What treatment services require pre-authorization?

by Kara Dolan-West | Mar 06, 2019 | Workers' Compensation

The BWC’s MCO standardized prior authorization table

ServicePrior Authorization Required No Prior Authorization Required
Physical medicine services, including chiropractic/osteopathic manipulative treatment and acupunctureYes
Psychological servicesYes
Evaluation and management servicesYes for psychological consults or chronic pain program consultsAll other evaluation and management services
Diagnostic testingYes. For drug test, please refer to the “Drug Testing” policy.Basic X-rays
Durable Medical Equipment (DME)Yes, if purchase price is equal or greater than $250

Yes, for DME rentals anticipated to or having the probability to exceed 80 percent of the purchase price of the DME

For DME, please refer to the “Durable Medical Equipment” policy.

DME purchase price is less than $250
Home/Vehicle modificationsYes. For home/vehicle modifications, please refer to the “Home and Vehicle Modifications” policy.
Home health agency servicesYes
All inpatient and outpatient hospital services treatment and ambulatory surgery center servicesYes, unless for emergency services. Emergency inpatient hospitalization may be through the emergency department or by direct admission
In-home physician servicesYes, after first visit

For in-home physician services, please refer to the “In-home Physician Visits and Physician Mobile Office Visits” policy.

First visit
Non-emergency ambulance (medical transportation) servicesYes
OrthoticYes, if greater than $250
Prosthetic or artificial appliance and/or repairYes, if greater than $250

For prosthetic or artificial appliance and/or repair, please refer to the “Artificial Appliance Requests” policy.

Skilled nursing facility (SNF)/Extended care facility (ECF)Yes
TENS and NMES unitsYes, for both rental and purchase

For TENS and NMES units, please refer to the “TENS and NMES” policy.

TENS and NMES monthly suppliesYes, with a maximum of six months per authorization

For TENS and NMES units, please refer to the “TENS and NMES” policy.

Vision and hearing servicesYes, if greater than $100Vision and hearing services less than or equal to $100
Vocational rehabilitation – all vocational rehabilitation services, in or out of planYes, unless meets the “NoPA Required” criteria

For vocational rehabilitation, please refer to the vocational rehabilitation policies (click here).

Transitional work on-site therapy services provided by an occupational therapist that fall under the presumptive authorization criteria

Note: Occupational rehabilitation/Comprehensive (work hardening) requires CARF

This means the requesting physician will need to submit a C9 requesting the listed treatments before payment of those treatments will be considered.

For questions or concerns, please contact our office at 614-545-9990.

If you sustained a workplace injury, contact the Bainbridge Firm to speak with one of our experienced Ohio Workers’ Compensation Attorneys.  Schedule a free consultation at our Columbus, Marion, Portsmouth, Waverly, Cambridge, and Springfield or Ironton law offices. Please call 800-762-1612 or contact us online

Tags: authorization BWC physician services treatment Workers' Compensation