Blank Ohio Bwc Writable C 9 Template

What is the Ohio BWC writable C-9 form used for?

The Ohio Bureau of Workers' Compensation (BWC) writable C-9 form is designed to be used by physicians or medical providers to request reimbursement for medical services provided to an injured worker, or to recommend additional conditions for an injury or occupational disease claim. It is a crucial tool in the process of treating workplace injuries and ensuring that all necessary treatments are authorized and reimbursed by the BWC or the employer, depending on the insurance status of the employer.

How do I fill out the C-9 form?

To correctly fill out the C-9 form, you should print or type the information to avoid misunderstandings. You must complete all applicable sections to prevent any delays in the processing of your request. This includes the injured worker’s information, diagnostic details, requested services—including CPT codes, duration, and frequency of these services—and any additional conditions you are recommending for the claim. Attaching supporting medical documentation is also necessary to support your request or recommendations.

Where do I send the completed C-9 form?

The destination of the C-9 form depends on the employer’s insurance status. If the injured worker is employed by a self-insuring employer, you should send the completed form directly to that employer. Meanwhile, if the worker is employed by a state-fund employer, you need to send the form to the appropriate Managed Care Organization (MCO). You can determine the correct MCO by asking the worker or employer, visiting the BWC’s website, or by calling the Ohio BWC.

What happens if I don’t include CPT codes in the request?

Failure to include CPT codes for the requested services may result in delays in the processing of your request. CPT codes provide a standardized way of communicating specific medical procedures and services to the BWC and MCOs, thus ensuring timely and accurate processing and reimbursement.

Can I use the C-9 form to request additional conditions for a claim?

Yes, the C-9 form can be used to recommend additional conditions for an industrial injury or occupational disease. However, it is important to provide a narrative diagnosis for each recommended condition and attach supporting medical documentation. Note that this option is not available for claims under self-insuring employers.

What if the service I provide is far from the injured worker's residence?

Travel reimbursement for the injured worker might not be authorized if the service provided is readily available within 45 miles round trip from the injured worker’s residence. It's important to identify the provider’s location accurately when filling out the form to help in determining this aspect.

How quickly will an MCO or self-insuring employer respond to a submitted C-9 form?

The Ohio BWC requires MCOs to fax or mail back the C-9 form to the submitting physician/provider within three business days of receipt, or within five business days if additional information is requested on a C-9-A form. For self-insuring employers, the response time is within ten days of receipt. If these timeframes are not met, the BWC may deem the authorization for treatment as granted, subject to their policy and excluding retroactive requests.

What should I do if a C-9 request is denied or authorization is pending?

If the C-9 request is denied or if authorization is still pending, you may file disputes to the MCO’s decision in writing, with supporting documentation, within 10 business days to allow for a treatment decision reconsideration. For cases where further investigation is required by the MCO, BWC will issue a decision in writing within 28 days and notify all parties involved.

Filling out the Ohio BWC Writable C-9 form efficiently and correctly is essential for ensuring that injured workers receive the medical services and reimbursements they are entitled to without unnecessary delays. However, common mistakes can hinder this process. Below are four typical errors to avoid:

1. Not providing complete provider information: Section IV requires the identification of the provider who will render the requested services, including the address where the services will be provided. Incomplete or inaccurate information may lead to delays in authorizing necessary medical services or in reimbursements for travel expenses, particularly if the required services are available within 45 miles round trip from the injured worker's residence.

2. Failure to attach necessary CPT codes for requested services: Section II mandates listing the requested services along with their corresponding CPT/HCPCS codes, including the frequency and duration of each. Neglecting to include these codes can stall the processing of the request since these codes are crucial for the managed care organization (MCO) or the self-insuring employer to understand exactly what services are being requested and to ensure accurate billing.

3. Inadequate documentation for recommending additional conditions: If there are additional conditions being recommended for the claim, Section III makes it clear that a narrative diagnosis is required along with supporting documentation for all conditions listed. Failure to provide adequate medical documentation can lead to denial of the request for additional conditions, as the BWC relies heavily on this documentation to make informed decisions on the claim.

4. Overlooking the importance of the signature and date: It’s a simple but critical element of the form. The physician/provider's signature, BWC provider number, and the date of the report (Section IV, Item 10) are mandatory for the submission to be considered complete. Unsigned forms or forms without a provider number and date are often not processed, delaying the authorization of services or payment.

For all parties involved in the handling and processing of the Ohio BWC Writable C-9 form, attention to detail is key. Avoiding these common mistakes can streamline the process, ensuring timely support and care for injured workers.

When dealing with workplace injuries or occupational diseases in Ohio, the Bureau of Workers' Compensation (BWC) system requires various forms and documents to process claims efficiently. The Ohio BWC Writable C-9 form is a critical component in this process, facilitating requests for medical service reimbursement or recommending additional conditions related to industrial injury or occupational disease. Alongside this essential form, there are several other documents often used to support, clarify, and expedite claims within the BWC system.

