Policy and Procedure Name:	Damage to Dentures, Eyeglasses and Hearing Aids
Policy #:	CP-4-07
Code/Rule Reference:	R.C. 4123.66; O.A.C. 4123-6-31
Effective Date:	03/11/22
Approved:	Ann M. Shannon, Chief of Claims Policy and Support
Origin:	Claims Policy
Supersedes:	Policy # CP-4-07, effective 10/12/18
History:	Previous versions of this policy are available upon request

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that a request for payment of repair or replacement of dentures, eyeglasses and/or hearing aids damaged in the course of an allowed work related injury is appropriate.

 

II. APPLICABILITY

 

This policy applies to BWC claims services staff and Managed Care Organization (MCO) staff.

 

III. DEFINITIONS

 

Dentures: Artificial replacement of a tooth or teeth.

 

Eyeglasses: For the purpose of this policy, refers to any removable prescriptive corrective lenses (i.e., glasses and contacts).

 

Hearing Aid: A removable electronic device used to amplify sound that is worn in or behind the ear of a person with a hearing impairment.

 

IV. POLICY

 

A.     General Policy Statement for Repair and Replacement

1.     It is the policy of BWC to ensure that the repair or replacement of dentures, eyeglasses and hearing aids damaged in the course of an injury or work related accident resulting in an allowed claim is covered regardless of:

a.     The allowed condition(s) in the claim; and

b.     Whether or not the items were in use at the time of the injury. For example, an injured worker (IW) has a hearing aid in a pocket and not his/her ear at the time of the injury, but the device is damaged in the course of the work related accident.

2.     BWC pays for repair, replacement, or adjustment of an item one time for each work related accident resulting in injury.

 

B.     Repair

1.     The MCO shall approve only a repair when:

a.     The dentures, eyeglasses or hearing aid is repairable; and

b.     The cost of the repair would be less than the replacement cost.

 

C.    Replacement

1.     BWC shall only pay for replacement dentures, eyeglasses or hearing aids when the IW submits documentation from the original supplier or a servicing provider (e.g., a bill or an itemized statement of the original item).

2.     The MCO shall only approve a deluxe feature (e.g., anti-reflective or scratch-resistant coating for glasses, bluetooth-capable hearing aids) on a replacement of dentures, eyeglasses or hearing aids when the IW submits documentation from the service provider attesting that a deluxe feature was on the damaged item.

3.     The MCO shall only approve a replacement of dentures, eyeglasses and hearing aids based on the BWC fee schedule.

4.     It is the responsibility of the IW to pay for any exams necessary to obtain replacement dentures, eyeglasses and hearing aids.

D.    Other Personal Use Items

1.     BWC shall not pay for any other personal use items damaged in a a work related accident (e.g., shoes, jewelry, clothes, wheelchairs). 

 

E.     Requests for Direct Reimbursement

1.     Requests to reimburse an IW directly for services the IW paid out-of-pocket must be submitted within the later of:

a.     One year of the date of service; or

b.     One year after the earlier of:

i.       The Staff Hearing Officer order; or

ii.      The final administrative or judicial order allowing payment.       

 

V. PROCEDURE

 

A.     General Claim Note and Documentation Requirements

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

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

 

B.     The MCO shall process requests submitted via the Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) in accordance with the C-9 procedures.

 

C.    Claims services staff shall refer all requests for repair or replacement submitted via a Motion (C-86) to the MCO on an “MCO Referral” letter, in accordance with the Motions policy and procedure.

 

D.    MCO Receipt of Reimbursement Request

1.     When the MCO receives a reimbursement request for repair or replacement of dentures, eyeglasses or hearing aid that the IW, employer or other third party has already paid, the MCO shall request:

a.     A receipt; and

b.     Proof of payment.

 

E.     MCO Determination of Payable Service

1.     The MCO shall review the documentation provided to determine if it is payable.

2.     If it is determined that the service is payable, the MCO shall:

a.     Submit to BWC a Service Invoice (C-19) with the explanation of benefits code 771 referenced; and

b.     Reimburse the IW, employer or other third party.

3.     If it is determined the service is not payable, the MCO shall notify the party requesting reimbursement.