Medical prior authorization requirements
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Effective Jan. 1, 2001, BWC initiated a pilot program to assist timely
return-to-work expectations for injured workers, as well as helping reduce
the administrative paperwork burden for you and the managed care
organizations (MCOs). Working together with the MCOs, we've developed
standardized prior authorization and presumptive approval guidelines.
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.
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Presumptive approval guidelines
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Effective Jan. 1, 2001, BWC implemented a pilot program giving providers
presumptive authorization to provide specific medical services without waiting
for prior authorization from the MCO.
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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:
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- A maximum of 12 physical medicine visits per injured worker claim which
may include any combination of osteopathic manipulative treatment, chiropractic
manipulative treatment, and physical medicine and rehabilitation services performed
by a provider whose scope of practice includes these procedures, including, but not
limited to, doctor of chiropractic, doctor of osteopathic medicine, doctor of
allopathic medicine (MD), physical therapist, occupational therapist, athletic trainer
or massage therapist;
- Diagnostic studies, including x-rays, CAT scans, MRI scans and EMG/NCV;
- Up to three soft tissue or joint injections involving the joints of the extremities
(shoulder including acromioclavicular, elbow, wrist, finger, hip, knee, ankle and foot
including toes) and up to three trigger point injections. Note: Injections of the paraspinal
region, including epidural injections, facet injections, and sacroiliac injections are
not included in the presumptive approval guidelines;
- E/M services and consultation services.
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You must complete the following before you initiate any or all of the
aforementioned services:
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You will still report injuries and provide written treatment plans to the MCO
for medical management. In addition, you agree to notify the MCO within 24 hours
if the injured worker will be off work for more than two calendar days. Except
for emergency services, the services listed in the
MCO
standardized prior authorization table that do not fall within the
presumptive approval parameters still require prior authorization. You must
submit a C-9 to request formal authorization.
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Why has BWC adopted the presumptive authorization policy?
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This change allows you to aggressively treat injured workers who suffer the
most common work-related injuries — soft tissue and musculoskeletal injuries.
This new policy supports BWC’s Health Partnership Program’s goals of early
and safe return to work with new emphasis on remain at work and transitional
work initiatives.
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What are soft tissue and musculoskeletal injuries?
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They are injuries, such as sprains, strains, superficial injuries and
contusions, per the International Classification of Diseases (ICD-9-CM)
book.
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Are there any limitations or non-covered procedures for diagnostic studies
under presumptive authorization?
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Medical necessity for the allowed conditions is always the driver for services.
Surgical diagnostics, such as arthroscopic procedures are not included, unless
it is an emergency.
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What are the benefits of the presumptive authorization program?
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By eliminating wait time for authorizations, you can immediately schedule
diagnostic testing and other procedures covered under the presumptive
authorization policy at the time of the office visit. Quicker treatment means
faster recovery, lower disability costs and injured workers returning to
gainful employment.
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Will MCO case managers advise providers when they identify procedures that
do not appear to be medically necessary?
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Yes, but as long as providers follow commonly accepted treatment guidelines
when treating the allowed conditions in a claim, the bill will be paid.
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Does presumptive authorization apply to treatments provided within the first
60 days or requested within the first 60 days and provided later?
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The presumptive approval guidelines apply to services provided within 60 days
from the date of injury.
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Where can I get more information on presumptive authorization?
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For more information on presumptive authorization call 1-800-OHIOBWC or the
local customer service office.
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