Table of Contents
The Ohio BWC Writable C-9 form plays a crucial role in the process of obtaining medical service reimbursement or recommending additional conditions related to industrial injuries or occupational diseases. This form is essential for both injured workers and healthcare providers, as it outlines the necessary steps for submitting requests for medical services. When completing the C-9, it is important to ensure that all sections are filled out accurately to avoid delays in processing. The form requires details such as the injured worker's name, claim number, and the specifics of the requested services, including treatment dates and relevant medical codes. Additionally, if there are any new conditions related to the claim, these must be documented with supporting medical evidence. For those employed by self-insuring employers, the completed form should be sent directly to the employer, while workers under state-fund employers must submit it to their managed care organization (MCO). Understanding the requirements and implications of the C-9 can significantly streamline the reimbursement process and facilitate timely medical care for injured workers.
Sample - Ohio Bwc Writable C 9 Form
Completing the Request for Medical Service
Reimbursement or Recommendation for Additional
Conditions for Industrial Injury or Occupational
Instructions
•Please print or type this report.
•If injured worker is employed by a
•If injured worker is employed by a
•To determine the appropriate MCO, ask the injured worker or employer to visit BWC’s Web site at bwc.ohio.gov, or call BWC at
•Use this form if this is a request for services even if services are being provided under the
•Complete all applicable sections of the form to avoid possible delays in processing this request.
•You can obtain additional copies of this form at bwc.ohio.gov or by calling BWC at
Section I – Injured worker
1Enter the injured worker’s name, BWC claim number, the date the injured worker was injured or contracted an occupational disease.
Section II – Requested services
2Treating diagnosis for this request to include body part/levels.
3Indicate the beginning and ending date of the requested service. Indicate the last exam or treatment date.
4List the requested services and CPT codes, including frequency and duration. Attach copies of current medical reports necessary to support request. Include any referrals, therapy, medications, diagnostic testing, expected outcomes of medical interventions, results of treatment and office notes that contain subjective and objective findings and
*Failure to add CPT codes may delay processing.
5Provide the
Section III – Additional conditions
6Complete if you are recommending additional conditions to the claim. Provide a narrative diagnosis. Supporting medical documentation is required for all conditions listed. Include any referrals, therapy, medications, diagnostic testing, expected outcomes of medical interventions, results of treatment and office notes that contain subjective and objective findings and
• BWC will notify all parties and the MCO of the decision.
7This refers to the establishment of a relationship between the injury or occupational disease and the industrial accident or exposure. An explanation is required when answering yes or no.
Section IV – Physician/provider information
8Identify the provider who will render the requested services and the address where he or she will provide the services (required). Travel reimbursement may not be authorized when the service provided is available within 45 miles round trip from the injured worker’s residence.
9Print, type or stamp requesting physician/provider name and address.
10Physician/provider signature, individual BWC provider number and date of this report are mandatory.
Section V –
•If completed by
•If the
•Claim inactive (further investigation required)
•An MCO can only use the disclaimer box on the
Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease
• Instructions for completing the |
Fax note |
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IW |
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1 Injured worker name |
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To
From
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Phone number |
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Phone number |
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Fax number |
⁜Claim number |
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⁜Date of injury |
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IV. Physician/providerinformation III. Additional conditions II. Requested services
V.
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Treating diagnosis for this request to include body part/levels. |
3 Date service begins |
⁜Date service ends ⁜Date of last exam or treatment |
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Requested services with CPT/HCPCS codes (required) |
Frequency |
Duration |
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2. |
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⁜3.
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5Provide the
If you are recommending additional conditions to the claim, supporting documentation is required. You may not use the C9 to request
additional conditions for claims of
6Provide diagnosis (narrative description only), and location and site for conditions you are requesting.
7In your opinion, based on the history from the injured worker, your clinical evaluation and expertise, is the diagnosis or condition causally related, either directly or proximately, to the alleged industrial accident or exposure?
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Yes, please attach explanation. |
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No, please attach explanation. |
8Identify the provider who will render the requested services and the address where he or she will provide the services (required).Travel reimbursement may not be authorized when the service provided is available within 45 miles round trip from the injured worker’s residence.
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Requesting physician/provider name and address (please print, type, or |
10 Physician/provider/authorized signature (required) |
n POR |
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stamp) |
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n Not POR — but treating |
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physician/provider |
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Individual BWC provider number (required) |
Date (M/D/Y) (required) |
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I certify the above information is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided by BWC or who knowingly accepts payment to which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment, or both.
