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Policy and Procedure Name:
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Claim Reactivation
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Policy #:
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CP-03-13
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Code/Rule Reference:
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OAC
4123-3-15; OAC
4123-3-23(D)
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Industrial Commission (IC) Resolution/Memo
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None
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Effective Date:
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05/20/2021
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Approved:
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Ann Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-03-13, effective 02/13/2017 and Procedure # CP-03-13.PR.1,
effective 05/06/2019
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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
Active Claim
Inactive Claim
Last Indemnity Paid Date
Last Paid Bill Service Date
Medical Benefits
Reactivation
Retro C-9
IV. POLICY
A. General
Information
B. Request
for Action in an Inactive Claim
C. Independent
Medical Examinations (IME) and Physician File Reviews (PFR)
D. Systematically
Updating a Claim to Inactive
V. PROCEDURE
A. General
Claim Note and Documentation Requirements
B. How
the Claims Management System Establishes Active or Inactive Claims
C. Action
Requests in an Inactive Claim
D. Processing
Timeframe for Requests
E. MCO
Process for Medical Treatment Requests in an Inactive Claim
F. BWC
Process in Receipt of Claim Reactivation and Medical Treatment Requests
G. IME
and PFR
H. Issuing
Decision on Claim Reactivation and Medical Treatment
I. Changing
Claim From Inactive to Active or Active to Inactive
The purpose of this policy is to ensure that when BWC
receives a request for compensation or medical benefits in a state-fund claim
that has had no activity or request for further action for more than a 24 month
period, BWC appropriately reactivates the claim if the request is causally
related to the allowed condition(s) in the claim and payment is appropriate.
This policy applies to claims
services staff and managed care organization (MCO) staff.
Active Claim:
A claim that has had payment of compensation, a paid date of service or a
reactivation within a 24-month period.
Inactive Claim:
A claim that has had no payment of compensation, no paid date of service and no
reactivation for more than a 24-month period.
Last Indemnity Paid Date:
The most recent date a compensation payment was made in a claim and the date
BWC will use for the active/inactive calculation if the last paid bill service
date is prior to this date.
Last Paid Bill Service Date:
The most recent date of service for which BWC paid medical benefits in a claim,
and the date BWC will use for the active/inactive calculation if the last
indemnity paid date is prior to this date.
Medical Benefits:
For purposes of this policy, including but not limited to office visits,
emergency room visits, surgeries, diagnostics (e.g., x-rays, MRI, or CT scan),
prosthetics, durable medical equipment, vocational rehabilitation, and
prescription medication.
Reactivation:
The process used to update a claim from inactive to active status.
Retro C-9:
A medical treatment request for reimbursement of service(s) that the provider
has already provided to the injured worker (IW).
1. It is
BWC’s policy to pay compensation or medical benefits in a state-fund claim that
has had no activity or request for further action in it for more than a 24-month
period when it receives a request for compensation or medical benefits that is
causally related to the allowed condition(s) in the claim and payment is
appropriate.
2. It
is the policy of BWC that when a request for medical treatment/medical bill
payment is not received within one year and seven days from the date of first
denial of the medical bill payment, the request will be denied, except when it
is the result of an error by the BWC or the MCO.
3. A
party to the claim may appeal a claim reactivation and medical treatment
decision to the Ohio Industrial Commission (IC).
1. It
is the policy of BWC that any request for action in an inactive claim requires
authorization from the MCO, not BWC, when medical treatment is for a:
a. Date
of service(s) prior to the inactive date; or
b. Prosthetic,
orthotic, vision, hearing or dental device, medical supplies, or durable
medical equipment (DME).
2. The
MCO shall refer a medical treatment request in an inactive claim to BWC for
action when the medical:
a. Treatment
request is accompanied by supporting medical evidence dated not more than 60
days prior to the date of the request; or
b. Evidence
is subsequently provided to the MCO upon request.
3. The
MCO may dismiss without prejudice and without a referral to BWC, a request for
medical treatment in an inactive claim when they do not receive supporting
medical evidence dated not more than 60 days prior to the date of the request.
