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Policy
and Procedure Name:
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Exposure
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Policy
#:
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CP-05-02
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Code/Rule
Reference:
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R.C. 4123.01; R.C. 4123.026
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Effective
Date:
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06/12/24
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Approved:
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Shawn
Crosby, Chief Operating Officer
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Origin:
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Claims
Policy
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Supersedes:
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Policy
# CP-05-02, effective 09/15/20
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|
History:
|
Previous
versions of this policy are available upon request
|
Table of Contents
I.
POLICY PURPOSE
II.
APPLICABILITY
III.
DEFINITIONS
Corrections
Officer
Detention
Facility
Drug
Emergency
Medical Worker
Exposure
Firefighter
Other
Chemical Substance
Peace
Officer
Physical
Injury
IV.
POLICY
A. Exposure Diagnosis
B. Exposure Claims Without Physical
Injury: Claim Denial and Bill Payment
C. Exposure Claims With Physical
Injury
D. Contraction of Occupational
Disease After Exposure
E. Firefighters with Cancer and
Firefighter Cardiac Claims
V.
PROCEDURES
A. General Claim Note and
Documentation Requirements
B. Processing Exposure Claims:
Summary
C. Determination of Physical Injury
D. Exposure Claims With Physical
Injury
E. Exposure Claims Without Physical
Injury: Determination of Occupation
F. Exposure Claims Without Physical
Injury Filed by a Firefighter, Peace Officer, Emergency Medical Worker, or
Detention Facility Employee Pursuant to R.C. 4123.026
G. Exposure Claims Without Physical
Injury for All Workers Not Covered Under R.C. 4123.026
H. No Exposure and No Physical
Injury
I. Contraction of Occupational
Disease After Exposure
The
purpose of this policy is to ensure that BWC claims services staff and MCO
staff handle claims filed for exposure properly, including claims covered by R.C.
4123.026 (also sometimes referred to as Senate Bill (SB) 223 claims).
This
policy applies to BWC claims services staff and MCO staff.
Corrections
Officer: A person
employed by a detention facility as a corrections officer.
Detention
Facility: Any public or
private place used for the confinement of a person charged with or convicted of
any crime in this state or another state or under the laws of the United States
or alleged or found to be a delinquent child or unruly child in this state or another
state or under the laws of the United States.
Drug: Any article, other than food,
intended to affect the structure or any function of the body of humans or
animals. Drugs may include:
·
Amphetamines;
·
Opiates;
·
Cocaine;
·
Benzodiazepines;
·
Barbiturates;
·
Oxycodone;
·
Methadone;
·
Fentanyl;
·
Marijuana;
or
·
Hydrocodone.
Emergency
Medical Worker: Either of the following:
·
A first
responder, emergency medical technician-basic, emergency medical
technician-intermediate, or emergency medical technician-paramedic, certified
under R.C. Chapter 4765, whether paid or volunteer.
·
Any of the
following when staffing a rotorcraft or fixed wing air ambulance on behalf of a
licensed air medical service organization in accordance with section 4766.17 of
the Revised Code, including transporting a patient from an incident scene or
medical facility into the air ambulance, or when transporting a patient from an
air ambulance to the entrance of a hospital:
o
A physician
who holds a current, valid license issued under Chapter 4731. of the Revised Code;
o
A registered
nurse who holds a current, valid license issued under Chapter 4723. of the Revised
Code;
o
Any other
person holding a current, valid certificate or license to practice a health
care profession in this state.
Exposure: When a worker
is subjected to a toxic substance or harmful physical agent (e.g., gas, bodily
fluid, chemical, poisonous vegetation, etc.) in the course of employment
through any route of entry (inhalation, ingestion, skin contact or absorption,
etc.).
Firefighter: A firefighter,
whether paid or volunteer, of a lawfully constituted fire department.
Other Chemical
Substance: Something
other than a drug to which an individual believes they were exposed and for
which they sought medical testing/treatment.
Peace Officer: An individual
legally vested with law enforcement rights who generally works for a city,
county or state public employer and can be either “traditional” (e.g., police
officer) or “non-traditional” (e.g., certain park rangers, tax agents or liquor
agents).
Physical Injury: Any traumatic
damage or attack on the physical structure of the body, which results in a
wound, tear or abnormal condition.
1.
A
diagnosis of “exposure” is not an allowable condition.
2.
BWC
will not allow the condition of “exposure” in any claim.
1.
