Providers who treat Ohio's injured workers assume an obligation to submit initial and
subsequent reports to the managed care organizations (MCOs) on behalf of the injured
worker. Providers must supply supporting medical documentation to the MCOs at the time
of the treatment request and reports on outcomes of treatment.
Providers also assume an obligation to complete all forms required by BWC or the
self-insuring employer. Providers may not charge for completing required forms or
for submitting necessary documentation. However, providers may charge a fee for
copies of medical records if the BWC claim already contains the documentation
being requested. All parties to the claim would have access to such medical records
electronically within the claim. The provider will base his or her fee on the actual
cost of furnishing such copies, not to exceed 25 cents per page.
In some instances, it's necessary for the provider to update the MCO throughout
treatment. Such instances include:
Injured worker does not comply with treatment regiment or misses appointments;
Negative/lack of response to treatment;
Changes in outcome or goals of treatment;
Diagnostic testing results;
Hospital discharge summaries;
Emergency room reports, operative reports or other situations that
indicate a need to alter a treatment plan/plan of care or concurrently monitor
the patientís care.
In such instances, the provider must submit the update to the MCO within five days
of delivery of service or the MCO's request.
When injured workers file a claim, they give BWC access to information related to the
claim. Consequently, when you submit medical reports to either BWC or an MCO you do not
need to have the injured worker sign a release.
The Health Insurance Portability and Accountability Act (HIPAA) privacy and electronic
transactions regulations do not directly apply to BWC and the MCOs. BWC and the MCOs
do not qualify as covered entities under HIPAA regulations.
The provider can release information to BWC, an MCO, a self-insuring employer
or Qualified Health Plan in a self-insured claim if the provider is treating an
injured worker and is:
- Requesting authorization for treatment;
- Requesting payment for treatment already rendered;
- Providing information with regard to the allowance of a
claim, or the allowance of an additional condition in an existing claim.
MCOs must integrate their case management and bill payment systems, so they will not
require providers to attach medical documentation to bills for previously approved treatment. However, providers must submit medical documentation in cases where services billed do not correspond to requested and approved treatment, or if the MCO needs information to show what services were provided.
For example, for a period not to exceed 60 days following the date of injury, physicians
have presumptive approval for providing E/M consultation services when treating soft tissue
and musculoskeletal injuries for allowed conditions in allowed claims. Although physicians
may render the E/M service without prior authorization, they must make documentation supporting
the components of the E/M service accessible. To justify payment for the service reported,
the documentation must be specific in describing the provided service.
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