4. Responsibilities
a. The
MCOs’ role is to review all incoming Request for Medical Service Reimbursement
or Recommendation for Additional Conditions for Industrial Injury or
Occupational Disease (C-9) forms for appropriateness under the Miller
Case Criteria policy and procedure, and make medical recommendations on
inactive claims in accordance with this policy. The MCO will address a request
when the claim is inactive as outlined in Section IV.B.1.a.-b. (above).
b. BWC’s
role is to review the MCO’s recommendations on the C-9 on inactive claims and
issue a decision on the issues in accordance with this policy. BWC will
address:
i.
Medical Benefits, except in Section IV.B.1.a.-b. (above).
a) Causal
relationship between the original injury and the current incident that is
triggering the medical treatment; and
b) Necessity
and appropriateness of the medical treatment request.
ii. Compensation
benefits, including the causal relationship between the original injury and the
current incident that is triggering the request for compensation; and/or
c. BWC’s
role is to review an additional allowance request, including the causal
relationship between the original injury and the current incident that is
triggering the request for an additional allowance.
d. The
MCO shall forward and work together with BWC to address:
i.
Multiple issues filed concurrently with dates of service both before and
after the inactive date on the request; and
ii. Eligibility
and feasibility requests for vocational rehabilitation.
5. It
is the policy of BWC that when prescription medication is prescribed in an
inactive claim, the MCO and BWC will evaluate the medical treatment that is
triggering the request for prescription medication.
6. It
is BWC’s policy that BWC will not process, and the MCO will dismiss, similar or
duplicate medical treatment requests in an inactive claim when new and changed
circumstances are not present to re-evaluate the request.
7. The
MCO and Disability Management Coordinator (DMC) shall consider a referral for
vocational rehabilitation in an inactive claim as a request for claim
reactivation and shall refer to the vocational rehabilitation Referrals,
Eligibility and Feasibility policy for additional information. The MCO
and the DMC shall work together with the BWC claim services staff to publish a
BWC subsequent order in accordance with Section V.H.
1. BWC
does not have to obtain an IME or PFR for claim reactivation when the:
a. Evidence
supports the request; or
b. Request
is untimely, including:
i.
Outside the statute of limitations; or
ii. Medical
bill payment request is outside the one year and seven days of the adjudication
of the initial medical bill.
2. If
the evidence does not support the request BWC will require a PFR or an IME
prior to issuing a BWC order or a Notice of Referral (NOR) to the IC. BWC must
have a PFR or an IME if issuing a denial order.
1. BWC’s
claims management system runs a program that systematically updates a claim to
inactive.
2. This
systematic update occurs when 24 months after the last paid date in a claim.
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.
1. The
claims management system uses the following criteria to establish claim
activity:
a. If
payment of compensation has been made, the date payment was made in the claim;
b. If
payment of medical benefits has been made, the system chooses the date based on
the latest of the following dates:
i.
Last paid bill service date; or
ii. If
no last paid bill service date exists, latest bill payment date.
c. If
both payment of compensation and medical benefits have been made, then the
later of the two, based on the criteria in Section V.B.2.
d. If
neither compensation nor medical benefits has been paid, the system uses the
claim filing date.
2. For
reactivation, the system uses the date the claims management system is updated
by BWC.
1. The
MCO or claims services staff may receive a request in an inactive claim in one
of the following ways:
a. The
treating physician submits the C-9;
b. A
party to the claim files a Motion (C-86);
c. A
party to the claim files a specific application for compensation; or
d. A
provider or a party to the claim makes a verbal request.
2. Upon
receipt of a medical treatment request, the MCO shall:
a. Process
in accordance with this procedure if the date(s) of service is:
i.
After the inactive date; or
ii. Both
prior to and after the inactive date.
b. Process
the request in accordance with the MCO Policy Reference Guide (MPRG) if
the date(s) of service is prior to the inactive date or it is a request
specified in Section V.E.7.
