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OhioBWC - Basics:  Medical documentation

               
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Medical documentation

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;
  • Specialist/consultation 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 patient’s 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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