Managed care organization (MCO) — If this page is not faxed or mailed back to the submitting physician/provider within three business days of receipt or within five business days of receipt of information requested on the
nApproved with disclaimer — This medical payment authorization is based upon a claim or additional condition that BWC/IC is considering as of the date of the MCO’s signature. If the claim or additional condition is ultimately disallowed, BWC may not cover the services/supplies to which this medical payment authorization applies.These services/supplies may be the responsibility of the injured worker (for MCO use only).
n Approved |
Date service begins |
Date service ends |
nAmended approval:
nDenied explanation:
You may file disputes to the decision in writing with supporting documentation to the MCO.
nPending: The documentation requested must be submitted to n Claim inactive: MCO cannot make a decision on this request,
the MCO case manager within 10 business days to allow for a |
further investigation required. BWC will issue a decision in writing |
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treatment decision. Failure to respond may result in denial. |
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within 28 days. |
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n Withdrawn |
n Dismissed |
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BWC claim status: n Allowed n Denied n Pending |
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MCO |
MCO name and signature (print, type or stamp and sign) |
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(please print, type or stamp) |
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MCO number
Telephone number
Date
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File Specs
| Fact Name | Description |
|---|---|
| Purpose | This form is used to request medical service reimbursement or to recommend additional conditions for an industrial injury or occupational disease. |
| Submission Guidelines | For self-insuring employers, the form must be mailed or faxed to the employer. State-fund employers should send it to the appropriate managed care organization (MCO). |
| Required Information | Complete all sections of the form, including the injured worker's details, requested services, and physician/provider information to avoid delays. |
| Supporting Documentation | Attach relevant medical reports and documentation to support the request, especially when recommending additional conditions. |
| Processing Time | The MCO must return the completed form within three business days; otherwise, authorization for service will be deemed granted. |
| Governing Law | This form is governed by Ohio Administrative Code 4123-19-03, which outlines the procedures for medical service requests. |
Ohio Bwc Writable C 9 - Usage Guidelines
Filling out the Ohio BWC Writable C-9 form is a crucial step in the process of requesting medical service reimbursement or recommending additional conditions for an industrial injury or occupational disease. Ensuring accuracy and completeness is essential to avoid delays. Follow these steps carefully to complete the form effectively.
- Section I – Injured Worker: Enter the injured worker’s name, BWC claim number, and the date of injury or occupational disease.
- Section II – Requested Services:
- Provide the treating diagnosis, including the body part or levels affected.
- Indicate the start and end dates for the requested service, as well as the date of the last exam or treatment.
- List the requested services along with their CPT codes, frequency, and duration. Attach any necessary medical reports to support the request.
- Include the two-digit facility site of service code, if applicable.
- Section III – Additional Conditions:
- Complete this section if recommending additional conditions. Provide a narrative diagnosis and supporting medical documentation.
- Explain the relationship between the injury or occupational disease and the industrial accident or exposure.
- Section IV – Physician/Provider Information:
- Identify the provider who will render the requested services and their address.
- Print or type the requesting physician/provider's name and address.
- Ensure the physician/provider signature, individual BWC provider number, and date of the report are included.
- Section V – MCO/Self-Insuring Employer Decision:
- If applicable, ensure the form is returned to the submitting physician/provider within the specified timeframe.
- Understand that if the claim is inactive, further investigation may be required before a decision is made.
After completing the form, review it for accuracy. Ensure that all required signatures and documentation are included before submitting it to the appropriate party, whether that is the employer or the managed care organization. This careful approach will help facilitate the processing of the request.
Your Questions, Answered
What is the purpose of the Ohio BWC Writable C-9 form?
The Ohio BWC Writable C-9 form is used to request medical service reimbursement or to recommend additional conditions related to an industrial injury or occupational disease. This form is essential for both self-insuring employers and state-fund employers to ensure that injured workers receive appropriate medical care and reimbursement for services rendered. It facilitates communication between the injured worker, the employer, and the managed care organization (MCO) involved in the worker's care.
How should the C-9 form be completed?
