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Policy and Procedure Name:
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Travel Reimbursement
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Policy #:
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CP-20-01
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Code/Rule Reference:
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O.A.C. 4123-3-09; O.A.C 4123-6-40; ORC 4123.52
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Effective Date:
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10/07/2021
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Approved:
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Ann M. Shannon, Chief of Claims Policy & Support
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Origin:
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Claims Policy
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History:
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Previous versions of this policy are available upon
request
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Travel Reimbursement Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
IV. POLICY
A. Travel Reimbursement-
General Policy Statement
B. Review
C. Preauthorization
D. Reimbursement of Travel
Expenses
E. Obtaining Reimbursement
F. Pre-Payment and
Overpayment of Travel Expenses
V. PROCEDURE
A. Standard Claim File
Documentation
B. Claims Services Staff
and MCO Responsibilities
C. Travel Reimbursement
Requests for Medical Examinations
D. Travel Reimbursement
Requests Due to Medical Treatment
E. Travel Reimbursement
Requests As Part of Vocational Rehabilitation Services
F. Pre-Authorization for
Travel Expenses
G. Payment for Transport by
Ambulance or Ambulette for Non-Emergency Travel
H. Travel for the Fifteen
Thousand Dollar Medical Only (15K) Program Claims
I. Calculating and
Approving Reimbursement
J. Denial of Travel
Reimbursement
K. Pre-payment of Travel
Expenses
L. Overpayment of Travel
Expenses
M. Issues Regarding Travel
The purpose of this policy and procedure is to ensure
consistent and efficient reimbursement to the injured worker (IW) for allowable
travel expenses.
This policy and procedure applies to managed care
organization (MCO) staff and BWC staff.
None
It is the policy of BWC to
reimburse an IW for medically necessary, reasonable, and appropriate travel
expenses, as detailed in the policy and procedure below.
1. MCO and BWC
staff shall review travel expenses prior to reimbursement to ensure medical necessity
and appropriateness.
2. MCO and BWC staff
shall discuss travel expense requests, and the MCO shall provide BWC staff with
documentation of its efforts to inform and assist the IW regarding travel.
1. The following
types of travel expenses must be pre-authorized by BWC to be reimbursable:
a. Lodging;
b. Travel in excess
of 400 miles round trip from IW’s residence;
c. Companion
travel; and
d. Travel by
taxicabs, bus, train, non-emergent air transport, or other special
transportation.
2. The MCO may
pre-authorize and reimburse medically necessary transportation by ambulance or
ambulette.
1. BWC
Reimbursement of Travel Expenses
a. It is the policy
of BWC to reimburse an IW for reasonable and necessary travel expenses, upon
the filing of a proper request, when the:
i. IW
is required by BWC or the Ohio Industrial Commission (IC) to undergo a medical
examination that is more than 45 miles round trip from the IW’s residence;
ii. MCO has approved
medical treatment, including a service contained in an approved vocational
rehabilitation plan that cannot be obtained within 45 miles or less round trip
from the IW’s residence; or
iii. IW’s allowed
conditions require the use of taxicab or other special transportation for
purposes of obtaining treatment or attending an examination because of an
allowed injury or occupational disease, and the taxicab or other special
transportation has been pre-authorized (no minimum mileage requirements are
necessary in this circumstance).
b. BWC shall
publish reimbursement rates on the Injured Worker
Reimbursement Rates for Travel Expenses (C-60A), which also details the
criteria for reimbursement of travel expenses.
2. Employer
Reimbursement of Travel Expenses
a. The employer is
responsible for reimbursing the IW for travel expenses when the travel is
related to a request for a medical examination by a physician of the employer’s
choice.
b. Reimbursement by
the employer of travel expenses under this provision shall not:
i. Require
an order of BWC or the IC, unless there is a dispute; and
ii. Be subject
to the minimum mileage requirement applicable to travel expenses reimbursed by
BWC.
3. Self-Insuring
Employer Reimbursement of Travel Expenses
a. The
self-insuring employer is generally responsible for reimbursement of travel
expenses if related to a self-insured claim.
b. BWC is
responsible for the reimbursement of travel expenses in a self-insured claim
only if the travel is for an:
i. Exam
to determine percentage permanent partial disability; or
ii. Appointment
related to the provision of a prosthetic device.