1. The
MCO has up to 16 business days to respond to a treatment request and forward
the claim reactivation issue to BWC.
a. Three
business days to:
i.
Review the medical treatment request and respond to the provider if
medical documentation is not needed; or
ii. Pend
the request to obtain medical documentation from the provider;
b. 10
business days for the provider to submit additional medical documentation to
the MCO if needed; and
c. Three
business days from receipt of requested additional medical documentation to
review and forward the claim reactivation to BWC.
2. BWC
has 28 calendar days to address the following:
a. The
causal relationship between the original injury and the current incident that
is triggering the medical treatment request; and
b. The
necessity and appropriateness of the medical treatment request.
3. BWC
shall address the issue of claim reactivation by:
a. Issuing
a BWC order; or
b. Making
a recommendation on a NOR to the IC when BWC does not have jurisdiction to
issue an order.
4. Once
the decision is final, BWC will notify the MCO of the decision, and the MCO
shall notify the provider by:
a. Letter
within three business days from receipt of the BWC notification when medical treatment
services have not yet been rendered;
b. Letter
within 30 calendar days from receipt of the BWC notification when medical
treatment services have been rendered;
c. Bill
payment when the MCO pays or adjusts the bill that was originally denied. In
this instance, the MCO does not need to send a letter as the payment of the
bill shall serve as the notice to the provider.
1. The
MCO may view the current inactive date on BWC’s website, and contact BWC claims services
staff for additional information if necessary.
2. MCO
Referral to BWC for Claim Reactivation
a. The
MCO shall refer a medical treatment request to BWC on an inactive claim when
the request is supported by:
i.
Medical evidence dated not more than 60 days prior to the date of the
request; or
ii. Such
evidence is subsequently provided to the MCO upon request (via a Request for
Additional Medical Documentation for C-9 (C-9-A) form or equivalent).
a) When
current medical documentation is not on file, the MCO shall request such
documentation from the provider via the C-9-A or equivalent; and
b) Document
the request in the MCO notes.
b. When
documentation requested from a provider is not received, the MCO shall dismiss
the request in accordance with Section V.E.6. (below).
c. The
MCO, prior to making a recommendation to allow or deny the medical treatment
request, may indicate an independent medical examination (IME) or physician
file review (PFR) is necessary. The MCO and BWC shall collaborate to have the
IME or PFR completed. Once the report/review is on file, the MCO shall provide
the clinical findings note.
d. When
referring the medical treatment request recommendation to BWC, the MCO shall email
the recommendation to BWC claims services staff copying the supervisor in a
secure email that includes:
i.
Standard subject title: “Request for Claim Reactivation Review;” and
ii. A
message that consists of, at a minimum, the following:
a) Claim
number;
b) IW name;
c) Name
of provider requesting the medical treatment;
d) The
date(s) of the C-9, C-86, or verbal request;
e) A
detailed description of the medical treatment request;
f)
The frequency and duration of the medical treatment request;
g) The
beginning and ending dates of the medical treatment requested (to determine
duplicate requests);
h) The
body part being treated, including International Classification of Diseases
(ICD) code(s);
i)
An indication if the medical treatment has been previously rendered or
not;
j)
The MCO recommendation to allow or deny the request;
k) The
medical evidence relied upon to support the MCO recommendation;
l)
An indication of which prong(s) from the Miller
Case Criteria policy and procedure treatment it does not meet, if the
recommendation is to deny request;
m) The MCO Medical
Director’s opinion and recommendation (when applicable); and
n) Any
other information the MCO would like to relay to BWC.
e. The
MCO shall create a clinical findings note with a title that reflects its
content (e.g., “Claim Reactivation Clinical Findings”) at the same time it
sends the secure email to BWC. The note should include, at a minimum:
i.