BWC
will deny a claim for exposure without an accompanying physical injury or
occupational disease.
2.
In
claims without an accompanying physical injury, BWC will not pay or reimburse
for post-exposure medical diagnostic services, except when the injured worker
(IW) meets all of the following criteria:
a.
The
IW is a firefighter, peace officer, emergency medical worker, or detention
facility employee (including a corrections officer);
b. In the course
of and arising out of the IW’s employment, or when responding to an inherently
dangerous situation, the IW was either exposed to:
i.
A
drug or other chemical substance; or
ii.
The
blood or other bodily fluids of another person through any of the following
means:
a) A splash or
spatter in the eye or mouth, including when received in the course of
conducting mouth-to mouth resuscitation;
b) A puncture in
the skin; or
c)
A
cut on the skin or another opening in the skin, such as an open sore, wound,
lesion, abrasion or ulcer.
c.
The
diagnostic services and preventative treatment are consistent with medical,
Centers for Disease Control and Prevention (CDC), and Occupational Safety and
Health Administration (OSHA) standards for diagnostic and preventive treatment
related to the exposure.
1.
If
a claim includes an exposure and a physical injury and all other required
factors pursuant to the Initial Claim
Determination
policy are met, it is the policy of BWC to accept the claim for the specific
physical injury, but not for the exposure.
2.
BWC
or the self-insuring employer will pay or reimburse for post-exposure medical
diagnostic services and/or preventative treatment if:
a.
Such
services are causally related to at least one of the allowed physical
conditions in the claim and consistent with medical, CDC, and OSHA standards
for diagnostic and preventive treatment related to the exposure; or
b. The IW
otherwise meets all the criteria set forth in R.C. 4123.026 (detailed above).
1.
If
an IW contracts an occupational disease following an exposure, the IW may:
a.
Make
a request for an additional allowance of an occupational disease in the claim
if there is a related allowed claim; or
b. File a new claim
for an occupational disease if there is not a related allowed claim.
2.
Additional
information may be found in the Occupational
Disease Claims
policy.
1.
For
claims involving firefighters with cancer, refer to the Firefighters
with Cancer Occupational Disease Claims policy.
2.
For
firefighter cardiac claims, refer to the “Statutory Occupational Disease
Claims” section of Occupational
Disease Claims
policy.
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.
This
section is a high-level summary of the procedure for evaluating and processing
a claim alleging an exposure. This is an overview and must not be used in place
of the detailed procedures in Sections C through I.
2.
When
a claim is filed alleging an exposure:
a.
Determine
whether the claim includes a physical injury. If the claim:
i.
Includes a physical
injury, the claim is processed in the same manner as any other claim alleging a
work-related injury.
ii.
Does
not include
a physical injury, move on to the next step.
b. Determine the
IW’s occupation. If the IW:
i.
Is
not
a firefighter, peace officer, emergency medical worker, or detention facility
employee (including a corrections officer) covered under R.C. 4123.026, post-exposure
testing is not covered by BWC. The claim is denied.
ii.
Is a firefighter,
peace officer, emergency medical worker, or detention facility employee
(including a corrections officer) covered under R.C. 4123.026, move on to the
next step.
c.
Determine
what substance the IW alleges they were exposed to. If the IW was exposed to:
i.
Any
substance other than a drug or other chemical substance, or blood or another
bodily fluid,
post-exposure testing is not covered by BWC. The claim is denied.
ii.
A
drug or other chemical substance, this claim meets all criteria for
processing under R.C. 4123.026. The claim is denied, but post-exposure testing is
covered or reimbursed by BWC.
iii. Blood or
another bodily fluid, move on to the next step.
d. Determine the
route to the body through which the IW was exposed. If the IW was exposed to
blood or another body fluid via:
i.
Any
route other than the eye or mouth, or an opening in the skin, post-exposure
testing is not covered by BWC. The claim is denied.
ii.
The
eye or mouth, or an opening in the skin, this claim meets all criteria
for processing under R.C. 4123.026. The claim is denied, but post-exposure
testing is covered or reimbursed by BWC.
3.
See
the procedure below for detailed directions regarding the processing of
exposure claims.
1.
When
a claim that alleges an exposure is received, claims services staff must first determine
if any documentation in the claim also reflects or alleges a physical injury
(e.g., needle stick, contact dermatitis, toxic effect of carbon monoxide.
2.