4. IC-Scheduled
Examinations- When the IC schedules an examination, the associated travel is
reimbursed by:
a. BWC for
state-fund claims; and
b. The
self-insuring employer for self-insured claims.
5. Travel
Reimbursement Requests Due to an Approved Vocational Rehabilitation Plan
a. When travel
expenses are authorized as part of an approved vocational rehabilitation
assessment plan, comprehensive vocational rehabilitation plan, or job retention
plan, BWC shall pay travel reimbursement.
b. Vocational
services that may be eligible for travel reimbursement include, but are not
limited to:
i. Training;
ii. Job
simulation;
iii. Job search
outside the IW’s community.
c. Any travel
reimbursement requests related to an approved vocational rehabilitation plan
are subject to the requirements of the procedures below.
1. To obtain
reimbursement for travel expenses, the IW must complete and submit to the party
responsible for payment an Injured Worker
Statement for Reimbursement of Travel Expense (C-60), or an equivalent
documented travel expense request.
2. Travel expenses
must be submitted within two years of the IW’s date of travel.
1. BWC may, at its
sole discretion, assist an IW by pre-paying allowable lodging and transportation
expenses, such as airplane or railroad fares.
2. BWC shall
collect any overpayment of travel expenses to the IW.
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 responsibilities include:
a. Reviewing the
C-60 or equivalent to determine if it contains complete and accurate
information;
b. Requesting IW
information or supporting documents (e.g., receipts, when applicable) that are
missing or require clarification;
c. Determining
if the travel expense request is medically necessary and reasonable under the
requirements of these procedures; and
d. Processing
requests for travel expenses within seven calendar days upon receipt of the
C-60 or equivalent, or within 14 calendar days if additional information or
clarification was requested.
2. MCO
Responsibilities- Education & Notice to the IW
a. The MCO shall
make the following efforts to minimize unnecessary or unreasonable travel
expenses:
i. The MCO
shall provide written notice to the IW regarding travel reimbursement. The
written notice shall use the following language: “Travel for medical treatment
in excess of 45 miles round trip from your residence may be eligible for
expense reimbursement. Any travel expenses related to this treatment request
must meet the requirements of Ohio Administrative Code rule 4123-6-40 to be reimbursed
and may require pre-authorization. For more information, please contact your CSS
at {contact info here}.”
ii. When an IW
requests treatment, the MCO shall contact the provider and/or IW to attempt to
determine who is providing the service, where treatment will occur, and whether
it will require travel in excess of 45 miles round trip from the IW’s residence.
iii. If the provider
or IW informs the MCO that treatment will require travel in excess of 45 miles
round trip from the IW’s residence, the MCO shall:
a) Evaluate
BWC’s certified provider list to determine whether there are treatment
alternatives that either eliminate or minimize the amount the IW must travel.
b) If no BWC
certified provider is available, evaluate whether there are non-certified
providers willing to enroll with BWC that can provide necessary services that
either eliminate or minimize the amount the IW must travel.
c) Provide
assistance to the IW in locating treatment options that are closer to home.
iv. If
alternate treatment options all require travel in excess of 45 miles round trip
from the IW’s residence, the MCO shall work with the IW to minimize the amount
of travel, in a manner that is reasonable and necessary.
b. The MCO shall
provide written documentation to the BWC claim file of its effort to educate
and inform individual IWs when travel expense requests are made (e.g. entering
a claim note).
1. If the IW’s
travel is for a BWC-ordered or authorized exam (including ADR) for a state-fund
claim, claims services staff shall:
a. Verify the IW
attended the exam;
b. Verify the
required mileage was met;
c. Review
appropriateness of other expense requests (e.g. meals, tolls, parking, etc.);
and
d. Grant the travel
reimbursement request if all requirements are met.
2. If the IW
travels for an IC-ordered exam, the IC shall review travel expense requests for
appropriateness and upload the C-60 or equivalent to the claim file:
a. For a
self-insured claim, the IC will send the employer a cover letter and the
approved C-60 or equivalent for payment.
b. For a state-fund
claim, the IC will send the approved C-60 or equivalent to BWC Benefits Payable
for payment.
3. If BWC receives a
C-60 or equivalent for a medical examination scheduled or requested by a state-fund
employer, claims services staff shall:
a. Return the
request to the IW; and
b. Advise the IW
that the request must be submitted to the state-fund employer for
reimbursement.
