1. What is a managed care organization (MCO)?
  2. What is HPP?
  3. What are the benefits of HPP?
  4. Do I have to have an MCO?
  5. What do MCO services cost?
  6. How do I select 1-888-OHIOCOMP as my MCO?
  7. What should I do if one of my employees is injured on the job?
  8. What should I do if a workers’ injury prevents him or her from returning quickly to the job?
  9. Is it costly to set up a transitional work program?

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  1. How do I file a claim?
  2. How long does it take to process my claim?
  3. Who is responsible to obtain the needed information to allow my claim?
  4. Can I go to any doctor I want?
  5. How will I know if a doctor is a BWC-certified provider?
  6. What if I can’t find a BWC-certified doctor in my area?
  7. Who is the doctor of record for my claim?
  8. How do my medical bills get paid?
  9. What should I do if I receive a bill?
  10. Has the request for treatment been received from my doctor?
  11. Has the request for treatment been approved?
  12. What’s the difference between BWC and an MCO?

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  1. How do providers request authorization for non-emergency medical services?
  2. How do providers request authorization if they have already treated the injured worker?
  3. Do TENS units that are under $250 require authorization?
  4. Do basic X-rays need prior authorization?
  5. Do consultations need prior authorization?
  6. Do consultations performed in the hospital require prior authorization?
  7. Why do providers need to submit a C-9 when prior authorization is not required?
  8. The presumptive authorization policy applies to soft tissue and musculoskeletal injuries. What does this mean?
  9. For presumptive authorization, does treatment have to be rendered within the first 60 days after the date of injury or within 60 days from the first treatment?
  10. Are there time frames for addressing the C-9?
  11. What happens if the C-9 is not responded to in three days or five days for additional information?
  12. How are medical bills paid?
  13. The bill was denied as it was past the two-year filing limit but I filed it timely, what should I do?
  14. The bill was denied as the diagnosis is not allowed in the claim, what should I do?
  15. The bills are being denied because I am not a BWC-certified provider, what should I do?
  16. What do I do if I do not believe that I was reimbursed at the full amount allowed by BWC?
  17. How long does it take BWC to determine the status of a claim?
  18. How long does it take to receive a claim number?
  19. Who is responsible for filing the FROI?
  20. Are there additional provider timeframes after submitting the FROI?
  21. What medical documents are providers required to submit?
  22. When does a provider need to update the injured worker’s MCO?
  23. Is a signed release of medical information required to provide information to 1-888-OHIOCOMP?
  24. What information should be included with the medical documentation being faxed to 1-888-OHIOCOMP?
  25. What is the difference between enrollment and certification?
  26. What is a BWC-certified provider?
  27. Do I need to be certified to see injured workers?
  28. How long does the enrollment/certification process take?
  29. What is ADR?
  30. What types of issues are disputed in ADR?
  31. Who initiates an ADR medical dispute?
  32. Can ADR be initiated on a claim that is in pending status?
  33. How much time do we have to file an appeal to 1-888-OHIOCOMP after we receive a treatment denial?
  34. Can the appeal to 1-888-OHIOCOMP be initiated by telephone?
  35. Is there a form available to file an ADR appeal?
  36. How many levels of appeal are there at the MCO level?
  37. What is the MCO’s deadline to make a decision on the appeal?
  38. If I disagree with 1-888-OHIOCOMP’s decision, what is my next step?
  39. Does the MCO handle the second level of ADR?
  40. What is BWC’s deadline to make a decision on the second level of ADR?
  41. Who receives copies of the BWC Order issued through ADR?
  42. If a provider disagrees with BWC’s ADR decision, can he/she file an appeal with the Industrial Commission (IC)?

