCO will contact the physician who submitted the C-9.

a. If the C-9 is missing a signature, the MCO must obtain a signed C-9; but

b. In all other cases, a new C-9 is not needed; however,

c. Evidence to support the existence of each recommended condition(s) and a causality statement will not be obtained verbally.

3. Following completion of the review and any actions taken as a result, the MCO will:

a. Enter a summary note, which details:

i. Their evaluation of the C-9, as detailed above; and

ii. If necessary, all actions taken to secure the missing information from the physician making the recommendation.

b. Send the C-9 to BWC, which will trigger a “BWC Action Required” work item.

4. The MCO should also assist the employer in understanding the medical information in the claim, when necessary.

C. Assessing the C-9 and Medical Evidence

1. Following review of the C-9 by the MCO and upon receipt of a “BWC Action Required” work item, the claims services staff must:

a. Immediately create a legal case in the claims management system with an additional allowance issue.

b. Review the claim to determine if:

i. The statute of limitations for the claim has expired.

a) If it has expired, generate the appropriate “Out of Statute of Limitations Letter”, depending on whether the claim is lost time or medical only.

b) For more information regarding the statute of limitations, refer to the:

i) “Statutory Life of a Claim Chart” under Tips and Tools on the Jurisdiction (Statute of Limitations, Statutory Life of a Claim) or Additional Allowance COR policy pages; and

ii) Jurisdiction (Statute of Limitations, Statutory Life of a Claim) policy and procedure.

ii. The recommendation is a moot issue (e.g., claim is disallowed, settled, or the condition is already allowed or denied), or the claim has been suspended. If so, notify the parties to the claim that the recommendation cannot be addressed by sending the “Additional Allowance Combination Letter”.

iii. A Settlement Agreement and Application for Approval of Settlement Agreement (C-240) or an Application for Compensation for Permanent Total Disability (IC-2) has been filed in the claim.

a) If a C-240 or IC-2 is on file, but the respective process is not complete, suspend the C-9.

b) The C-9 may then be processed if the claim is not settled.

c) Regardless of the IC’s decision to allow or deny PTD, claims services staff must process the request for additional allowance once the IC decision regarding PTD becomes final.

c. If the claim has expired, the recommendation is moot, the claim has been suspended, or a C-240 or IC-2 is pending:

i. Notify the MCO of the final decision.

ii. The MCO will then notify the treating physician of the status of the C-9.

2. Assessing the Medical Evidence

a. Claims services staff must determine whether the C-9 is recommending the additional allowance of:

i. A single or multiple physical condition(s);

ii. Both physical and psychological or psychiatric conditions; or

iii. A single or multiple psychological or psychiatric condition(s).

b. If any condition(s) recommended on the C-9 are physical:

i. Claims services staff must review:

a) Claim notes entered by the MCO regarding their review and assessment; and

b) Medical documentation in the claim and “Workbook - MEDD Resource Guide” to determine if additional evidence is needed for any of the recommended physical conditions.

ii. If additional evidence is needed and an MCO note has been entered, claims services staff must review MCO notes to determine the MCO’s progress on obtaining the missing evidence.

iii. If additional evidence is needed and the MCO has been unsuccessful at obtaining the necessary evidence, claims services staff must make an additional request for the evidence to the physician who submitted the C-9.

a) If insufficient evidence is on file and no additional evidence is received when requested, claims services staff must:

i) Document the evidence requested and that it was not received; and

ii) Continue considering the recommendation.

b) If no evidence is on file and none is received when requested,

i) Claims services staff must:

a. Dismiss the C-9 recommendation by sending the “Additional Allowance Combination Letter”; and

b. Notify the MCO of the dismissal.

ii) The MCO will then notify the treating physician that the recommendation has been dismissed due to lack of evidence.

iv. If additional evidence is needed but no MCO note has been entered:

a) Claims services staff must contact the MCO and attempt to obtain details about MCO actions taken.