4. If BWC receives
a C-60 or equivalent and the IW is employed by a self-insuring employer:
a. Claims services
staff shall:
i. Return
the request to the IW; and
ii. Advise the
IW that the request must be submitted to the self-insuring employer for
reimbursement, unless the travel is for:
a) An exam prior to
a determination for percentage permanent partial disability; or
b) The provision of
a prosthetic device pursuant to the Artificial
Appliance Requests policy.
b. If the travel
reimbursement request is related to V.C.4.a.ii immediately above, claims
services staff shall review the request for appropriateness of payment.
5. In the event an
IW is medically unable to self-transport to a BWC-scheduled exam due to the allowed
condition(s) in a claim, the minimum mileage requirement will be waived.
Example: The IW’s
allowed conditions are two broken legs. The IW does not have personal access to
transportation that accommodates a wheelchair. In this case, BWC would pay for
round trip travel to the exam, regardless of the distance.
D. Travel Reimbursement
Requests Due to Medical Treatment
1.
When the provider or IW informs the MCO that requested medical treatment
would require the IW to travel more than 45 miles roundtrip from the IW’s
residence, the MCO:
a. Shall identify whether
there is a closer provider of the service, utilizing the hierarchy of distance
(i.e., a provider in the following order of preference: within the local
community, regional community, statewide community, or contiguous states where
services can be obtained);
b. May need to
investigate to determine the location of the rendering provider or medical
treatment facility in order to determine if the IW will need to travel for
medical treatment; and
c. Shall
document all actions taken in claim notes.
2. If equivalent
medical treatment can be obtained closer to the IW’s residence, the MCO shall:
a. Discuss its recommendations
regarding closer treatment options with the treating physician and the IW
before authorizing treatment and document this discussion in claim notes; and
b. Inform the IW
that travel expenses will not be reimbursed should the IW choose medical
treatment that requires travel. If the treating physician and IW do not agree
to move the treatment to a closer facility, the MCO shall also document this
information in claim notes.
3. If the MCO has
determined that treatment necessary for the IW’s allowed condition is required
and cannot be obtained 45 miles or less round trip from the IW’s residence, the
MCO shall notify BWC and BWC shall proceed with its review under V.I of this procedure.
4. The MCO shall
advise the IW to contact BWC for more information regarding requirements and
procedures for obtaining reimbursement of travel expenses.
1. The DMC shall
review all requests for travel reimbursement when travel is being requested as
part of vocational rehabilitation services.
2. For appeals of
travel reimbursement requests associated with vocational rehabilitation, please
see the Disputes
Regarding Vocational Rehabilitation Decisions policy and
procedures.
3. The DMC shall
staff any issues with the BWC Rehab Policy Unit.
1. The MCO and
claims service staff shall work together to inform and assist the IW when
pre-authorization for travel expenses is necessary.
2. The MCO shall
review the medical treatment to determine if closer treatment options are
available as outlined in Section V.D.
above.
3. If closer treatment
options are not available and requested treatment has been determined to be
medically necessary, claims services staff shall contact
the IW to:
a. Provide
information regarding pre-authorization requirements; and
b. Obtain
information on which type of travel expenses the IW anticipates incurring and
additional details regarding lodging and special transportation (e.g., selected
hotel and mode of transportation).
4. If the
pre-authorization request is for travel reimbursement for special transport
(e.g. taxicab, bus, train, or air), claims services staff shall:
a. Discuss with the
MCO to determine if there is a medical necessity for special transportation due
to the allowed conditions in the claim;
b. Review to
determine whether the type of transportation expenses requested are a reasonable
means of transportation for the IW.
5. If the IW
submits a valid request for travel reimbursement for special transport due to
medical necessity, there is no minimum mileage requirement.
6. Upon receipt of the
request for pre-authorization of travel expenses, claims services staff shall:
a. Review MCO notes
to verify need for travel;
b. Confirm that the
travel expenses requested are reasonable;
c. If
necessary, contact the IW via phone in an attempt to resolve any questions or
problems related to the pre-authorized travel reimbursement request; e-authorized
or not;
d. Prepare written
approval or denial of pre-authorization for travel expenses;
e. Send a letter to
the IW notifying the IW of BWC’s decision regarding the pre-authorization of
travel expenses; and
f. Document
the decision in a claim note.
