OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Exposure

Policy #:

CP-05-02

Code/Rule Reference:

R.C. 4123.01; R.C. 4123.026

Effective Date:

06/12/24

Approved:

Shawn Crosby, Chief Operating Officer

Origin:

Claims Policy

Supersedes:

Policy # CP-05-02, effective 09/15/20

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

 

I. POLICY PURPOSE

 

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).

 

II. APPLICABILITY

 

This policy applies to BWC claims services staff and MCO staff.

 

III. DEFINITIONS

 

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.

 

IV. POLICY

 

A.       Exposure Diagnosis

1.        A diagnosis of “exposure” is not an allowable condition.

2.        BWC will not allow the condition of “exposure” in any claim.

 

B.       Exposure Claims Without Physical Injury: Claim Denial and Bill Payment

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.

 

C.       Exposure Claims with Physical Injury

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).

 

D.       Contraction of Occupational Disease After Exposure

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.

 

E.       Firefighters with Cancer and Firefighter Cardiac Claims

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.

 

V. PROCEDURES

 

A.       General Claim Note and Documentation Requirements

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.

 

B.       Processing Exposure Claims: Summary

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.

 

C.       Determination of Physical Injury

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.

 

H.      No Exposure and 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.

 

I.          Contraction of Occupational Disease After Exposure

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.