Physicians treating Ohio state-fund claims use this form to send the managed care organization (MCO) a comprehensive treatment plan, recommend additional conditions, or report a changed diagnosis. It is used even when services fall under the 60-day presumptive authorization. The MCO records its decision in Section V, while BWC rules on any recommended additional conditions and notifies all parties.
The physician of record (POR) completes Sections I to III and must sign with an individual BWC provider number; Section IV names the treating physician, such as a surgeon, if different from the POR. The MCO completes Section V.
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Physician's Treatment Request
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No. The instructions state that the form cannot be used for claims of self-insuring employers. It is for injured workers employed by state-fund employers, and the completed request goes by mail or fax to the managed care organization assigned to the claim.
The MCO uses it when BWC or the Industrial Commission is still considering the claim for initial allowance on the date the MCO signs. If the claim is ultimately disallowed, BWC may not cover the authorized services or supplies, and the injured worker may be responsible for them.