G. Payment for Transport
by Ambulance or Ambulette for Non-Emergency Travel
1. If there is a
request for medical treatment but no specific request for special
transportation (e.g. ambulance or ambulette) exists, the MCO may:
a. Review to
determine whether there is a need for special transportation; and
b. Pre-authorize
special transportation if there is an urgent, time-driven need (e.g., IW needs
to be moved by ambulance from a hospital to a step-down facility) without
staffing with claims services staff.
2. When the MCO
determines that special transportation (e.g. ambulance or ambulette) is
necessary and supported by the medical evidence on file, the MCO shall:
a. Document its
efforts to pre-authorize the travel for special transportation by ambulance or
ambulette;
b. Ensure the
transportation provider is eligible to become or is enrolled as a certified
provider;
c. Obtain a
C-9 request retrospectively whenever possible, or document rationale as to why
a C-9 was not obtained; and
d. Arrange for
payment for special transportation as an MCO medical payment.
1. When claims
services staff receives a travel reimbursement request, staff shall verify if
the claim is enrolled in the 15K program.
2. If the claim is
enrolled, claims services staff shall follow the procedures for travel
reimbursement outlined in the $15,000
Medical-Only Program policy.
I. Calculating
and Approving Reimbursement
1. If travel
expenses associated with approved medical treatment in the claim appear necessary,
claims services staff shall determine reasonableness of the travel expenses by calculating
reimbursement in the following manner:
a. Reimbursement
for travel by a personal vehicle shall be at the rate indicated on the C-60A,
per mile, for the date(s) of travel.
i. The
total reimbursement is determined by multiplying the number of miles traveled
by the per mile rate.
ii. Internet
resources may be used as a tool to help determine reasonable and necessary
mileage.
b. Reimbursement
for the reasonable cost for meals shall be at the rates indicated on the C-60A
when the travel:
i. Includes
an overnight stay; or
ii. Totals
more than 12 hours in one day.
c. Pre-authorized
lodging for the IW shall be reimbursed at reasonable actual cost (receipts
required), up to the maximum amount indicated on the C-60A, plus applicable
taxes.
d. Travel by taxi,
train, airplane, bus or other special transportation shall be reimbursed at
actual and necessary cost (receipts required).
e. Miscellaneous
travel expenses, such as tolls and parking, shall be reimbursed at the actual
amount (receipts required).
f.
Approved travel expenses related to pre-authorized companions shall be
reimbursed at the same rates permitted for the IW, except:
i. Claims
services staff shall not reimburse for lodging for the companion unless special
circumstances require the companion to have a separate room; and
ii. Claims
services staff shall only reimburse mileage to the IW.
2. To process and
document the C-60 form, claims services staff shall:
a. Enter the
calculations in the appropriate section of the “Official Use Only” section of
the form;
b. Indicate the
appropriate procedure code(s) to be charged;
c. Check the
“Surplus Fund” box if the travel expenses are related to:
i. A
percentage permanent partial exam for state funded covered claims;
ii. Services
in an approved vocational rehabilitation plan;
iii. A prosthetic
provided to the IW pursuant to the Artificial
Appliance Requests policy; or
iv. A medical exam for a
denied statutory occupational disease. (See the Occupational
Disease Claims policy for further information).
d. Sign, date,
enter their phone number and “A” number where indicated, image a copy of the
C-60 into the claim and, send a copy to the IW with a copy of the C-60A; and
e. Fax a copy of
the completed C-60 or equivalent to BWC Benefits Payable.
i. Benefits
Payable will notify claims services staff if a C-60 or equivalent is not
completed properly.
ii. Claims
services staff shall be responsible for correcting and resubmitting the C-60 or
equivalent.
3. If the request
for travel reimbursement has not been submitted on a C-60, claims services
staff shall process and document the request noting on the request or any
attached document:
a. Calculations of
reimbursable travel expenses;
b. The related
procedure codes, as designated on the C-60; and
c. Whether
any charges are to be made to the Surplus Fund.
4. If any of the
IW’s travel reimbursement request appears unreasonable or unnecessary, or is
otherwise questionable, claims services staff shall contact the IW in an
attempt to resolve.
Example: Mileage
submitted by IW is 30 miles more than an online resource indicates the trip
would be, using the most direct route. Contact with the IW reveals that there
was an accident causing a detour, resulting in the additional miles.