The date(s) of the C-9, C-86, or verbal request;
ii. A
detailed description of the medical treatment request;
iii. The frequency
and duration of the medical treatment request;
iv. The
beginning and ending dates of the medical treatment requested (to determine
duplicate requests);
v. The
body part being treated, including ICD code(s);
vi. An
indication if the medical treatment has been previously rendered or not;
vii. The MCO recommendation
to allow or deny the request;
viii. The medical evidence relied upon
to support the MCO recommendation;
ix. An
indication of which prong(s) of Miller
Case Criteria policy and procedure treatment does not meet, if the
recommendation is to deny request;
x. The
MCO Medical Director’s opinion and recommendation (when applicable); and
xi. Any other
information the MCO would like to relay to BWC.
3. Multiple
Medical Treatment Request(s) When Claim Reactivation is in Process:
a. When
the MCO receives a similar or duplicative medical treatment request(s) and a
previous request sent to BWC is pending, the MCO shall:
i.
Send the request to BWC if the prior request(s) can be handled together
on one BWC order.
a) The
MCO shall immediately contact BWC claims services staff to make BWC claims
services staff aware there is an additional request(s) that must be addressed.
b) BWC claims
services staff shall address all medical treatment requests at the same time,
which may include obtaining an addendum to an IME or PFR.
i)
BWC claims services staff may not address the medical treatment request
if the BWC order is already issued; and
ii) BWC
claims services staff shall immediately notify the MCO if an order has already
been issued.
ii. Not
send the medical treatment request to BWC when a BWC order has already been
issued. The MCO shall:
a) Notify
the provider the medical treatment request is deferred for consideration and
will not be addressed until the current claim reactivation/medical treatment
request is resolved and all appeals are exhausted.
b) Include
the following statement on medical treatment requests in a letter to the
provider, “C-9 is pended as claim reactivation review is currently in process
based on a prior medical treatment request dated <Enter Date of
Request>.”
b. When
the MCO receives a new medical treatment request that is not a similar or
duplicate request of a previous request pending before the BWC or the IC, the
MCO shall staff with BWC claims services staff to determine if the new request
for medical treatment is to be included or not with the current medical
treatment request for claim reactivation.
i.
If the new medical treatment request will be addressed with the prior
request, the MCO shall:
a) Prepare
clinical findings note that contains each of the elements listed in Section
V.E.2.e. (above); and
b) Send a
secure email that contains each of the elements listed in Section V.E.2.d.
(above).
ii. If
the new medical treatment request will not be included with the prior request,
the MCO shall:
a) Defer
consideration of the medical treatment request until the previous request
pending is resolved and decision is final; and
b) Notify the
provider that the request is deferred for consideration as indicated in Section
V.E.3.a.ii.
4. Similar
or duplicate medical treatment request when the claim reactivation decision is
final.
a. For
a final decision denying the prior request, the MCO shall review the
documentation in the claim to determine if there are new and changed
circumstances that would impact the previous claim reactivation denial.
i.
If there is documentation of new and changed circumstances that may
impact the previous claim reactivation denial, the MCO shall perform the claim
reactivation review pursuant to this policy.
ii. If
there is no documentation of new and changed circumstances that would impact
the previous claim reactivation denial, the MCO shall dismiss subsequent
medical treatment requests that are similar or duplicate pursuant to Section
V.E.6. (below).
iii. For example,
when an additional condition(s) in the claim has recently been allowed, this
could be considered a new and changed circumstance that justifies consideration
of an apparent duplicate treatment request. In this situation, it is
appropriate to address the request for treatment through the claim reactivation
process.
b. For
a final decision allowing the prior request, the MCO shall address and process
deferred or subsequent C-9/medical treatment requests utilizing the MPRG.
5. The
MCO shall refer a request to BWC for BWC to issue a denial when the request is
not submitted within one year and seven days from the adjudication date of the
previously submitted and denied medical bill, except in cases of an error by
BWC or the MCO.
a. Example:
A medical bill for treatment rendered on 12/21/2014 is denied on 1/5/2015. The
MCO receives a request on 1/6/2016 for payment for medical treatment rendered
on 12/21/2014. MCO/BWC will process request.
b. Example
of MCO Error: MCO receives and approves a C-9 request for medical treatment on
11/1/2014. A medical bill (for approved C-9 on 11/1/2014) for medical treatment
rendered on 12/21/2014 is denied on 1/5/2015. The MCO receives a request on
2/29/16 in an inactive claim for payment of medical treatment on 12/21/2014.
