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Policy
and Procedure Name:
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Catastrophic
Claims and Extremely Severe Injuries
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Policy
#:
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CP-03-14
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Code/Rule
Reference:
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R.C. 4123.511; R.C.
4121.121(B)(3)
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Effective
Date:
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10/13/23
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Approved:
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Shawn
Crosby, Chief Operations Officer
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Origin:
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Claims
Policy
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Supersedes:
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Policy
# CP-03-14, effective 04/01/21
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History:
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Previous
versions of this policy are available upon request
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Table of Contents
I.
POLICY PURPOSE
II.
APPLICABILITY
III.
DEFINITIONS
Catastrophic
(CAT) Claim
Extremely
Severe Injury Claim
IV.
POLICY
A. Claim Review and Referral
B. Claim Assignment
C. MCO Role in CAT Claims and
Collaboration with BWC
V.
PROCEDURE
A. General Claim Note and
Documentation Requirements
B. Claim Review and Referral
C. CAT Claim Determination Process
D. CAT and Extremely Severe Injury
Claim Handling by Special Claims II Team
The
purpose of this policy is to ensure that BWC claims services staff identify and
manage catastrophic claims appropriately during initial claim determination.
This
policy applies to BWC claims services staff.
Catastrophic (CAT)
Claim:
A claim in which there is a serious injury or occupational disease resulting in
limited mobility and/or cognition related to the allowed conditions in the
claim that severely limits the ability of the injured worker (IW) to perform
activities of daily living and has a high probability of resulting in permanent
disability.
Extremely
Severe Injury Claim: A claim in which there is an injury that, while
not deemed to meet the definition of a CAT claim, is significant enough that it
may include multiple significant conditions, involvement of multiple body
parts, high risk of complications, or extended projected length of disability,
and thus requires special handling.
1. It is BWC’s
policy that CAT claims may include, but are not limited to:
a. Brain injuries,
moderate to severe;
b. Amputations,
fractures, or crush injuries of a major extremity, or loss of use of one or
more limbs;
c. Spinal cord
injuries such as paraplegia, quadriplegia, hemiplegia or diplegia;
d. Total occupational
blindness;
e. Severe burns, including
second-or third-degree burns on more than 25 percent of the body;
f.
Actual
and anticipated hospitalization in excess of four weeks, (i.e., ventilators, intensive
care unit, psychiatric hospitalization);
g. Severe
occupational diseases and bloodborne pathogens (not end stage);
h. Toxic exposure
with long term complications; and
i.
Any
other medical diagnoses identified by the managed care organization (MCO) and CAT
nurse.
2. It is the
policy of BWC that claims services staff refer claims with the indicators outlined
above to the CAT nurse for determination of catastrophic claim status.
1. It is the policy
of BWC that CAT claims and claims involving extremely severe injuries are
handled by a specialized team called Special Claims II.
2. A CAT nurse decides
whether a claim meets the appropriate criteria to be deemed a CAT claim.
3. Claims not
deemed CAT will be reviewed by a supervisor to decide whether they meet the
criteria of an extremely severe injury to be handled by the Special Claims II team.
1. The MCO, not
the CAT nurse, is responsible for providing case management for all CAT claims
including, but not limited to, on-site visits.
2. The BWC CAT nurse
provides oversight and assists the MCO with issues that may arise during the
case management process.
3. For additional
details on MCO management of CAT claims, please refer to the Catastrophic
Claims portion of the MCO Policy Reference Guide.
1. BWC staff shall
refer to the Standard Claim
File Documentation and Altered Documents policy and procedure for claim
note requirements; and
2. Shall follow
any other specific instructions for claim notes included in this procedure.