If
the First Report of an Injury, Occupational Disease or Death (FROI) or
other documentation references only “exposure”, and it is unclear whether the
IW also incurred a physical injury (e.g., needle stick, contact dermatitis,
toxic effect of carbon monoxide), claims services staff must conduct additional
investigation consistent with the Initial Claim
Determination
and ICD
Modification
procedures.
a.
Investigation
may include:
i.
Referring
to the Compensable
Injuries
policy and procedure;
ii.
Seeking
clarification from treating provider, as necessary;
iii. Staffing the
claim with the supervisor and/or BWC attorney, as necessary; and
iv. Referring the
claim for a medical review, if appropriate.
b. Example:
i.
A
FROI is filed stating the IW was exposed to carbon monoxide.
ii.
The
medical documentation reflects that the IW reported headache, dizziness and
nausea.
iii. The doctor’s
report states there is exposure to carbon monoxide but does not give a medical
diagnosis or condition associated with the exposure.
iv. Claims services
staff conducts further investigation as required by the Initial Claim
Determination
policy and procedure, sends the claim for medical review, and subsequently
receives a medical diagnosis of toxic effect of carbon monoxide (a physical
injury).
3.
If
claims services staff determine that the claim includes a physical injury,
claims services staff will follow the directions detailed in the Exposure
Claims With Physical Injury section of this procedure.
4.
If
claims services staff determine that the claim does not include a physical
injury and is solely for exposure, claims services staff must then determine
the occupation of the IW, following the directions detailed in the Exposure Claims Without Physical Injury:
Determination of Occupation section of this procedure.
D.
Exposure
Claims with Physical Injury
1.
If,
upon investigation, claims services staff determines that a physical injury
occurred and all other factors pursuant to the Initial Claim
Determination
policy are met, claims services staff will:
a.
Accept
the claim for the physical injury only, using the Initial Allowance Order;
b. Enter the
appropriate ICD code related to the physical injury (not the exposure) pursuant
to the Initial Claim
Determination
and ICD
Modification
policy and procedure;
c.
Enter
a note in the claims management system that indicates that the claim is accepted
for the physical injury but not for the exposure; and
d. Continue to
process the claim in the same manner as any other claim alleging a work-related
physical injury.
2.
The
MCO will:
a.
Ensure
that all post-exposure testing is related to an allowed physical condition(s)
in the claim;
b. Accept the CDC and OSHA standards for diagnostic and preventive
treatment related to exposure to blood or other potentially infectious
materials (OPIM); and
c.
Submit
bills to BWC’s Medical Billing and Adjustments (MB&A) unit.
3.
Example:
a.
A
FROI is filed alleging a work-related exposure to poison ivy.
b. The medical
documentation reflects that the IW has an area of skin with swelling, redness,
and blisters which are symptoms consistent with poison ivy exposure, but there
is no diagnosis of a physical injury included in the claim.
c.
Claims
services staff sends the claim for a medical review and subsequently receives a
diagnosis of contact dermatitis (a physical injury).
d. Claims services
staff enters the appropriate ICD code for contact dermatitis and processes the
claim in the same manner as any other claim alleging a work-related physical
injury.
4.
Example:
a.
A
FROI is submitted alleging that a nurse sustained a laceration on the arm and
was smeared with a patient’s blood.
b. Upon
investigation, claims services staff determines that:
i.
A
physical injury occurred; and
ii.
The
blood entered the wound on the IW’s arm.
c.
Claims
services staff:
i.
Enters
the appropriate ICD code for the laceration; and
ii.
Accepts
the claim for the laceration only; noting in “add-text” in the Initial
Allowance Order that, while BWC does not allow claims for exposure, BWC
will pay or reimburse for post-exposure testing related to the laceration.
d. The MCO
receives a request for post-exposure diagnostics and preventative treatment for
exposure to blood.
e.
Because
the exposure is directly related to the allowed physical injury, the MCO
approves the request and submits the bills to BWC for payment.
5.
Example:
a.
A
FROI is submitted alleging that a nurse sustained a laceration on the arm and
was smeared with a patient’s blood.
b. Upon
investigation, claims services staff determines that:
i.
A
physical injury occurred; but
ii.
The
blood was smeared on the IW’s neck only.
c.
Claims
services staff:
i.
Enters
the appropriate ICD code for the laceration; and
ii.
