Standardized Prior Authorization Requirements

Since January 1, 2001, the Ohio Bureau of Workers' Compensation (BWC) has been implementing standardized prior authorization requirements, designed to facilitate timely return-to-work for injured workers, as well as help reduce the administrative burden on providers and managed care organizations (MCOs). As a result, prior authorization requirements have been standardized across all MCOs in the state. In addition, "presumptive approval" guidelines enable providers to provide certain medical services during the first 45 days following an injury without the need for prior authorization from an MCO such as University Hospitals CompCare.

Presumptive approval guidelines

Effective for dates of service on or after July 1, 2001, basic X-rays that are medically necessary for the claim allowance will not require prior authorization from the MCOs.

For a period not to exceed 45 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:

• Up to 10 physical medicine visits, including osteopathic, chiropractic, physical therapy and occupational therapy, and transitional work onsite therapy.

• Diagnostic studies, including X-rays, CAT scans, MRI scans and EMG/NCV.

• Up to three soft tissue or joint injections, excluding epidural injections.

• E/M services and consultation services.

Providers must take the following actions before initiating any of the aforementioned services:

• File the First Report of Injury (FROI) with the employer's MCO.

• Complete and file the Physician's Report/Treatment Plan for Industrial Injury or Occupational Disease (Form C-9), with documentation, to the employer's MCO. If the claim involves a University Hospitals CompCare employer client, we will notify the provider within three business days acknowledging receipt of the C-9 and that a review was completed to ensure that services being rendered are medically necessary.

• Notify the MCO within 24 hours of treatment 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. Click for online access to BWC's C-9 form.

Still have questions about presumptive approval? Click for answers.