b) If this contact is unsuccessful, claims services staff must discuss with their supervisor whether:

i) Additional contact with the MCO is necessary; or

ii) If the matter should be referred to the BWC MCO Business Unit, documenting the MCO’s non-response to BWC’s attempts to obtain required information.

c. If the condition(s) recommended on the C-9 include psychological or psychiatric conditions only:

i. Claims services staff must:

a) Send the “C-9 Additional Allowance Closure Letter,” which notifies the IW that they need to file a C-86 for BWC to consider allowance of the psychiatric or psychological condition(s); and

b) Notify the MCO.

ii. The MCO will then notify the treating physician the status of the recommendation.

d. If the conditions recommended on the C-9 include psychological or psychiatric and physical conditions, claims services staff must:

i. Complete the actions detailed above in C.2.b. for a physical condition(s) and C.2.c. for a psychological or psychiatric condition(s); and

ii. Notify the IW by phone that:

a) BWC will address the physical conditions recommended on the C-9; but

b) The IW must submit a C-86 for the recommended psychological or psychiatric conditions, as outlined in the “C-9 Additional Allowance Closure Letter.”

e. If a C-9 has been received that recommends an additional condition that has previously been addressed:

i. Claims services staff must determine if new and changed circumstances exist by reviewing:

a) Claim notes; and

b) The medical evidence that supports the recommendation.

ii. If new and changed circumstances exist, claims services staff must continue consideration of the allowance of the recommended condition(s).

iii. If new and changed circumstances do not exist, claims services staff will send the “C-9 Additional Allowance Closure Letter.”

f. Once claims services staff has completed review of all the recommended conditions as detailed above, they must enter the International Classification of Diseases (ICD) code of each condition to be considered into the claims management system.

D. Contacting the IW or IW Representative

1. Following their assessment of the C-9 and medical evidence, claims services staff must contact the IW or IW representative by phone to discuss the physician’s recommendation.

a. Claims services staff will contact the IW representative only, unless:

i. The IW has expressed that they would like to be included;

ii. The representative is not responding to the contact attempts; or

iii. The IW does not have a representative.

b. If claims services staff must leave a voicemail, the IW or IW representative has three full business days to return the call. Claims services staff will not make a decision regarding the additional allowance until:

i. A response is received; or

ii. The response period has ended.

c. If phone contact is successful, or the IW or IW representative responds to a previous contact attempt, claims services staff must:

i. Verify that the IW or IW representative agrees with BWC evaluating the condition(s) recommended by the treating physician for allowance in the claim; and

ii. For lost time claims only:

a) Discuss the possibility of an Independent Medical Examination (IME) to determine allowance of the recommended condition(s); and

b) Obtain and enter the IW’s exam availability in a claim note titled “IW Availability.”

iii. If the IW or IW representative:

a) Agrees with the treating physician’s recommendation(s), send the “C-9 IW Acknowledgement Letter” to the IW, and copy all other parties to the claim. This letter serves as confirmation of the IW or IW representative’s verbal request to evaluate the condition(s).

b) Does not agree with the treating physician’s recommendation(s), or the IW or IW representative does not respond to a previous contact attempt within three full business days:

i) Claims services staff must:

a. Send the “C-9 Additional Allowance Closure Letter” to the IW and copy all other parties to the claim;

b. Delete the recommended condition(s) from the claims management system; and

c. Notify the MCO of the final decision.

ii) The MCO will then notify the treating physician of the status of the recommendation.

b. When phone contact with the IW or IW representative is not successful and leaving a message via voicemail or other means is not an option, claims services staff will send the “C-9 Additional Allowance Due Process Letter” to all parties to the claim.

i. The letter may be sent by:

a) Mail;

b) E-mail (encrypted using Zixmail); or

c) Fax.

ii. The parties have:

a) Three full business days to respond, if the letter is sent by fax or e-mail; or

b) Seven calendar days to respond, if the letter is sent by mail (plus four additional days per the Mailbox Rule policy).

iii. Claims services staff must set a work item for:

a) Four (3+1) full business days in the future, if the letter is sent by fax or e-mail; or

b) Twelve (7+4+1) calendar days in the future if the letter is sent by mail.