Accepts
the claim for the laceration only; noting in “add-text” in the Initial
Allowance Order that post-exposure testing will not be paid for because it
is not related to the physical injury.
d. The MCO
receives a request for post-exposure diagnostics and preventative treatment for
exposure to blood.
e.
Because
the exposure is not directly related to the allowed physical injury, the MCO
denies the request.
6.
Example:
a.
A
FROI is filed alleging that a nurse incurred a needle stick after injecting a
patient.
b. Claims services
staff enters the appropriate ICD code for the needle stick; and accepts the
claim for the physical injury only;
c.
Post-exposure
testing and preventative treatment, consistent with standards of medical care,
will be covered for the exposure to blood from the needle stick.
E.
Exposure
Claims Without Physical Injury: Determination of Occupation
1.
For
purposes of exposure claim processing, claims services staff must determine
whether the IW’s occupation meets the statutory criteria laid out in R.C.
4123.026.
2.
When
BWC receives a claim that indicates the IW may be a firefighter, peace officer,
emergency medical worker, or detention facility employee (including a
corrections officer):
a.
Claims
services staff must verify that the IW is:
i.
A
firefighter of a lawfully constituted fire department;
ii.
A
peace officer as defined by R.C. 2935.01, including, but not limited to:
a) Sheriff;
b) Deputy sheriff;
c)
Marshal;
d) Deputy marshal;
or
e) Member of an
organized police department;
iii. An emergency medical
worker, meaning either:
a) Certified under
R.C. Chapter 4765 and listed below:
i)
First
responder;
ii) Emergency medical
technician-basic;
iii) Emergency
medical technician-intermediate; or
iv) Emergency
medical technician paramedic; or
b) Any of the
following when staffing a rotorcraft or fixed wing air ambulance on behalf of a
licensed air medical service organization in accordance with section 4766.17 of
the Revised Code, including transporting a patient from an incident scene or
medical facility into the air ambulance, or when transporting a patient from an
air ambulance to the entrance of a hospital:
i)
A
physician who holds a current, valid license issued under Chapter 4731. of the
Revised Code;
ii) A registered
nurse who holds a current, valid license issued under Chapter 4723. of the
Revised Code;
iii) Any other
person holding a current, valid certificate or license to practice a health
care profession in this state.
iv. A detention
facility employee (including a corrections officer).
b. If it is
unclear whether the IW’s occupation meets the criteria listed above, claims
services staff must:
i.
Contact
the parties to the claim (IW, employer, and/or the IW and employer
representatives) to request evidence to that the IW’s occupation qualifies
under R.C. 4123.026; and/or
ii.
Staff
the claim with a supervisor and/or BWC attorney, as necessary.
3.
If,
upon investigation, claims services staff determines that the IW’s occupation
is covered under R.C. 4123.026, claims services staff will follow the directions
detailed in the next section of this procedure.
4.
If
upon investigation, claims services staff determines that the IW’s occupation
is not covered under R.C. 4123.026, claims services staff will follow the directions
detailed in the Exposure Claims
Without Physical Injury for All Workers Not Covered by R.C. 4123.026 section of
this procedure.
F.
Exposure
Claims Without Physical Injury Filed by a Firefighter, Peace Officer, Emergency
Medical Worker, or Detention Facility Employee Pursuant to R.C. 4123.026
1.
After
verification that the IW’s occupation is covered by R.C. 4123.026, claims
services staff will enter the IW’s occupation in the claims management system.
2.
Claims
services staff must then determine if, in the course of and arising out of the
IW’s employment, the IW has come into contact with either:
a.
A
drug or other chemical substance; or
b. The blood or
other body fluid of another person through:
i.
A
splash or spatter in the eye or mouth, including when received in the course of
conducting mouth-to mouth resuscitation;
ii.
A
puncture in the skin; or
iii. A cut in the
skin or another opening in the skin, such as an open sore, wound, lesion,
abrasion or ulcer.
3.
Claims
services staff must staff the claim with Legal by sending an e-mail to BWC Exposure Claims to assist in
determining whether the exposure type qualifies the claim for medical bill
payment under R.C. 4123.026.
4.
If
claims services staff determines (and Legal staffing confirms) that the IW has
been exposed to a drug or other chemical substance, or blood or another bodily
fluid via one (or more) of the routes described above, and there is no
accompanying physical injury:
a.
Claims
services staff will:
i.
Enter
a proper ICD-10 code and ensure that the narrative description of the code
reflects, or is modified to reflect, an exposure to blood or other body fluid,
or an exposure to a drug or other chemical substance (see the ICD
Modification
policy and procedure for further information);
ii.
