With the change in the ADR Process, does the rule still apply that if the MOC does not respond to a C-9 within 10 days the service is approved?
Answer: NO. Now the MCO Policy Reference Guide says:
A medical service request will be considered approved and the provider may initiate treatments when all of these criteria are met:
(1) The MCO fails to communicate a decision to the physician within three business days of receipt of an original medical services request or five business days if the request was pended;
(2) The physician has documented the medical services request completely and correctly on a C-9 or other acceptable document;
(3) The physician has proof of submission to the appropriate MCO;
(4) Medical services are for the allowed conditions;
(5) The claim is in a payable status.
In instances when a C-9 is not responded to within three business days and the provider initiates treatment, the MCO will provide concurrent and retrospective review of that treatment. If it is found before, after or during delivery, that any treatment, approved or not approved within three business days, is not medically indicated or necessary, not producing the desired outcomes, or patient is not responding, the MCO will notify the parties of the decision to discontinue payment of said treatment. Only charges for treatments already rendered will be paid. If the provider, IW or employer wish to dispute the decision, they may do so via the ADR process. The MCO shall obtain beginning and estimated ending dates for inpatient services if not provided on the request for medical services.
Previously, if services were approved, they were not subject to change. Now, approvals can be rescinded at any time.
In this ‘new’ era of Ohio BWC Policy, you need an attorney to represent your interests more than ever !