• C-1 Form (First Report of an Injury, Occupational Disease or Death): This is the initial report filed by an employer when an employee suffers a work-related injury or occupational disease. It captures essential details about the employee, the employer, and the incident.
• Medco-14 Form (Work Ability Assessment): Used by healthcare providers to report an injured worker's physical capabilities and limitations. It helps in determining the types of work the injured worker can perform during their recovery.
• FROI-1 (First Report of Injury): Filed electronically by employers, injured workers, or their representatives to initiate a claim with the Ohio BWC for a work-related injury or disease.
• C-84 Form (Request for Temporary Total Compensation): Used by the injured worker to apply for temporary total disability benefits when they are unable to return to work due to their work-related injury or occupational disease.
• C-86 Form (Motion for Additional Allowance): Filed to request additional allowances for conditions not originally recognized or allowed in the claim. It is used when new conditions arise or are discovered.
• BWC Medical Statement: This form is used by healthcare providers to document an injured worker's medical condition and the treatments they are receiving for their work-related injury or disease.
• MCO-22 Form (Pharmacy Information): Submitted by pharmacies or prescribing physicians to provide detailed information about medications prescribed for the work-related condition, facilitating the approval process for medication reimbursement.

Together, these forms and documents create a comprehensive framework for managing and processing workers' compensation claims. They ensure that workers receive the necessary medical care and benefits following a workplace injury or illness, while also providing a structured process for employers and healthcare providers to follow. It's important for all parties involved to understand the purpose and requirements of each form to ensure timely and effective handling of claims.

The Ohio BWC Writable C-9 form is closely related to the "Medical Treatment Authorization Request" form often used in other workers' compensation systems across the United States. This form serves a similar purpose in authorizing necessary medical treatment for injured workers and ensuring that the treatment provided is directly related to the workplace injury or disease. Both forms require detailed information about the requested medical services, including diagnosis, treatment codes, and expected outcomes. They play a crucial role in the approval process for medical care and rehabilitation services, ensuring workers receive timely and appropriate care.

Another document akin to the C-9 form is the "Physician's Report on Workers' Compensation Injury (DWC-25)" used in states like Florida. This form, like the C-9, collects comprehensive information regarding the injured worker's condition, treatment plan, and the causality between the condition and the work-related accident. It is paramount for establishing the legitimacy of the claim and the necessity of the medical services requested, aiding in the swift processing and reimbursement of medical expenses.

The "Request for Consultation and/or Treatment" form is another document with similarities to the Ohio BWC's C-9 form. It is designed to facilitate the referral process to specialists when an injured worker needs further evaluation or treatment that their primary care physician cannot provide. It encompasses details about the worker's current diagnosis, the reason for the referral, and the type of specialist care needed, paralleling the C-9 form's objective to establish and authorize necessary medical care within the workers' compensation framework.

"Prior Authorization Request Form" utilized by various health insurance programs, including Medicare and Medicaid, parallels the C-9 form. This document is essential for obtaining pre-approval for specific treatments, procedures, or medications not immediately authorized under a patient's health care plan. Similarly, the C-9 form seeks authorization from the worker's compensation insurance to ensure the proposed treatment is covered and deemed necessary for the worker's recovery or rehabilitation.

The "Permanent Partial Disability (PPD) Award Application" form, although different in its end goal, shares the procedural essence with the C-9 form. The PPD application is used when an injured worker has reached maximum medical improvement but still suffers from lasting effects of their injury. Both forms require detailed medical data and justifications to assess the worker's condition, but while the C-9 form focuses on immediate treatment needs, the PPD application focuses on long-term impairment evaluation.

The "Change of Physician Request Form" in workers' compensation cases is another document sharing common ground with the C-9 form. This form is necessary when an injured worker needs to change their treating physician for any reason during their treatment. Like the C-9, it involves administrative processes to ensure that the new treatment plan and provider are approved and that the treatment remains consistent with the worker's compensation claim's requirements and objectives.

The "Work Capacity Evaluation Form" is used to assess an injured worker's ability to return to work, either in their previous capacity or in a modified role. This form collects information on the worker's physical or mental restrictions and aligns with the purpose of the C-9 form by determining the appropriate level of medical intervention required to support the worker's rehabilitation and return to employment.

Finally, the "Prescription Drug Request Form" within workers' compensation systems mirrors the C-9 form in its goal to ensure injured workers receive necessary medications without undue delay. This form specifically addresses the need for medication, including dosage and duration, akin to how the C-9 form outlines the need for medical services, therapies, or procedures. Both forms are key to managing the treatment plan and recovery process of injured workers.

When it comes to completing the Ohio BWC Writable C-9 form, it's crucial to do it correctly to ensure your request for medical service reimbursement or recommendation for additional conditions related to industrial injury or occupational disease is processed smoothly. Here are five things you should do, and five things you shouldn't:

• Print or type cleanly to ensure all information is readable. This helps avoid misunderstandings or delays.
• Make sure to complete all applicable sections of the form. Partially filled forms may result in processing delays.
• Include accurate CPT codes for requested services. This detail is critical for the processing of your request.
• Attach supporting medical documentation
  as required. This includes medical reports, referrals, therapy notes, medication details, and expected outcomes.
• Double-check that you have the correct managed care organization (MCO) information if the injured worker is employed by a state-fund employer, and send the form to the appropriate MCO for processing.