Issue
an Initial Denial Order:
a) Select “SB223
Denial” as the First Denial Reason; and
b) Under “SB223
Reasons”, select the insert, “SB223 no disease with testing payable”.
iii. Send notice to
the MCO to facilitate payment of the diagnostic and preventive treatment
related to the exposure:
a) In Claim
Details>Details>Claim Handling>Is this a denied claim requiring bill
payment?, mark “Yes”; and
b) Select SB 223
from the resulting drop-down box (because the claim met all of the criteria set
forth in R.C. 4123.026.
iv. Enter a note in
the claims management system that indicates the following: RC 4123.026 applies-claim
is disallowed due to no physical injury, but the worker did have a qualifying exposure
to a drug or other chemical substance, or blood or body fluid.
b. The MCO will:
i.
Accept
the CDC and OSHA standards for diagnostic and preventive treatment related to
exposure to a drug or other chemical substance, or blood or OPIM;
ii.
Not
require prior authorization for and must not deny services that are consistent
with CDC and OSHA standards. Post-exposure medical diagnostic services that may
be appropriate due to exposure to blood, or other body fluids include, but are
not limited to:
a) Office visits,
b) Emergency
Department visits;
c)
Treatment,
such as cleaning, suturing, and dressing of the area;
d) Tetanus, HIV or
hepatitis testing;
e) Counseling;
f)
Prophylactic
treatment/medication; and
g) Follow-up
testing and treatment.
iii. Price bills
submitted for these services at $0.00; and
iv. Submit the bill
to BWC’s MB&A unit.
5.
If
claims services staff determines (and Legal staffing confirms) that the IW did
not suffer a physical injury and was exposed to any substance other than a drug
or other chemical substance or blood or other body fluid, OR if the exposure to
blood or another body fluid was not through any of the routes described above, claims
services staff will issue an Initial Denial Order:
a.
Select
“SB223 Denial” as the First Denial Reason; and
b. Under “SB223
Reasons”, select the insert, “SB223 no contact with body fluid”.
G.
Exposure
Claims Without Physical Injury for All Workers Not Covered Under R.C. 4123.026
1.
If
the IW incurred an exposure with no physical injury, claims services staff will
deny the claim due to no physical injury, using an Initial Denial Order:
a.
Select
“SB223 Denial” as the First Denial Reason; and
b. Under “SB223
Reasons”, select the insert, “Not SB223 Exposed but no disease” (This will
provide language on the order indicating that the IW’s employer may be required
to pay for diagnostic testing and treatment).
2.
Example:
a.
A
FROI is filed by a nurse alleging a work-related exposure to blood (blood
smeared on the IW’s hand while treating a patient).
b. A smear of
blood on the hand by itself does not constitute a physical injury and
documentation does not indicate that the IW has any physical injury related to
the incident causing the blood smear.
c.
Claims
services staff denies the claim because there is no physical injury.
1.
If
evidence does not support that the IW suffered an exposure or a physical injury,
claims services staff will deny the claim due to lack of physical injury; and
2.
Send
an Initial Denial Order.
1.
Claims
services staff must consider an application for the contraction of an occupational
disease after exposure consistent with the Occupational
Disease Claims
policy, either as:
a.
An
additional allowance to a related allowed claim; or
b. A new claim, if
the related claim was not allowed (or there was no other related claim).
2.
Examples:
a.
Additional
Allowance
i.
The
IW files a claim for exposure to blood and a needle stick.
ii.
The
claim is allowed due to the physical injury of the needle stick.
iii. Medical
treatment is approved for the needle stick and for diagnostic testing and
preventive treatment for the exposure.
iv. The IW later
develops hepatitis B (an occupational disease) related to the exposure.
v.
The
IW files for an additional allowance in the existing allowed claim for the
occupational disease contracted from the exposure.
b. New Claim
i.
The
IW files a claim for exposure to blood or other body fluid, but there is no
physical injury.
ii.
The
claim meets the criteria of R.C. 4123.026.
iii. The claim is
disallowed due to no physical injury, but the IW is reimbursed for diagnostic
testing and preventive treatment for the exposure, consistent with standards of
medical care.
iv. The IW later is
found to have contracted an occupational disease related to the exposure.
v.
The
IW files a new claim for occupational disease, which is processed consistent
with the Occupational
Disease Claims
policy.