MCO denied the bill in error since treatment was prior approved. MCO/BWC will
process request.
c. Example
of BWC Error: On 12/23/2014, the provider files an additional allowance (AA)
request on a C-9 with a medical bill for treatment rendered on 12/21/2014. On
1/5/2015, the MCO denies the medical bill for treatment rendered on 12/21/2014
and forwards the C-9 to BWC to address the AA request. BWC processes the AA
request and allows the condition. However, BWC fails to notify the MCO of the
final decision as required. On 5/12/2016, the MCO receives a request to
adjudicate the previously denied medical bill for payment of treatment rendered
on 12/21/2014. Since BWC failed to provide notification to the MCO of the final
decision on the AA request, the MCO/BWC will process the request.
6. MCO
Dismissal
a. The
MCO shall dismiss without prejudice, and without referral to BWC, a medical
treatment request that:
i.
Is not accompanied by supporting medical evidence dated not more than 60
days prior to the date of the request; and
ii. Such
evidence is requested by, but not subsequently provided to, the MCO.
b. When
the MCO dismisses a request, the MCO shall:
i.
Notify all parties to the claim;
ii. Notify
the provider; and
iii. Send to BWC
following the MCO imaging requirements.
c. For
a dismissal of a similar or duplicate medical treatment request that was
previously denied, the MCO shall ensure that the dismissal also includes:
i.
Date of the final BWC/IC order that denied claim reactivation;
ii. Date
of the C-9/medical service request; and
iii. Specific medical
treatment requested.
d. The
MCO shall ensure there is no appeal language in the dismissal.
e. The
MCO shall ensure there are no new and changed circumstances prior to issuing a
dismissal.
7. The
MCO shall refer all medical treatment requests to BWC claims services staff in
an inactive claim, except in the following situations:
a. The
medical treatment request is for a date of service(s) prior to the inactive
date;
b. The
medical treatment request is only requesting the following:
i.
Prosthetics;
ii. Orthotics;
iii. DME categories
as outlined in the Centers for Medicare and Medicaid Services (CMS) Healthcare
Common Procedure Coding System (HCPCS), Level II codes:
a) Canes;
b) Crutches;
c) Walkers;
d) Decubitus
Care Equipment (e.g., heel or elbow protector);
e) Heat/Cold
Application (e.g., electric heat pad);
f)
Safety equipment;
g) Restraints;
and
h) Other
orthopedic devices, (e.g., adjustable elbow extension).
iv. Vision, hearing,
and dental devices (e.g., eyeglasses, hearing aids, dentures); and
v. Medical
supplies (e.g., hearing aid battery).
c. The
MCO may request BWC update the claim to active status when the medical
treatment request does not need a referral to BWC and the MCO allows the
request. The MCO will send a secure email to BWC staff that:
i.
Requests BWC staff to update the claim to active in the claims
management system; and
ii. Provides
the rationale to support making the claim active.
1. BWC
claims services staff may obtain the active/inactive claim history located on
the status window under “milestone dates” and assist the MCO with the active
and inactive history.
2. BWC
claims services staff shall identify when a claim is inactive by looking in the
claims management system on the Status > Details window and the status
reason would be “Inactive Claim.”
3. Upon
request for medical services in an active claim that had previously been
believed to have been inactive, BWC shall notify the MCO to process the request
in accordance with the MPRG.
4. BWC
may receive a request for action in an inactive claim for issues other than
requested medical treatment (e.g., compensation, additional allowance, lump sum
settlement).
a. BWC
claims services staff shall process the request as directed in the policy and
procedure specific to the request.
b. CSS
shall follow the steps to open a claim to process the request as outlined in
the Claim Reactivation Job Aid on COR.
c. If
an application for compensation is approved, BWC claims services staff shall
refer to Section V.I.1.-2. (below) to make the claim active prior to issuing
payment.
