Completing the Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease Instructions • Please print or type this report. • If injured worker is employed by a self-insuring employer, complete this form and mail or fax it to his or her employer. • If injured worker is employed by a state-fund employer, complete this form and mail or fax it to the appropriate managed care organization (MCO). • To determine the appropriate MCO, ask the injured worker or employer to visit BWC’s Web site at ohiobwc.com, or call BWC at 1-800-OHIOBWC, and listen to the options. • Use this form if this is a request for services even if services are being provided under the 60-day presumptive authorization, if recommending additional condition(s) or if diagnosis has changed. • Complete all applicable sections of the form to avoid possible delays in processing this request. • You can obtain additional copies of this form on ohiobwc.com or by calling BWC at 1-800-OHIOBWC and listening to the options. Section I – Injured worker 1 Enter the injured worker’s name, BWC claim number, the date the injured worker was injured or contracted an occupational disease, address and telephone number. Section II – Requested services 2 Treating diagnosis for this request to include body part/levels. 3   Indicate the beginning and ending date of the requested service. Indicate the last exam or treatment date. 4 List 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 pre-existing conditions. * Failure to add CPT codes may delay processing. 5 Indicate site of service by two-digit site of service code or written description of the Centers for Medicare and Medicaid Service. Section III – Additional conditions 6 Complete 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 pre-existing conditions. You may not use the C-9 to request additional conditions for claims of self-insuring employers. • BWC will notify all parties and the MCO of the decision. 7 This 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 8 Identify provider of services (required). 9 Print, type, or stamp requesting physician/provider name and address. 10 Physician/provider signature, individual BWC provider number and date of this report are mandatory. Section V – MCO/Self-insuring employer decision • If completed by self-insuring employer, refer to self-insuring employer section. • If the C-9 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 the C-9-A, a request for additional information, BWC shall deem the authorization for service granted subject to our policy, excluding retroactive requests. • Claim inactive (further investigation required) — The MCO cannot make a decision on this C-9 request. Further investigation is required, and BWC will issue a decision in writing within 28 days. The MCO will notify the provider of the BWC decision. • An MCO can only use the disclaimer box on the C-9 or any other physician generated service request when BWC/IC is considering the claim or the condition for which the service is requested as of the date of the MCO’s signature. Disclaimers shall not be used when authorizing treatment for allowed claims and conditions that are within the statute of limitation. BWC-1113 (rev. 2/23/2011) C-9 (Combines C-1-A & C-161) American LegalNet, Inc. www.FormsWorkFlow.com Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease IW Fax note Toll-free phone number Phone number From Toll-free fax number Fax number   Claim number • Instructions for completing the C-9 on reverse side. To  Date of injury 1 Injured worker name 3 Date service begins    Date service ends      Date of last exam or treatment 2 Treating diagnosis for this request to include body part/levels. II. Requested services      / /   / /   / / Frequency 4 Requested services with CPT/HCPCS codes (required) 1.        / / Duration   2.  3.  4. 5 Identify location where services are rendered or provide two-digit site of service code as used by the Centers for Medicare and Medicaid Services (CMS). III. Additional conditions 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 self-insuring employers. 6 Provide diagnosis (narrative description only), and location and site for conditions you are requesting. 7 In 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? Yes, please attach explanation. No, please attach explanation. IV. Physician/provider information 8 Medical services will be provided by: 9 Requesting physician/provider name and address (please print, type, or stamp) 10 Physician/provider/authorized signature (required) Individual BWC provider number (required) POR Not POR — but treating physician/provider Date (M/D/Y) (required) 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. V. MCO/Self-insuring employer decision 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 C-9-A, BWC shall deem the authorization for treatment granted subject to our policy, excluding retroactive requests. Approved 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).   Approved Date service begins _____ /_____ /_____ Date service ends _____ /_____ /_____   Amended approval: Denied explanation: You may file disputes to the decision in writing with supporting documentation to the MCO. Pending: The documentation requested must be submitted to the MCO case manager within 10 business days to allow for a treatment decision. Failure to respond may result in denial.      Withdrawn BWC claim status:      Claim inactive (MCO cannot make a decision on this request, further investigation required): BWC will issue a decision in writing within 28 days. Dismissed Allowed Denied MCO company/Self-insuring employer name (please print, type or stamp) Pending MCO name and signature (print, type or stamp and sign) MCO number Telephone number Self-insuring employer ( ) Date / / Self-insuring employer use only — Fax or mail this page to the submitting physician/provider within 10 days of receipt or the authorization for treatment shall be deemed granted per Ohio Administrative Code 4123-19-03 (K)(5). Self-insuring employer signature Date BWC-1113 (rev. 2/23/2011) C-9 (Combines C-1-A & C-161) / / American LegalNet, Inc. www.FormsWorkFlow.com