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  1. What is a managed care organization (MCO)?
    An MCO is a private company that an employer contracts to medically manage the workers’ compensation claims for injured employees. MCOs are an integral part of the Ohio Bureau of Workers’ Compensation’s Health Partnership Program (HPP).
  2. What is HPP?
    The Ohio Bureau of Workers’ Compensation (BWC) and certified private-sector MCOs work together to provide comprehensive claims-management and medical-management services to the employers and employees of Ohio.
  3. What are the Benefits of HPP?
    Some of the benefits of the Health Partnership Program are:
    • Competition between MCOs is geared to drive up the quality of health care while containing cost;
    • HPP focuses on providing quality care with the purpose of safely returning injured workers to the job;
    • HPP will eventually reduce overall health-care costs to treat injured workers;
    • Lower claims costs translate to lower premium costs for employers.
  4. Do I have to have an MCO?
    Yes. Employers are required to select an MCO. Employers who do not select may have an MCO randomly assigned to them.
  5. What do MCO services cost?
    HPP is funded by BWC. Therefore, there is no direct cost to an employer for these valuable, cost-saving services.
  6. How do I select 1-888-OHIOCOMP as my MCO?
    If you’re an employer new to Ohio, you have 30 days to select an MCO to provide medical-management service for your workers’ compensation claims. To select 1-888-OHIOCOMP as your MCO, simply click here. It’s that simple. We’ll notify BWC of your selection.

    If you already have an MCO, you may select a new MCO only during open enrollment, which occurs every two years. The next open enrollment will be held in May 2008.
  7. What should I do if one of my employees is injured on the job?
    Advise the employee to seek medical attention. Call 1-888-OHIOCOMP to report the injury.
  8. What should I do if a workers’ injury prevents him or her from returning quickly to the job?
    1-888-OHIOCOMP will work with you to set up a transitional work program for the injured worker. Implementing a transitional work program, even before the injured worker is 100 percent recovered, is an important cost-containment tool. Transitional work programs use real job duties, within the injured worker’s medical restrictions, during the recovery process and leading up to return to full duty.
  9. Is it costly to set up a transitional work program?
    No, in fact it’s your best bet for keeping disability costs under control and saving money. BWC offers transitional work grants to help employer defray the cost of setting up a transitional work program – up 80 percent. And 1-888-OHIOCOMP feels so strongly about the benefits of a transitional work program that we’ll pay the remaining 20 percent when you partner with our accredited transitional work developers.

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  1. How do I file a claim?
    In case of medical emergency, seek immediate treatment at the nearest medical facility. Contact or have your supervisor contact your 1-888-OHIOCOMP nurse as soon as possible to file a First Report of Injury form. If you need additional medical care, the 1-888-OHIOCOMP nurse will direct you to the appropriate medical provider.

    At the time of your injury, notify your supervisor immediately. Your employer will provide you with your 1-888-OHIOCOMP identification card. Please present your 1-888-OHIOCOMP identification card to the medical provider when you begin treatment.
  2. How long does it take to process my claim?
    Immediately after receiving the First Report of Injury, BWC begins the process of gathering information and investigating the claim. A decision will be made to allow or deny the claim within 28 days.
  3. Who is responsible to obtain the needed information to allow my claim?
    1-888-OHIOCOMP serves as the link between BWC and the health-care provider in obtaining and sending in medical information.
  4. Can I go to any doctor I want?
    The rules governing the HPP program provide that an injured worker has the right to be treated by the doctor of their choice as long as the doctor is a BWC-certified provider.
  5. How will I know if a doctor is a BWC-certified provider?
    You can contact BWC at 1-800-OHIOBWC to see if a doctor is certified or you can visit www.ohiobwc.com to access BWC’s Certified Provider Look-up.
  6. What if I can't find a BWC-certified doctor in my area?
    Contact 1-888-OHIOCOMP for help finding a physician.
  7. Who is the doctor of record for my claim?
    Contact 1-888-OHIOCOMP to find out the doctor of record.
  8. How do my medical bills get paid?
    Once the claim is allowed, the providers (other than pharmacies) who have treated you for the work-related injury should submit their bills to 1-888-OHIOCOMP. 1-888-OHIOCOMP reviews and prices the bills and forwards them electronically to BWC. BWC pays the MCO who in turn disburses payment to the providers.
  9. What should I do if I receive a bill?
    Contact the provider who sent you the bill and advise that the treatment was for a work-related injury. Give the provider 1-888-OHIOCOMP’s billing address and request that a bill be sent to us. Our billing address is 2900 Carnegie Ave., Cleveland, OH 44115
  10. Has the request for treatment been received from my doctor?
    Call 1-888-OHIOCOMP to obtain this information. Requests for treatment are forwarded to the MCO for consideration.
  11. Has the request for treatment been approved?
    Call 1-888-OHIOCOMP to obtain this information. The MCO reviews all medical treatment requests and issues approval or denial.
  12. What’s the difference between BWC and an MCO?
    BWC is the State of Ohio government agency responsible for Ohio’s workers’ compensation system. Your MCO, 1-888-OHIOCOMP, is a private company selected by your employer to medically manage the employer’s workers’ compensation claims.