5. Upon
request for medical treatment (and/or a combination request of multiple issues)
on an inactive claim, BWC shall:
a. Immediately
begin processing the request when the MCO has acted upon it and sent its
recommendations to BWC; or
b. Forward
the request to the MCO if BWC claims services staff determines that the MCO has
not seen the request.
c. When
the request to reactivate the claim is vague and non-specific, and there is no
other request for specific benefits and/or medical treatment, BWC claims
services staff shall:
i.
Contact the filing party to determine the specific benefits and/or
medical treatment requested;
ii. Send
the request to the MCO to begin processing if specific benefits and/or medical
treatment is identified;
iii. Dismiss the
request to reactivate the claim by using the “Dismissal Letter” if specific
benefits and/or medical treatment cannot be identified;
iv. Note the
request and outcome in claim notes.
6. When
BWC claims services staff receives a secure email from the MCO with its
recommendations for the claim reactivation and medical treatment request, BWC
claims services staff shall respond to the MCO in a secure email within three
business days notifying the MCO that its recommendations were received and that
BWC has started processing the request.
7. BWC
Investigation
a. If
the medical treatment request is made more than five years from the date of
injury and the claim is inactive, BWC claims services staff shall ensure the
claim is statutorily active, as referred to in the Jurisdiction
(Statute of Limitations, Statutory Life of a Claim) policy and
procedure.
b. If
the claim is an inactive self-insured bankrupt claim, BWC claims services staff
shall audit the claim to determine the following prior to beginning the
investigation:
i.
All allowed conditions are documented in the claims management system;
ii. The
claim is appropriately labeled as inactive; and
iii. Validate that
the claim is statutorily open.
c. BWC
claims services staff shall provide notification of the pending request by
attempting to call the parties to the claim at least once. If BWC claims
services staff is able to leave a message, allow three business days for the
parties to provide a response.
d. When
phone contact is unsuccessful, BWC claims services staff shall send the
letter(s) below located on COR; when sending by fax or email allow three full
business days and if by mail allow seven calendar days (plus four days per the Mailbox
Rule policy) for response:
i.
The “Claim Reactivation IW Due Process” letter; and
ii. The
“Claim Reactivation Employer Due Process” letter.
e. BWC
claims services staff shall investigate issues prompting the medical treatment
request to determine if the requested medical treatment is causally related to
the original claim allowance. BWC claims services staff may staff with the
appropriate discipline (e.g., BWC attorney on the timeliness of filing a
medical treatment request) as the situation warrants.
f.
As part of the investigation, BWC claims services staff may send the Claim
Reactivation Investigation Questionnaire letter, allowing seven calendar
days for response, to the:
i.
Employer;
ii. IW;
and
iii. Provider.
1. BWC
claims services staff may refer the claim for an IME or PFR as the situation
warrants. BWC claims services staff shall create the appropriate medical exam
scheduling case or medical file review case in the claims management system.
2. BWC
claims services staff shall document in notes and notify the supervisor when
the IME or PFR will cause the processing of the request to exceed 28 days.
3. BWC
claims services staff shall add the appropriate set of questions for all issues
being addressed (e.g., additional allowance and/or temporary total
compensation), to the questions that address the medical treatment and claim
reactivation request.
1. If
BWC claims services staffs’ recommendation is to deny the request, an IME or
PFR must be on file to support the denial prior to issuing the BWC subsequent order.
2. BWC
claims services staff shall:
a. Issue
a BWC subsequent order when:
i.