To complete the C-9 form accurately, it is important to print or type the information clearly. The form requires specific details, such as the injured worker's name, BWC claim number, and the date of injury or occupational disease. Additionally, the form must include the treating diagnosis, requested services with CPT codes, and relevant medical documentation. All applicable sections should be filled out to avoid processing delays. If the injured worker is employed by a self-insuring employer, the form should be sent to the employer. For those employed by a state-fund employer, it should be sent to the appropriate MCO.
What happens if the C-9 form is not processed within the specified time frame?
If the C-9 form is not faxed or mailed back to the submitting physician/provider within three business days, or within five business days of receiving additional information requested on the C-9-A, the authorization for service will be deemed granted by the BWC. This is subject to the organization's policies, excluding retroactive requests. It is crucial for the MCO to adhere to these timelines to ensure timely medical care for the injured worker.
Can additional conditions be requested using the C-9 form?
Yes, additional conditions can be recommended using the C-9 form, but only for claims that are not self-insured. When requesting additional conditions, the form must include a narrative diagnosis and supporting medical documentation. This documentation is necessary to establish a relationship between the new condition and the original industrial accident or exposure. The MCO will notify all parties involved of the decision regarding these additional conditions.
Common mistakes
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Neglecting to Complete All Sections: One of the most common mistakes is leaving sections blank. Each part of the form is designed to provide essential information. Incomplete forms can lead to delays in processing.
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Incorrectly Entering the Claim Number: Providing the wrong BWC claim number can result in the request being misdirected. Double-check this number to ensure accuracy.
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Failing to Include CPT Codes: Omitting CPT codes can significantly delay the processing of the request. These codes are crucial for identifying the services being requested.
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Not Providing Supporting Documentation: It's vital to attach all necessary medical reports and documentation. Without this information, the request may be denied or delayed.
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Ignoring the Facility Site of Service Code: If applicable, the two-digit facility site of service code must be included. This code helps in identifying where the service will be provided.
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Submitting Without a Signature: A common oversight is failing to sign the form. The physician/provider's signature is mandatory and must be included for the request to be valid.
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Missing Dates: Ensure that all relevant dates, including the date of injury and service dates, are filled out. Missing dates can lead to confusion and processing delays.
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Not Verifying the MCO Information: If the injured worker is employed by a state-fund employer, it is essential to confirm the correct Managed Care Organization (MCO). Incorrect MCO details can result in the request not reaching the right party.
Documents used along the form
The Ohio BWC Writable C-9 form is crucial for requesting medical service reimbursement or recommending additional conditions related to industrial injuries or occupational diseases. Alongside this form, several other documents often play a key role in the claims process. Below is a list of these documents, each with a brief description.
- C-1 Form: This form initiates the workers' compensation claim process. It provides essential details about the injury and the injured worker, allowing the Bureau of Workers' Compensation (BWC) to assess the claim.
- C-9-A Form: This is a request for additional information regarding a C-9 submission. It helps clarify any uncertainties before a decision is made on the medical service request.
- C-84 Form: Used to apply for temporary total disability benefits, this form documents the injured worker's inability to work due to the injury, supporting their claim for wage loss compensation.
- MCO Enrollment Form: This form enrolls the injured worker in a Managed Care Organization (MCO), which coordinates medical services and manages the treatment process for workplace injuries.
- Medical Reports: These documents provide detailed accounts of the injured worker's medical condition, treatment history, and prognosis. They are essential for supporting requests made on the C-9 form.
- Provider Authorization Form: This form allows healthcare providers to obtain authorization for specific treatments or services related to the injured worker's claim, ensuring proper billing and payment processes.
- Diagnostic Testing Results: These results, such as X-rays or MRIs, provide objective evidence of the injury and help substantiate the claims made in the C-9 form.
- Referral Letters: When a worker needs to see a specialist, referral letters from the primary care provider outline the necessity of the visit and any relevant medical history.
- Return-to-Work Form: This document indicates when an injured worker can safely return to their job, often required for processing benefits and ensuring compliance with workplace safety standards.
- Claim Status Update Form: This form provides updates on the status of the claim, including approvals or denials, helping all parties stay informed about the progress of the case.
Understanding these documents and their purposes can streamline the claims process and ensure that all necessary information is provided for a timely resolution. Properly completing and submitting these forms is essential for both the injured worker and the healthcare providers involved.