    BWC makes decisions regarding claim allowances and issues benefit payments. The MCOs coordinate medical care and make treatment decisions.

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  1. How do providers request authorization for non-emergency medical services?
    Complete and submit the C-9 form to 1-888-OHIOCOMP. We will respond within three business days.
  2. How do providers request authorization if they have already treated the injured worker?
    Complete and submit the C-9 form to 1-888-OHIOCOMP. We will respond to retroactive requests for authorization within 30 days of receipt.
  3. Do TENS units that are under $250 require authorization?
    TENS units require authorization because the purchase price of a TENS unit is greater than $250.
  4. Do basic X-rays need prior authorization?
    Basic X-rays do not need prior authorization.
  5. Do consultations need prior authorization?
    Only psychological and chronic pain program consultations require prior authorization.
  6. Do consultations performed in the hospital require prior authorization?
    Only psychological and chronic pain management consultations require prior authorization. Other types of consultations do not.
  7. Why do providers need to submit a C-9 when prior authorization is not required?
    Providers are required to communicate their treatment plans to 1-888-OHIOCOMP. You can facilitate open communication by submitting a C-9 to the MCO along with medical documentation.
  8. The presumptive authorization policy applies to soft tissue and musculoskeletal injuries. What does this mean?
    Soft tissue and musculoskeletal injuries are sprains, strains, superficial injuries and contusions, as defined in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) book.
  9. For presumptive authorization, does treatment have to be rendered within the first 60 days after the date of injury or within 60 days from the first treatment?
    The presumptive approval guidelines apply to services provided within 60 days of the date of injury.
  10. Are there time frames for addressing the C-9?
    1-888-OHIOCOMP must respond to the physician within three business days. If we are unable to make a decision within three business days due to the need for additional information, we will send a Request for Additional Medical Documentation for C-9 (C-9-A). The MCO then has five business days from the date additional information is received to make a subsequent decision.
  11. What happens if the C-9 is not responded to in three days or five days for additional information?
    In instances when the C-9 is not responded to in three days or five days and the provider initiates treatment, 1-888-OHIOCOMP will provide concurrent and retro review. If it is found that treatment is not necessary, we will notify all parties to advise that treatment will be discontinued. Charges for services rendered will be paid.
  12. How are medical bills paid?
    Medical bills must be submitted to 1-888-OHIOCOMP. We will review, price and submit the bills to BWC. BWC further reviews the bills and remits payment 1-888-OHIOCOMP. We then reimburse the provider.
  13. The bill was denied as it was past the two-year filing limit but I filed it timely, what should I do?
    You must submit proof of timely submission, such as an explanation of benefits (EOB) or MCO date-stamped copy of the bill, to 1-888-OHIOCOMP. If the bill is otherwise payable, we will submit a request for adjustment to BWC.
  14. The bill was denied as the diagnosis is not allowed in the claim, what should I do?
    Call 1-888-OHIOCOMP to discuss whether the claim needs to be amended to add the condition that you are treating to the claim. Depending on the circumstances, the claim may amended or we may authorize payment without amending the claim, or it may be determined that the condition being treated is not related to the workers’ compensation claim.
  15. The bills are being denied because I am not a BWC-certified provider, what should I do?
    To be reimbursed for services rendered to an Ohio injured worker, all providers must be enrolled with BWC. In addition, providers located in Ohio also are required to be BWC-certified to participate in the Health Partnership Program.

