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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.