iv. Claims services staff will not proceed with consideration of the issue until:

a) the response period has expired; or

b) they have received a response.

v. If the IW or IW representative responds to the “C-9 Additional Allowance Due Process Letter”:

a) And indicates that they agree with the treating physician’s recommendation, claims services staff must:

i) Update claim notes documenting the IW or IW representative’s agreement and the date it was obtained; and

ii) If the IW or IW representative’s response is by phone, send the “C-9 IW Acknowledgement Letter” to the IW and copy all other parties to the claim.

b) And indicates they disagree with the treating physician’s recommendation, or if the IW or IW representative does not respond within the specified response period:

i) Claims services staff must:

a. Send the “C-9 Additional Allowance Closure Letter” to the IW and copy all other parties to the claim;

b. Delete the recommended conditions from the claims management system; and

c. Notify the MCO of the final decision.

ii) The MCO will then notify the treating physician of the status of the recommendation.

2. Upon receipt of the IW or IW representative’s agreement to continue evaluating the condition(s) recommended on the C-9, claims services staff may request a medical review by a medical service specialist.

E. Requesting a Medical Review

1. Claims services staff must request a medical review if:

a. The condition is not included in the “Workbook - MEDD Resource Guide”; or

b. Claims services staff:

i. Needs assistance determining causality; or

ii. Feels that a medical review is necessary.

2. Prior to referring the claim, claims services staff must:

a. Ensure that they have:

i. Utilized all available resources to identify any appropriate medical documentation that would be needed to determine allowance of the conditions (e.g., online research for conditions not listed in the “Workbook - MEDD Resource Guide”); and

ii. Received all necessary medical information.

b. Follow the “SOP Medical Referral Note Guidelines”; and

c. Document the following information in claim notes:

i. The type of application the recommendation was submitted on;

ii. Date the application was received;

iii. The condition(s) being recommended (narrative), including level and location, when applicable;

iv. Previous claims if the IW has any;

v. Suspect intervening injury and a corresponding Insurance Services Office (ISO) report if it exists;

vi. Their rationale for sending the referral for medical review;

vii. Titles and indexing dates of supporting medical evidence, including causality statement; and

viii. Any other pertinent information.

3. Claims services staff must create a “Nurse-AA” case event, which will in turn create a work item for a Medical Services Specialist (MSS).

4. Refer to the Independent Medical Examinations (IMEs) and Physician File Reviews (PFRs) policy and procedure for more information regarding IMEs and PFRs.

F. Decision

1. Prior to making a decision on the C-9, claims services staff will await the employer’s response to the “IW Acknowledgement Letter.”

a. If the employer or employer representative responds to the letter and indicates they agree with the treating physician’s recommendation, or if they do not respond within three full business days for letters sent by fax or e-mail or seven calendar days (plus four additional days per the Mailbox Rule policy) for letters sent by mail, claims services staff will:

i. Enter a claim note documenting either the agreement and the date it was obtained, or the employer’s non-response; and

ii. Continue considering allowance of the condition(s).

b. If the employer or employer representative responds to the letter and indicates they disagree with the treating physician’s recommendation, claims services staff must:

i. Enter a claim note documenting the employer or employer representative’s disagreement and the date it was obtained; and

ii. Prepare a NOR to the IC, following the Notice of Referral to the Industrial Commission policy and procedure.

c. Claims services staff will not contact employers who are out of business or no longer doing business in Ohio. The exception to this is if the employer has retained an authorized representative to oversee their claims. In such cases, claims services staff will contact the employer representative.

