Clearly, there are times when medical care can’t wait or when waiting will exacerbate your condition. If you are crushed by machinery on the factory floor at Worthington Industries, or you are knocked unconscious in a fall while filling orders at an Amazon fulfillment center, you will need emergency treatment immediately. Even though these will be workers’ compensation claims, don't worry about that yet. That’s because, in certain situations, medical treatment has presumptive approval by the Bureau of Workers’ Compensation (BWC).
Criteria for Presumptive Approval in Ohio
The BWC understands that immediate treatment can mean faster recovery and lower rates of long-term disability. It is in their best interest to avoid the worst outcomes for your injury. Even in certain non-emergency situations involving soft tissue and musculoskeletal injuries, you can schedule diagnostic and treatment appointments in the first 60 days after the injury without having to wait for BWC authorization. Still, you are limited to these services:
- A maximum of 12 physical medicine visits. These treatments can include chiropractic manipulation, physical therapy, athletic training, occupational therapy, and recognized specialists' massage therapy.
- Diagnostic testing. X-rays, MRIs, and CAT scans do not require prior authorization if they are determined to be medically necessary by a physician. Other diagnostics, such as exploratory surgery, are only allowed in emergencies.
- Casts. Casting or splinting of fractures—or recasting as medically necessary—has presumptive approval.
- Injections. Up to three soft tissue or joint injections and three trigger point injections are allowed without prior authorization. Injections might include corticosteroids, anti-inflammatories, and pain relievers or may draw out fluid.
- Consultations. Visits to consult with a physician or other specialist about treatment for a work injury also have presumptive approval.
While these services do not require prior authorization, they do require that your Managed Care Organization (MCO) has received a First Report of Injury (FROI) form from you, a C-9 form from your physician, and has been notified within 24 hours of treatment if you are going to miss over two days of work. Presumptive approval only applies to allowed conditions in allowed claims, so if it is later determined that your injury did not occur at work and your claim is rejected, you could have to pay for these services.
Services Requiring Prior Authorization
While these exceptions can help get the medical care you need quickly, they do not apply in other situations. Many of the work-related injury or illness treatments you will need require prior authorization, including:
- Inpatient and outpatient hospital services. Any hospital care, including outpatient surgery centers, requires prior approval unless it is an emergency.
- Psychological treatment. Ohio workers’ comp only covers mental conditions caused by a claimant’s compensable physical injury and only by prior approval.
- Dental care. Work-related dental injuries will require prior authorization for treatment.
- Non-emergency medical transportation. Emergency ambulance transportation does not require prior approval, but scheduled transportation by ambulance does.
- Skilled nursing or extended care facility. Admission to a nursing home or rehab center must be pre-approved by the MCO.
- Vision and hearing services. These services have presumptive approval up to $100. Beyond that, you must get authorization.
- Durable Medical Equipment. Walkers, wheelchairs, oxygen tanks, and other equipment do not require authorization if the purchase price is $250 or less. For purchases above $250 and rentals of equipment, prior authorization is required.
When you consult a workers’ compensation attorney in Ohio, we will work with your doctor's office to help obtain all required authorizations so you don’t have to worry about which services have presumptive approval and which do not.
How Monast Law Office Can Help
Workers’ compensation benefits provide medical care and wage replacement vital to injured Ohio workers. The outcome of your claim can affect you and your family for years to come–shouldn't you give yourself the best possible chance for success? Please request a copy of our free book, The Worker’s Guide to Injury Compensation in Ohio, to learn more about your rights, the workers’ compensation system, and how we here at Monast Law Office may help.