Ohio physicians of record and treating providers use this two-page request to get authorization for non-emergency services, including those given under the 60-day presumptive authorization, and to recommend additional allowed conditions or a changed diagnosis. It goes to the managed care organization for state-fund claims or to the self-insuring employer, and either must answer within set time limits or the request is deemed approved.
The physician of record or a treating provider completes Sections I to IV: injured worker details, requested services with CPT or HCPCS codes, any recommended additional conditions with a causality answer, and the signed provider block. The MCO records its decision in Section V and a self-insuring employer in Section VI.
Enter the injured worker's name, BWC claim number and the date of injury or the date the occupational disease was contracted. The fax header at the top of page two also asks who the request is going to and the sender's phone and fax numbers, which the MCO or self-insuring employer uses to return its decision.
Give the treating diagnosis for this request, including body part and levels, the dates the service begins and ends, and the date of the last exam or treatment. List each service with its CPT or HCPCS code, frequency and duration, and attach current reports, office notes with subjective and objective findings, and test results. Add the two-digit CMS site-of-service code if applicable, and name the rendering provider and service address, which is required.
Complete only when recommending conditions be added to the claim. Give a narrative description (an ICD code is not required here) with location and site, and note any supporting diagnostic evidence such as an X-ray. Item 8 asks whether, based on the history, your clinical evaluation and expertise, the condition is causally related, directly or proximately, to the alleged accident or exposure. Check yes or no and attach an explanation.
Mark whether you are the physician of record (POR) or a treating provider who is not the POR. Print, type or stamp the requesting provider's name and address, then sign. The signature, individual BWC provider number and report date are all mandatory, and signing certifies the information under a felony fraud warning.
The MCO marks the request approved with service dates, approved with disclaimer, amended, denied, pending, claim inactive, withdrawn or dismissed, or refers an additional-condition recommendation to BWC. A pending decision gives the provider 10 business days to send the requested documentation, and a denial can be disputed in writing with the MCO through alternative dispute resolution.
A self-insuring employer records whether medical treatment is approved or denied, with its name, signature and date. It must notify the submitting provider within 10 days of receipt or the authorization is deemed granted under Ohio Administrative Code 4123-19-03(L)(7). Recommendations for additional conditions are handled separately by the employer.
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Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease
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Sources for this guide
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The MCO must decide within three business days of receipt, or within five business days after receiving information it asked for on a C-9-A. If it does not send a decision back in that time, BWC deems the authorization granted, except for retroactive requests. A self-insuring employer has 10 days to respond or the authorization is deemed granted.
Yes. Section III is for recommending additional conditions. Give a narrative diagnosis with location and site, check yes or no on causality, and attach an explanation plus supporting medical evidence such as exam and test findings. For state-fund claims BWC investigates and notifies all parties, while a self-insuring employer addresses the recommendation separately.
Yes. The form's instructions say to use it for service requests even when services fall under the 60-day presumptive authorization. BWC's prior authorization policy requires both the FROI and the C-9 to be filed with the MCO before presumptive treatment starts, and the MCO acknowledges receipt within three business days.
BWC prefers the C-9, but its prior authorization policy accepts any physician-generated document that contains, at a minimum, the data elements on the C-9. Whatever format is used, the provider signature, individual BWC provider number and report date are required, and missing CPT codes can delay processing.