1. If, after
reviewing the C-60 or other submitted documentation, claims services staff
determines that all or some of the submitted travel expenses do not meet the
criteria for reimbursement, claims services staff shall publish
a miscellaneous order which states:
a. “After a
thorough review of your request for travel reimbursement filed on [date], BWC
has determined that [a portion of] your request does not meet the criteria
listed below:”
b. The appropriate
travel denial reason; and
c. Any
additional explanation needed to explain the basis for the denial and the
following statement: “Therefore, we have denied [a portion of] your request for
travel reimbursement.”
2. If only a
portion of a travel reimbursement request is denied, claims services staff
shall do the following after all administrative appeals are finalized:
a. Strike out the
denied expenses on the C-60;
b. Calculate the
totals for the allowed expenses and indicate the amount of reimbursement;
c. Image a
copy of the amended C-60 into the claim and send a copy to the IW with a copy
of the C-60A; and
d. Fax the amended
C-60 to BWC Benefits Payable.
1. If the IW
requests assistance from BWC to prepay lodging and other transportation
expenses (e.g., hotel, airfare, bus fare), claims services staff shall submit
the request to BWC management (i.e., team leader, supervisor or claims director)
for review and approval as soon as possible prior to travel.
a. The Pre-Pay
Travel (PPT) unit shall be available for consultation via the BWC Pre-Pay
Travel email box.
b. Claims services
staff shall also advise the IW that approval must be granted before any travel
arrangements are made.
2. Claims services
staff and BWC management shall staff the request.
a. If approved by
BWC management, claims services staff, in consultation with the IW, shall
complete the Injured Worker Travel Card Authorization Log (A-53),
located on COR, and submit it to the PPT unit BWC Pre-Pay Travel email box for
final approval or disapproval.
b. Within two
business days of receipt of the A-53, the PPT unit will approve or disapprove
the request and notify claims services staff by email.
i. If
approved, the PPT unit will proceed with making travel arrangements.
ii. If
disapproved, the A-53 will be cancelled and returned to claims services staff.
iii. Claims services
staff shall document the approval or disapproval in the claim notes.
3. To process the
approved A-53:
a. The PPT unit
will:
i. Document
the travel arrangements on the A-53 with the confirmed vendor, dates of travel,
the total cost of travel and the confirmation numbers;
ii. Attach any
itineraries received from the appropriate vendors and fax this information
along with the approved A-53 to claims services staff; and
iii. Maintain the
completed and confirmed copy of the A-53 and fax a copy to BWC Benefits Payable
to be processed.
b. Claims services
staff shall:
i. Image
the A-53 and document the travel approval in the claim notes;
ii. Prepare a
letter of confirmation to send to the IW, which includes the arrangements made
by the PPT unit, any itineraries, and a C-60 or equivalent for any expenses
incurred by the IW that are not prepaid but approved, or otherwise meet the
requirements of these procedures;
iii. Set a work item
for the next business day after the expected return date of the IW’s travel;
iv. Verify the IW traveled
and kept the appointment per the arrangements confirmed on the A-53 and
document the verification in claim notes; and
v. Ensure
that any travel reimbursement request submitted by the IW does not include the
pre-paid travel arrangements.
c. If claims
services staff determines that the prearranged travel was not utilized, claims
services staff shall:
i. Contact
the IW to determine if there are justifiable reasons or circumstances that
prevented the travel; and
ii. Document
the details of the contact in claim notes.
4. If, for any
reason, the IW cancels the arrangements and does not make alternative
arrangements, claims services staff shall notify the PPT unit immediately via
the BWC Pre-Pay Travel email box.
The PPT unit will contact the vendors and cancel the arrangements to avoid fees
or penalties.
a. Upon receipt of
the cancellation notice, the PPT unit shall send a copy of the A-53 with the
required cancellation notations, including any fees or penalties to BWC
Benefits Payable;
b. Claims services
staff shall document the travel cancellation in the claim notes; and
c. If new
travel arrangements are made, a new A-53 shall be prepared and processed
consistent with these procedures.
1. If there is an
overpayment of travel expenses, claims services staff shall issue an order
indicating the overpayment and that the overpayment will be collected at 100%
from any future approved travel expense reimbursement to the IW.
2. The IW may also
repay the overpayment amount at any time.
1. Claims services
staff shall staff any questions and unusual situations regarding travel
pre-authorization and reimbursement with a BWC attorney as needed.
2. The MCO shall
staff catastrophic and complex injury travel issues with the BWC catastrophic
nurse assigned to the claim.