Allowing the medical treatment request in its entirety;
ii. Denying
the medical treatment request in its entirety;
iii. Allowing the
medical treatment request in part and denying in part (e.g., part of the
treatment request is causally related to the original injury and appropriate,
but a portion of the medical treatment requested is for experimental treatment
and cannot be approved);
iv. The issue
is for eligibility and feasibility of vocational rehabilitation. BWC claims
services staff shall work with the DMC and MCO for the appropriate order insert;
v. The
decision includes multiple issues including the request for medical treatment
(e.g., additional allowance and/or temporary total compensation);
vi. BWC has
jurisdiction to address all the issues in the request. BWC claims services
staff shall select the appropriate order inserts.
b. Send
a NOR to the IC when BWC does not have jurisdiction to issue a decision on all
parts of the request for reactivation (e.g., The reactivation request is for
medical treatment, an additional allowance and temporary total compensation,
but the evidence does not support the additional allowance or the temporary
total requests. BWC does not have jurisdiction to deny the additional allowance
or temporary total so the entire reactivation request must be referred to the
IC).
3. BWC
claims services staff shall include in the BWC subsequent order the following
information:
a. The
date(s) of the C-9, C-86, or request;
b. A
detailed description of the requested medical treatment, without Current
Procedural Terminology (CPT) codes;
c. The
frequency and duration of requested treatment, if appropriate;
d. The
beginning and ending dates of the requested treatment, if appropriate;
e. The
supporting justification used for the determination;
4. BWC
claims services staff shall notify the MCO when:
a. The
BWC order or NOR is issued;
b. An
appeal is filed to the BWC or IC order; and
c. The
appeal period has expired for a final decision of a BWC or IC order.
5. After
all appeals have been adjudicated, BWC claims services staff shall update the
claims management system to the appropriate status.
6. The
MCO shall, upon notification from BWC of a final decision, notify the provider
in the following manner:
a. If
the medical treatment request is denied, the MCO shall:
i.
Provide written notification to the provider within three business days
from receipt of the BWC notification; or
ii. If
the medical treatment has previously been rendered, communicate the bill
payment decision to the provider within 30 calendar days from receipt of the
BWC notification.
b. If
the medical treatment request is allowed, the MCO shall:
i.
Approve the medical treatment request; or
ii. Pay/adjust
the bill originally denied, which serves as notice to the provider.
1. BWC
claims services staff shall activate a claim in the claims management system
when:
a. The
MCO requests, with support, that the claim be made active. For example:
i.
BWC receives a request from the MCO for claim reactivation for an IW
with an approved prosthetic for new bolts and screws;
ii. The
IW has received new bolts and screws for the approved prosthetic every other
year for the last 16 years. The request was later than usual this year as the
provider was unavailable and the IW could not get in to see the provider until
after the claim became inactive.
iii. BWC and the MCO
shall staff the claim and grant the request without an order to avoid further
delay for the necessary bolts and screws.
b. BWC
claims services staff is paying compensation in a claim;
c. BWC
issues a “Approval of Settlement Agreement” letter; or
d. There
is a final decision approving reactivation of a claim.
2. BWC
claims services staff may make a claim inactive in the claims management system
as follows:
a. If a
claim is activated, BWC claims services staff may reset the claim to inactive
status if the claim was:
i.
Placed in active status inappropriately;
ii. Placed
in active status to update data that will not result in a payment.
b. When
payment is made for medical benefits or compensation, the claim cannot be reset
to an inactive status unless, after review, BWC claims services staff
determines it was not appropriate to make payment for medical benefits and/or
compensation.
i.
For inappropriate payment of compensation, BWC claims services staff
shall make an adjustment(s) to the Indemnity Benefit plan and the claims
management system will adjust the last indemnity paid date in the claim and
evaluate for closure. Please refer to the Adjustment
of Overpaid Compensation policy and procedures for details about this
process.
ii. For
inappropriate payment of medical, BWC claims services staff shall ensure the
medical treatment bill is adjusted and a new medical paid date will be sent,
and the claims management system will evaluate for closure.
iii. BWC claims
services staff shall ensure that a note is entered in the claims management
system documenting the action completed.
c. BWC
claims services staff shall not set the claims management system to an inactive
status when an appropriate medical treatment or indemnity payment is made in
the claim.
3. BWC
claims services staff shall refer to the Claim Reactivation Job Aid on
COR for procedures on activating and inactivating a claim in the claims
management system.