    In-state providers: If you are an Ohio provider who is not enrolled with BWC or who is enrolled but not certified, contact BWC provider enrollment at 1-800-OHIOBWC, and follow the options to request an application. If you are already enrolled with BWC but do not wish to become certified, 1-888-OHIOCOMP to find out if you can be reimbursed without certification.

    Out-of-state providers: If you are not enrolled with BWC (i.e., you do not have a BWC provider number), Contact 1-888-OHIOCOMP for assistance in getting enrolled as a non-certified provider. If you are enrolled with BWC, you are not required to become certified.
  16. What do I do if I do not believe that I was reimbursed at the full amount allowed by BWC?
    Check the fee schedule look-up at www.ohiobwc.com to determine the appropriate reimbursement amount. When utilizing the look up, keep in mind that rates for services performed in a doctor’s office are shown under non-facility. The rates for services performed in any other setting are shown under facility.
    Note: This look-up is not valid for services billed on a UB-92. For dates of service prior to Jan. 1, 2002, you must use a hard-copy fee schedule for the appropriate year. If you no longer have the previous years’ fee schedule, call 1-800-OHIOBWC, and follow the options.
  17. How long does it take BWC to determine the status of a claim?
    After receiving the First Report of Injury (FROI), BWC notifies the injured worker, employer and their authorized representatives that a claim has been filed. Within 28 days of this notice, BWC is legally required to determine the claim.
  18. How long does it take to receive a claim number?
    After receiving a first report of injury (FROI), 1-888-OHIOCOMP electronically transmits the information about the injury to BWC’s system. Upon receiving that initial notification, BWC automatically assigns a claim number to the reported injury. The injured worker and employer will receive written notice of the claim number. If the provider number was submitted to 1-888-OHIOCOMP, the treating physician or provider who reported the injury also will receive written notice from BWC.
  19. Who is responsible for filing the FROI?
    Providers are required to report new injured worker claims to 1-888-OHIOCOMP within 24 hours or one business day of the initial treatment or initial visit.
  20. Are there additional provider timeframes after submitting the FROI?
    Yes. There are other timeframes to be met. Providers play a critical role in providing 1-888-OHIOCOMP with pertinent medical documentation and diagnosis information during the initial phase of a new injury.
  21. What medical documents are providers required to submit?
    Ohio workers’ compensation rules and policies require providers who are treating injured workers to submit initial and subsequent reports to MCOs on behalf of injured workers. Providers must supply medical documentation to 1-888-OHIOCOMP when requesting treatment authorizations or when requested by the MCO or BWC.
  22. When does a provider need to update the injured worker’s MCO?
    In some instances, it is necessary for the provider to update 1-888-OHIOCOMP either when making a treatment request or at various points during the treatment of the injured worker. Examples of the circumstances or documents that require updates include:

    Injured worker non-compliance or missed appointments;
    Negative/lack of response to treatment;
    Changes in outcomes or goals of treatment;
    Diagnostic testing results;
    Hospital discharge summaries;
    Emergency room reports, operative reports or other situations indicating a need to alter or concurrently monitor the injured worker's care.

