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Physicians Request For Medical Service Or Recommendation For Additional Conditions For Industrial Injury Or Occupational Disease BWC-1113 - Ohio

Physicians Request For Medical Service Or Recommendation For Additional Conditions For Industrial Injury Or Occupational Disease Form. This is a Ohio form and can be used in Medical Providers Workers Comp .
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Completing the Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease Instructions · Pleaseprintortypethisreport. ·If injured worker is employed by a self-insuring employer, complete this form and mail or fax it to his or her employer. ·Ifinjuredworkerisemployedbyastate-fundemployer,completethisformandmailorfaxittotheappropriatemanaged careorganization(MCO). · TodeterminetheappropriateMCO,asktheinjuredworkeroremployertovisitBWC'sWebsiteatohiobwc.com,orcallBWC at1-800-OHIOBWC,andlistentotheoptions. ·Usethisformifthisisarequestforservicesevenifservicesarebeingprovidedunderthe60-daypresumptiveauthorization, ifrecommendingadditionalcondition(s)orifdiagnosishaschanged. ·Completeallapplicablesectionsoftheformtoavoidpossibledelaysinprocessingthisrequest. ·Youcanobtainadditionalcopiesofthisformonohiobwc.comorbycallingBWCat1-800-OHIOBWCandlisteningtothe options. Section I ­ Injured worker 1 Entertheinjuredworker'sname,BWCclaimnumber,thedatetheinjuredworkerwasinjuredorcontractedanoccupational disease. Section II ­ Requested services 2 Treatingdiagnosisforthisrequesttoincludebodypart/levels. 3 Indicatethebeginningandendingdateoftherequestedservice.Indicatethelastexamortreatmentdate. 4 List the requested services and CPT codes, including frequency and duration.Attach copies of current medical reports necessarytosupportrequest.Includeanyreferrals,therapy,medications,diagnostictesting,expectedoutcomesofmedical interventions,resultsoftreatmentandofficenotesthatcontainsubjectiveandobjectivefindingsandpre-existingconditions. *FailuretoaddCPTcodesmaydelayprocessing. 5 Providethetwo-digitfacilitysiteofservicecodeasusedbytheCentersforMedicareandMedicaidServices(CMS),ifapplicable. Section III ­ Additional conditions 6 Completeifyouarerecommendingadditionalconditionstotheclaim.Provideanarrativediagnosis.Supportingmedical documentationisrequiredforallconditionslisted.Includeanyreferrals,therapy,medications,diagnostictesting,expected outcomesofmedicalinterventions,resultsoftreatmentandofficenotesthatcontainsubjectiveandobjectivefindingsand pre-existingconditions.You may not use the C-9 to request additional conditions for claims of self-insuring employers. ·BWCwillnotifyallpartiesandtheMCOofthedecision. 7 Thisreferstotheestablishmentofarelationshipbetweentheinjuryoroccupationaldiseaseandtheindustrialaccidentor exposure.Anexplanationisrequiredwhenansweringyesorno. Section IV ­ Physician/provider information 8 Identify the provider who will render the requested services and the address where he or she will provide the services (required).Travelreimbursementmaynotbeauthorizedwhentheserviceprovidedisavailablewithin45milesroundtrip fromtheinjuredworker'sresidence. 9 Print,typeorstamprequestingphysician/providernameandaddress. 10 Physician/providersignature,individualBWCprovidernumberanddateofthisreportaremandatory. Section V ­ MCO/Self-insuring employer decision · If completed by self-insuring employer, refer to self-insuring employer section. · IftheC-9isnotfaxedormailedbacktothesubmittingphysician/providerwithinthreebusinessdaysofreceiptorwithin fivebusinessdaysofreceiptoftheC-9-A,arequestforadditionalinformation,BWCshalldeemtheauthorizationforservice grantedsubjecttoourpolicy,excludingretroactiverequests. · Claiminactive(furtherinvestigationrequired)--TheMCOcannotmakeadecisiononthisC-9request.Furtherinvestigation isrequired,andBWCwillissueadecisioninwritingwithin28days.TheMCOwillnotifytheprovideroftheBWCdecision. · An MCO can only use the disclaimer box on the C-9 or any other physician generated service request when BWC/IC is consideringtheclaimortheconditionforwhichtheserviceisrequestedasofthedateoftheMCO'ssignature.Disclaimers shallnotbeusedwhenauthorizingtreatmentforallowedclaimsandconditionsthatarewithinthestatuteoflimitation. BWC-1113(rev.12/28/2011) C-9(CombinesC-1-A&C-161) American LegalNet, Inc. www.FormsWorkFlow.com Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease Fax note To From Toll-freefaxnumber Phonenumber Phonenumber Faxnumber · Instructions for completing the C-9 on reverse side. IW 1 Injuredworkername 2 Treatingdiagnosisforthisrequesttoincludebodypart/levels. Claimnumber Dateofinjury // 3 DateservicebeginsDateserviceendsDateoflastexamortreatment 4 RequestedserviceswithCPT/HCPCScodes(required) 1. 2. 3. 4. // II. Requested services Frequency // // Duration 5 Providethetwo-digitfacilitysiteofservicecodeasusedbytheCentersforMedicareandMedicaidServices(CMS),ifapplicable. III. Additional conditions Ifyouarerecommendingadditionalconditionstotheclaim,supportingdocumentationisrequired. You may not use the C9 to request 6 Providediagnosis(narrativedescriptiononly),andlocationandsiteforconditionsyouarerequesting. additional conditions for claims of self-insuring employers. 7 Inyouropinion,basedonthehistoryfromtheinjuredworker,yourclinicalevaluationandexpertise,isthediagnosisorconditioncausally related,eitherdirectlyorproximately,totheallegedindustrialaccidentorexposure? Yes,pleaseattachexplanation. No,pleaseattachexplanation. 8 Identifytheproviderwhowillrendertherequestedservicesandtheaddresswhereheorshewillprovidetheservices(required).Travel IV. Physician/provider information reimbursementmaynotbeauthorizedwhentheserviceprovidedisavailablewithin45milesroundtripfromtheinjuredworker'sresidence. 9 Requestingphysician/providernameandaddress(pleaseprint,type,or stamp) 10 Physician/provider/authorizedsignature(required) IndividualBWCprovidernumber(required) POR NotPOR--buttreating physician/provider Date(M/D/Y)(required) Icertifytheaboveinformationiscorrecttothebestofmyknowledge.Iamawarethatanypersonwhoknowinglymakesafalsestatement,misrepresentation, concealmentoffactoranyotheractoffraudtoobtainpaymentasprovidedbyBWCorwhoknowinglyacceptspaymenttowhichthatpersonisnotentitled, issubjecttofelonycriminalprosecutionandmay,underappropriatecriminalprovisions,bepunishedbyafine,imprisonment,orboth. Managed care organization (MCO) --Ifthispageisnotfaxedormailedbacktothesubmittingphysician/providerwithinthreebusinessdaysofreceiptor withinfivebusinessdaysofreceiptofinformationrequestedontheC-9-A,BWCshalldeemtheauthorizationfortreatmentgrantedsubjecttoourpolicy, excludingretroactiverequests. V. MCO/Self-insuring employer decision Approved with disclaimer --ThismedicalpaymentauthorizationisbaseduponaclaimoradditionalconditionthatBWC/ICisconsidering asofthed
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