1. Claims services
staff will monitor their assigned claims for indicators or changes in the IW’s
condition that would suggest that the claim is or may become catastrophic. If there is
insufficient medical evidence on file to make this determination, claims
services staff must work with the MCO to ensure that it has been requested.
a. If claims services
staff is unsure whether a claim should be referred to the CAT nurse for CAT
claim determination, they will staff the claim with a supervisor.
b. Claims services
staff will refer a claim meeting the criteria listed in this policy to the CAT
nurse within three business days of receipt of the claim.
2. Upon referral
to a CAT nurse, claims services staff will:
a. Enter a note in
the claim indicating the reasoning for the need for the referral being made to
the CAT nurse.
b. Create a work
item in the claim.
i.
From
the task template drop down select “Review for Possible Catastrophic Claim;”
ii. Select the
Assign to team radio button;
iii. From the Team
drop down select ‘Nurse – Catastrophic;’
iv. Enter the name
of the MCO in the Description box; and
v. Click the
finish button.
3. When a new
claim is referred to the CAT nurse for review, a referral should not
also be made to a medical services specialist (MSS).
1. Upon receipt of
a claim referred for CAT claim determination, the CAT nurse will use the medical
evidence on file to assist with making a determination within two business days,
whenever possible.
2. If the CAT
nurse receives a claim referral without medical or other relevant evidence, the
CAT nurse will review claim notes to ensure that the evidence has been
requested.
a. If evidence has
been requested, the CAT nurse will use their discretion to determine the CAT
status or to leave the referral open and wait until the evidence is received to
make a determination.
b. If the CSS is
unsuccessful at obtaining missing documentation, the CAT nurse will contact the
MCO to obtain the evidence.
3. If the CAT
nurse determines that the claim is catastrophic:
a. The CAT nurse
will:
i.
Review
and determine the appropriate allowances and obtain a physician review, if
indicated;
ii. Enter a claim
note documenting the decision, using the appropriate note template.
iii. Place the
ICD-10 code recommendations into the claims management system and request
modifications, if necessary;
iv. Update the
claims management system to designate the claim as a CAT claim (for information
on this process, refer to the CoreSuite – Catastrophic Advocate Nurse (CAT)
Group manual); and
v. Notify the
claims services specialist (CSS), injury management supervisor (IMS) of the
Special Claims II team, and MCO that:
a) The claim will
be handled as a CAT claim (including the information contained in the claim
note template referenced in Section V.C.3.a.ii above); and
b) ICD
modification is complete, if applicable.
b. The IMS of the
Special Claims II team will reassign the claim to a CSS on Special Claims II.
4. If the CAT
nurse determines that the claim is NOT catastrophic:
a. The CAT nurse
will:
i.
Enter
a claim note documenting the decision, using the appropriate note template;
ii. Send an email
to the referring CSS, IMS of the Special Claims II team, and the MCO informing
them of the decision; and
iii. Ensure that the
Catastrophic Injury box is unchecked in the claims management system.
b. The IMS of the
Special Claims II team will review the claim to determine whether the claim
will be considered an extremely severe injury.
i.
If
so, the claim will be reassigned to the Special Claims II Team for handling.
ii. If not, the
claim will remain with the referring CSS.
D.
CAT
and Extremely Severe Injury Claim Handling by Special Claims II Team
1. Claims managed
by the Special Claims II team will be staffed by a multidisciplinary team (including
BWC Legal and Policy) as needed.
2. In general, these
claims will remain with the Special Claims II team for the life of the claim.
Claims will be reassigned to another team in cases:
a. Of statutory occupational
disease;
b. Where the IW is
found permanently and totally disabled; and
c. When the IW
dies and BWC receives an application for death benefits.
3. The CSS will
establish
communication with the IW. If the CSS is unable to speak to the IW because the
IW is unreachable due to hospitalization or incapacitation, the CSS will
attempt to contact the following individuals to obtain necessary information:
a. The IW’s
attorney of record, if applicable;
b. The IW’s
guardian or health care power of attorney, if applicable;
c. The IW’s family
member(s) or other individuals that have knowledge of the IW; or
d. The IW’s
employer of record.