For the Provider


Presumptive Authorization

Effective November 1, 2002, providers have presumptive approval to provide services during the first 60 days following an injury. The MCO shall adhere to the following standardized prior authorization and presumptive approval guidelines.

For a period not to exceed 60 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:

The following criteria must be met prior to initiating any or all of the aforementioned services:

Please refer to the BWC's Provider Billing & Reimbursement Manual (BRM) for further clarification.

Grievance and Dispute Process

Grievance Process
Premier Comp has a process to resolve administrative issues or complaints affecting the management of the claim or an employee. All complaints regarding a Case Management issue or Administrative process should be directed to Premier Comp. Managers will attempt to bring resolution within 48 hours for all complaints or grievances. If grievances are not resolved to the satisfaction of the customer, they may formally appeal the decision, in writing, to Premier Comp within 14 days of the decision.

Premier Comp is required by the BWC to have an Alternative Dispute Resolution (ADR) process. ADR affords due process regarding conflicts in medical treatment issues. Disputed issues may include:

Injured workers, employers and their representatives, or providers may initiate ADR by contacting Premier Comp in writing. The disputing party should identify the issue with Premier Comp's decision, within 14 calendar days of receipt of written notice of an initial treatment reimbursement determination.

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MCO Standardized Prior Authorization Table

In an effort to ease the burden of providers having to accommodate different prior authorization requirements by each MCO, the Ohio BWC and the MCO's collaborated and developed a Standardized Prior Authorization Table. Services listed in the standardized prior authorization table and not indicated as exceptions still require prior authorization. Providers must submit a C-9 to indicate services to be provided through formal authorization. The physician of record (POR) or treating physician must submit requests for medical services that require prior authorization. Provider types whose signatures must appear on the C-9 treatment request include all POR provider types (MD, DO, DC, DDS, DMT, DPM, psychologist, optometrist, advanced practice nurse, physician assistant, independent social worker, and professional advanced clinical counselor). Treatment requests from any other provider type should not be processed. Please refer to the BWC's Provider Billing & Reimbursement Manual (BRM) for further clarification.

Service Requirement
Physical medicine services, including chiropractic/osteopathic manipulative treatment and acupuncture Prior Authorization (PA)
Consultations - Psychological/chronic pain program only PA
Dental PA
Diagnostic Testing PA
(except basic X-rays which do not require PA)
DME PA if purchase
price is > $250
PA for all DME rental
Home/auto/van modifications PA required from BWC
Home health agency services PA
Hospital inpatient treatment, including surgery and outpatient/ASC surgery PA for surgery from date of injury, if not emergency
In-home physician services PA after first visit
Injections PA
Non-emergency ambulance services PA
Orthotic and prosthetic devices and/or repair PA > $250
Skilled Nursing Facility (SNF)/Extended Care Facility (ECF) PA
TENS and NMEs units PA for both rentals and purchases
TENS and NMEs monthly supplies PA for maximum of
six months per authorization
Vision and hearing services PA > $100
Vocational rehabilitation - All vocational rehabilitation services, including remain at work, in our out of plan

PA

Note: PA not required for transitional work on-site therapy's provided by an occupational therapist that fall under the presumptive authorization guidelines.
Note: Occupational rehabilitation (work hardening) requires CARF accreditation.
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Forms

Online access to BWC's C-9 form in PDF format. Other forms available here.

Premier Comp Billing

All Bills may be sent to:
Premier Comp
P.O. Box 1124
Massillon, OH 44648

Billing Questions may be addressed at: 1.800.776.4771

Electronic billing is available. Providers who want to bill electronically should contact Premier Comp to initiate training.

Online Provider Billing and Reimbursement Manual

By logging on to www.ohiobwc.com you can view, print or download BWC's Provider Billing & Reimbursement Manual. A Dolphin account is not required to access the online BRM. You can access the online BRM from the green Medical provider page under the Service section. The BRM documents provider reimbursement policies and procedures. BWC's medical policy department publishes quarterly updates, which are titled BWC Provider Update. These updates also can be accessed on www.ohiobwc.com.

Additional Dolphin online services for providers include:

*Denotes that a provider account is required to access the online service.

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