    In these situations, the provider must submit the update to 1-888-OHIOCOMP within five days of delivering the service or as requested by 1-888-OHIOCOMP.
  23. Is a signed release of medical information required to provide information to 1-888-OHIOCOMP?
    Under Ohio law, by filing a workers’ compensation claim, the injured worker authorizes the release of all information related to the claim to BWC, the MCO or any of the claim’s parties (i.e., the injured worker, employer and their authorized representatives). Therefore, submitting medical documents does not require a separate release of information.
  24. What information should be included with the medical documentation being faxed to 1-888-OHIOCOMP?
    To avoid confusion and to help match the medical documents with the correct claim, please separate all information for each injured worker and submit it along with an individual coversheet. On the coversheet, include the injured worker’s name, Social Security number (if possible) and claim number. Also, please include this information on each page of the fax. Following these steps will provide 1-888-OHIOCOMP with important information and minimizes the possibility that claim authorizations will be delayed.
  25. What is the difference between enrollment and certification?
    Enrollment is the process of entering provider data into BWC’s database. Enrollment information includes the provider’s business names, addresses, specialties, business relationships, etc. Certification is awarded when providers meet or exceed BWC’s minimum credentialing criteria.
  26. What is a BWC-certified provider?
    A BWC-certified provider is a credentialed provider who is approved by BWC for participation in the Health Partnership Program (HPP) and who has signed a provider agreement with BWC.
  27. Do I need to be certified to see injured workers?
    For claims with dates of injury on or after Oct. 21, 1993, injured workers must see a BWC-certified provider. For claims with dates of injury prior to Oct. 20, 1993, injured workers may continue to be treated by their physicians of record even if they are not BWC-certified. However, in the case of a claim prior to Oct. 20, 1993, if injured workers change providers, they are required to see one that is BWC-certified.
  28. How long does the enrollment/certification process take?
    Generally, it takes four to six weeks after BWC receives the required information.
  29. What is ADR?
    ADR stands for Alternative Dispute Resolution, which is a means of resolving disputes over medical issues that arise between the managed care organization (MCO), BWC, employer, injured worker and/or provider without litigation.
  30. What types of issues are disputed in ADR?
    Only medical treatment/service issues are disputed in ADR. It does not address claim reactivation, fee schedule or bill payment issues.
  31. Who initiates an ADR medical dispute?
    Providers, employers and their representatives, and injured workers and their representatives may file ADR disputes.
  32. Can ADR be initiated on a claim that is in pending status?
    ADR disputes may only be filed on allowed claims, not on claims that are in either a pending or disallowed status.
  33. How much time do we have to file an appeal to 1-888-OHIOCOMP after we receive a treatment denial?
    Appeals must be filed within 14 days of receipt of the MCO’s initial written determination.
  34. Can the appeal to 1-888-OHIOCOMP be initiated by telephone?
    No, the appeal must be in writing and must be signed by the appellant. It may be faxed or mailed to the MCO.
  35. Is there a form available to file an ADR appeal?
    The ADR appeal to the Request to Appeal MCO Medical Treatment/Service Decision (C-11) is available from BWC forms and publications. Call 1-800-OHIOBWC and follow the options.
  36. How many levels of appeal are there at the MCO level?
    There is only one level of appeal at the MCO level.
  37. What is the MCO’s deadline to make a decision on the appeal?
    1-888-OHIOCOMP has 21 days from written receipt of a dispute to make a decision regarding the appeal.
  38. If I disagree with 1-888-OHIOCOMP’s decision, what is my next step?
    If the injured worker, employer, representative or provider still disagrees with the MCO’s decision, he or she may request a second level of dispute resolution within seven days of receiving a written notice of the MCO’s decision.
  39. Does the MCO handle the second level of ADR?
    The second level of dispute resolution is sent to BWC from the MCO for an independent review within seven days of receiving a written appeal from the provider, employer or representative, injured worker or representative.
  40. What is BWC’s deadline to make a decision on the second level of ADR?
    BWC has 14 days from the time the dispute is received to issue a BWC Order.
  41. Who receives copies of the BWC Order issued through ADR?
    The injured worker, employer, his or her representative and 1-888-OHIOCOMP receive a copy of the BWC Order. The BWC ADR department also sends a copy to the provider of record.
  42. If a provider disagrees with BWC’s ADR decision, can he/she file an appeal with the Industrial Commission (IC)?
    By law, providers are not parties to the claim; therefore they cannot appeal any BWC Order, including those regarding medical issues. However, an appeal at the IC level may be filed by the injured worker, employer or their representatives.

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