|
Why has BWC adopted the presumptive approval policy?
This change allows providers to aggressively treat
injured workers who suffer the most common work-related
injuries -- soft tissue and musculoskeletal injuries.
This 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.
What are soft tissue and musculoskeletal injuries?
They are injuries, such as sprains, strains, superficial
injuries and contusions, per the International
Classification of Diseases (ICD-9-CM) book.
Are there any limitations or non-covered procedures for
diagnostic studies under presumptive authorization?
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.
What are the benefits of the presumptive authorization program?
By eliminating wait time for authorizations, providers
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.
Will MCO case managers advise providers when they identify
procedures that do not appear to be medically necessary?
Yes, but as long as providers follow commonly accepted
treatment guidelines when treating the allowed conditions
in a claim, the bill will be paid.
Does presumptive authorization apply to treatments provided
within the first 45 days or requested within the first 45 days
and provided later?
The presumptive approval guidelines apply to services
provided within 45 days from the date of injury.
BWC's MCO Standardized Prior Authorization Table
Services listed in the standardized prior authorization
table below and not indicated as exceptions require prior
authorization (PA) of treatment by the managed care
organization and/or the Ohio Bureau of Workers' Compensation.
Medical providers must submit a C-9 to indicate services to
be provided through formal authorization.
|