2. Addressing Multiple Physical Conditions

a. If one or more recommended conditions are supported by sufficient medical evidence, but there is no medical evidence to support the other condition(s):

i. Claims services staff must contact the IW or IW representative by phone, fax, or e-mail to determine if they prefer that:

a) The entire recommendation be referred to the IC; or

b) The condition(s) in the recommendation be bifurcated to:

i) Allow the conditions that are supported by sufficient medical evidence; and

ii) Dismiss the conditions for which there is insufficient medical evidence.

ii. The IW or IW representative may respond either verbally or in writing.

iii. If the IW or IW representative:

a) Chooses to bifurcate the recommendation, claims services staff must issue a BWC Order:

i) Allowing the conditions that are supported by sufficient medical evidence; and

ii) Dismissing the others, using the following language: “IW/IW representative <<verbally dismissed, dismissed in writing>> the following condition(s) <<dismissed conditions>> on <<date of dismissal>> without prejudice.”

b) Does not want to bifurcate the issues, or does not respond within three full business days, claims services staff will complete their investigation and prepare a NOR to the IC following the Notice of Referral to the Industrial Commission policy and procedure.

iv. Example:

a) A claim is allowed for back sprain.

b) BWC receives a C-9 for allowance of right knee sprain and herniated disc at L5-S1.

c) A treatment request for the right knee has been submitted to the MCO.

d) The PFR supports allowance of the right knee sprain, but does not support allowance of the herniated disc.

e) Claims services staff contacts the IW or IW representative to determine if they would like to dismiss the recommendation for herniated disc (the condition that is not supported).

f) The IW or IW representative agrees to dismiss the recommendation for herniated disc, which allows claims services staff to move forward with allowance of the right knee sprain and allows the MCO to consider the associated treatment.

g) Claims services staff issues a “BWC Subsequent Order” that addresses the allowance of the right knee sprain (the condition that is supported by sufficient medical evidence), and includes language dismissing the recommendation for the herniated disc.

b. If the decision is to allow all recommended conditions, claims services staff must follow the directions detailed immediately below.

3. Allowance

a. Claims services staff will issue a “BWC Subsequent Order” to allow the conditions when:

i. The IW agrees to consider the recommended condition(s);

ii. BWC agrees with the allowance of the condition(s); and

iii. The employer:

a) Agreed with allowance of the condition(s); or

b) Did not provide a response when contacted regarding allowance of the condition(s).

b. Claims services staff must notify the MCO when:

i. Claims services staff refers the recommendation via a NOR to the IC; or

ii. Claims services staff issues a BWC Order to allow the condition(s);

iii. BWC receives an appeal to the BWC Order; and

iv. The order is final.

v. The MCO will notify the treating physician of the status of the recommendation.

4. Waivers

a. If BWC is allowing the condition(s) and both the employer or employer representative and the IW or IW representative submit a signed waiver, claims services staff will immediately update the claims management system.

b. For more information about waivers, refer to the Orders, Waivers, Appeals and Hearings policy and procedure.

5. Claims services staff must update the conditions in the claims management system:

a. When a BWC Order to allow or dismiss the condition(s) is issued;

b. Upon completion of a NOR to the IC;

c. When an appeal is filed to a BWC or IC order;

d. When all parties to the claim have waived the appeal period; and

e. When the appeal period expires.

G. Additional Allowance Recommendation(s) Received Prior to the Final Initial Determination

1. If BWC has not yet published an initial claim decision, the newly recommended conditions must be included in the initial decision, even though the conditions are not listed on the First Report of Injury, Occupational Disease or Death (FROI).

2. When a recommendation is filed prior to the initial determination of the claim becoming final (during the appeal period with an appeal filed), the recommendation will be suspended until the claim is fully adjudicated.

a. Claims services staff may call the filing party to notify them that the recommendation has been suspended or send the “Additional Allowance Combination Letter” to notify parties to the claim that the recommendation has been suspended.

b. Claims services staff must notify the MCO that the recommendation has been suspended, and the MCO will notify the treating physician of the status of the recommendation.

c. If the claim is allowed, BWC will consider the conditions immediately.

d. If the claim is denied, consideration of the conditions is a moot issue.

3. If an initial claim decision has been issued and a recommendation is filed during the appeal period, but no appeal is filed, the previous order may be vacated with a new decision issued to include the new recommendation. However, it may be appropriate to let the appeal period expire and issue a subsequent decision to facilitate timely payment of compensation and benefits to the IW.