For the Provider


Presumptive Authorization

Effective November 1, 2002, providers have presumptive approval to provide services during the first 60 days following an injury. The MCO shall adhere to the following standardized prior authorization and presumptive approval guidelines.

For a period not to exceed 60 days following the date of injury, physicians have presumptive approval for providing the following services when treating soft tissue and musculoskeletal injuries for allowed conditions in allowed claims:

The following criteria must be met prior to initiating any or all of the aforementioned services:

Please refer to the BWC's Provider Billing & Reimbursement Manual (BRM) for further clarification.

Grievance and Dispute Process

Grievance Process
The Health Plan Managed Workers' Compensation Program (MWCP) provides for a grievance process for operational, non-medical complaints including case management activities that may arise between the claim parties. Issues can be reported either telephonically or in writing to the Manager. All efforts will be made to resolve the issue within 48 hours of notice. Unresolved issues will be forwarded to the Director of Employer Services for review and action.

The Alternative Dispute Resolution (ADR) process is intended to handle medical disputes regarding quality assurance, utilization review, medical necessity and other treatment and provider issues. Disputes must be received in writing within 14 days of receipt of written notice of a treatment determination.

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MCO Standardized Prior Authorization Table

In an effort to ease the burden of providers having to accommodate different prior authorization requirements by each MCO, the Ohio BWC and the MCO's collaborated and developed a Standardized Prior Authorization Table. Services listed in the standardized prior authorization table and not indicated as exceptions still require prior authorization. Providers must submit a C-9 to indicate services to be provided through formal authorization. The physician of record (POR) or treating physician must submit requests for medical services that require prior authorization. Provider types whose signatures must appear on the C-9 treatment request include all POR provider types (MD, DO, DC, DDS, DMT, DPM, psychologist, optometrist, advanced practice nurse, physician assistant, independent social worker, and professional advanced clinical counselor). Treatment requests from any other provider type should not be processed. Please refer to the BWC's Provider Billing & Reimbursement Manual (BRM) for further clarification.

For dates of injury on or after Nov. 1, 2002, BWC has expanded the time frame for presumptive approval to provide services from the first 45 days to the first 60 days following the injury. We've also added services and clarified others.

Service Requirement
Physical medicine services, including chiropractic/osteopathic manipulative treatment and acupuncture Prior Authorization (PA)
Consultations - Psychological/chronic pain program only PA
Chronic Pain Program including pre-admission evaluation and treatment PA
Dental PA
Diagnostic Testing PA
(except basic X-rays which do not require PA)
DME PA if purchase
price is > $250
PA for all DME rental
Home/auto/van modifications PA required from BWC
Home health agency services PA
All inpatient and outpatient hospital services treatment and ambulatory surgery center services PA, except for emergency* services. Emergency inpatient hospitalization may be through the emergency department or by direct admission
In-home physician services PA after first visit
Injections PA
Non-emergency ambulance services PA
Orthotic and prosthetic devices and/or repair PA > $250
Skilled Nursing Facility (SNF)/Extended Care Facility (ECF) PA
TENS and NMES units PA for both rentals and purchases
TENS and NMES monthly supplies PA for a maximum of
six months per authorization
Vision and hearing services PA > $100
Vocational rehabilitation - All vocational rehabilitation services, in or out of plan

Note: PA not required for transitional work on-site therapy services provided by an occupational therapist or physical therapist that fall under the presumptive authorization guidelines.
Note: Occupational rehabilitation (work hardening) requires CARF accreditation.


* Per Ohio Administrative Code 4123-6-01(O), "Emergency" means: Medical services that are required for the immediate diagnosis and treatment of a condition that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death, or that are immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency, but is necessary to determine whether an emergency exists.

Forms

Online access to BWC's C-9 form in PDF format. Other forms available here.

The Health Plan Managed Workers' Compensation Program (MWCP) Billing

All Bills may be sent to:
The Health Plan Managed Workers' Compensation Program (MWCP)
PO Box 97
St. Clairsville, OH 43950

Billing Questions may be addressed at: 1.888.847.7810

Electronic billing is available. Providers who want to bill electronically should contact The Health Plan Managed Workers' Compensation Program (MWCP) to initiate training.

Online Provider Billing and Reimbursement Manual

By logging on to www.ohiobwc.com you can view, print or download BWC's Provider Billing & Reimbursement Manual. A Dolphin account is not required to access the online BRM. You can access the online BRM from the green Medical provider page under the Service section. The BRM documents provider reimbursement policies and procedures. BWC's medical policy department publishes quarterly updates, which are titled BWC Provider Update. These updates also can be accessed on www.ohiobwc.com.

Additional Dolphin online services for providers include:

*Denotes that a provider account is required to access the online service.

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