Similar forms
The Ohio BWC Writable C-9 form shares similarities with the Workers' Compensation Claim Form, often referred to as the C-3 form. Both documents serve as essential tools for injured workers seeking compensation for medical services related to their injuries. The C-3 form specifically initiates a claim for workers' compensation benefits, while the C-9 focuses on the reimbursement for medical services or recommendations for additional conditions. Each form requires detailed information about the injured worker, the nature of the injury, and the services requested, ensuring that all relevant medical documentation is included for processing. This thoroughness is crucial for a smooth claims process.
Another document akin to the C-9 is the Medical Service Request Form (MSR). Like the C-9, the MSR is used to request medical services for injured workers. The MSR typically outlines the specific treatments being requested, along with necessary supporting documentation. Both forms emphasize the importance of providing accurate CPT codes and medical histories to avoid delays in processing. The MSR, however, may be used in various contexts outside of Ohio, making it a more generalized form compared to the C-9's specific application within the state's workers' compensation system.
The C-9 form is also similar to the Authorization for Release of Health Information form. This document allows healthcare providers to share the injured worker's medical information with relevant parties, including employers and insurance companies. While the C-9 focuses on requesting medical services, the Authorization form ensures that the necessary medical data is available to support the claims process. Both forms require the injured worker's consent and aim to facilitate communication between healthcare providers and insurers, ultimately benefiting the injured worker's claim.
Additionally, the C-9 form resembles the Claim for Compensation form (C-7). The C-7 form is submitted by injured workers to request compensation for lost wages due to work-related injuries. While the C-9 is specifically for medical service requests, the C-7 focuses on financial compensation. Both forms require detailed information about the injury and the worker's employment status, ensuring that the claims are processed efficiently and accurately. The interrelation of these forms highlights the comprehensive approach to managing workers' compensation claims in Ohio.
Lastly, the C-9 has similarities with the Appeal of Claim Decision form. This document is used when an injured worker wishes to contest a decision made by the Bureau of Workers' Compensation (BWC) regarding their claim. While the C-9 is proactive in requesting medical services, the Appeal form is reactive, addressing decisions made after the initial claim submission. Both documents require clear and concise information to support the injured worker's position, reinforcing the importance of documentation and communication in the claims process.
Dos and Don'ts
When filling out the Ohio BWC Writable C-9 form, there are important steps to follow. Here are five things you should and shouldn't do:
- Do print or type the report clearly.
- Don't forget to include all applicable sections to prevent delays.
- Do ensure you attach all necessary medical documentation.
- Don't use the C-9 form for self-insuring employers when requesting additional conditions.
- Do confirm the facility site of service code if applicable.
Following these guidelines will help ensure that your request is processed smoothly and efficiently.
Misconceptions
Understanding the Ohio BWC Writable C-9 form can be challenging, and several misconceptions often arise. Here are six common misunderstandings:
- It can be used for any claim type. The C-9 form is specifically for state-fund employers. It cannot be used for claims involving self-insuring employers.
- Submitting the form is optional. Completing and submitting the C-9 is mandatory when requesting medical services or additional conditions related to an industrial injury or occupational disease.
- All sections of the form are optional. Each section must be completed as applicable. Missing information can lead to delays in processing your request.
- Only the injured worker needs to sign the form. The requesting physician or provider must also sign the form, along with providing their BWC provider number.
- Any medical service can be requested. The form requires specific details about the requested services, including CPT codes and supporting documentation. Generic requests may not be accepted.
- Approval is automatic once submitted. The MCO must review the request, and approval is not guaranteed. The decision will be communicated in writing.
Addressing these misconceptions can help ensure a smoother process when dealing with the Ohio BWC Writable C-9 form.
Key takeaways
Here are key takeaways for filling out and using the Ohio BWC Writable C-9 form:
- Print or type the report to ensure clarity.
- For self-insuring employers, send the completed form directly to them.
- For state-fund employers, send it to the appropriate managed care organization (MCO).
- To find the right MCO, visit ohiobwc.com or call 1-800-OHIOBWC.
- Use this form for service requests, even under 60-day presumptive authorization.
- Complete all sections thoroughly to prevent delays in processing.
- Attach necessary medical reports and documentation to support your request.
- Include CPT codes; omitting them can slow down the process.
- Travel reimbursement may not be granted if services are within 45 miles of the injured worker's home.
- Signature and provider information are mandatory for the form to be valid.
Remember, accuracy and completeness are key to ensuring a smooth experience with the BWC process.