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My BWC Claim Was Allowed. Who pays for the Medical Bills & Prescription Costs?
Once your BWC claim is allowed, medical bills and prescription medications related to the allowed conditions are payable.
In order to make sure that your therpay and diagnostic testing is allowed, your physician of records must submit a request for prior authorization to the BWC Medical Care Organization (MCO) on a BWC Form called a C-9 . You should not get the treatment until you know the treatment or diagnostic testing has been approved. You can call your MCO to find out if the mediacl treatment is approved. Find out which MCO is responsible for your BWC claim here.
Some Ohio employers are self-insured. In claims involving a self-insured employer, the request for authorization must be filed first with the employer.
In instances where the MCO or the Self Insured Employer deny the request for authorization, you must file an appeal to the OhioBWC. That will start the administrative appeal process. You will need to obtain medical information from the requesting doctor to support the request for the treatment which has been denied. The appeal issue will then be referred to the Bureau of Workers' Compensation and the Industrial Commission, where a hearing on the appeal will take place.
If the employer participates in the BWC's state insurance fund, requests for treatment must be submitted to the employer's managed care organization (MCO). The The same is true of the Self-Insured Employer, which has its own MCO.
The MCO assigned to your claim is responsible for determining whether the requested treatment initially will be approved or denied. Appeals from the MCO's initial denial are filed with the BWC for further evaluation. Should the BWC uphold the denial, the Injured Worker must appeal that denial to the Industrial Commission for hearing on the merits.
ICD-9 Codes and How They Affect Your Claim
ICD-9 Codes are three, four or five-digit numeric codes that represents a uniform, international classification system of coding disease and injury diagnoses and are used to report allowed, non-allowed or disallowed/denied conditions. ICD-9 is an acronym for International Classification of Diseases, 9th Revision. ICD-9 coding is a statistical classification system that arranges diseases and injuries into code categories according to established criteria. For example, an injury such as a broken arm could be classified and coded as follows: fractured radius, 813.81 Using the broken arm example; the left, right, or bilateral (both) arms would be identified. In addition, an injury site may also be listed if necessary. Site locations apply to injuries to the fingers, teeth, and toes.
How does BWC use ICD-9 codes?
Since ICD-9 codes identify the type and nature of the injury sustained, they are also used to determine what medical treatment is appropriate for an injured worker. For example, if a claim were allowed for a torn medial meniscus, a serious knee injury, surgery would likely be an appropriate type of treatment. However, if the claim were allowed for a sprained knee, a less serious injury, surgical intervention would not be appropriate and authorization would not be granted.
In addition, when medical providers bill BWC for services, the ICD-9 code is listed on the billing forms. All bills that are submitted are reviewed to determine if the medical provider is treating the allowed injuries in the claim. If bills are submitted for injuries that are allowed within the claim they will be paid. If bills are submitted for injuries that are not allowed within the claim the bill will be denied.
What is an invalid ICD-9 code?
BWC has defined the following information as an invalid ICD-9 code:
- A code for an injury/condition that is not causally related to an industrial injury or occupational disease;
- The proper application of coding principles (Code assignment requires the highest level of specificity, i.e., must assign the maximum number of digits for a code.) BWC has identified all three and four digit codes that require a fourth and fifth digits respectively;
- An unspecified injury/condition or site code therefore a more specific code exists;
- A symptom code;
- A multiple injury/site code. Reported injury/condition with more than one injury/site are assigned individual codes for each.
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