by Andrew Bainbridge | Mar 14, 2022 | Medical Care Benefits
If you have been injured on the job or suffer from an occupational disease you most likely will need to see a doctor and need medication to help with your injury or occupational disease. How do you go about getting your medical bills and prescriptions paid for by the Ohio Bureau of Workers’ Compensation (BWC)? Like most things involving the BWC, you must follow a certain set of rules, and our Ohio workers’ compensation attorneys can help.
For Medical Bills to be Paid Under Your Claim
Initial Medical Visit /Emergency Visit
If you endure a work-related injury, your first visit to a medical provider can be a medical provider, hospital, or urgent care of your choosing. This is to ensure injured workers get medical treatment immediately following a work injury. Just be sure to tell the medical provider, hospital, or urgent care that you are being treated for a work-related injury and provide them with the name of your Employer’s Managed Care Organization (MCO).
After Initial Medical Visit /Emergency Visit
After your initial visit, either you, your medical provider, or your employer must file a compensation claim with the BWC. This document is called a First Report of Injury, commonly referred to by Ohio workers’ compensation lawyers and others as the “FROI-1.” Once the BWC receives your claim they will send you a BWC ID card, which contains your claim number and the name of your Employer’s MCO.
- Your employer’s MCO manages the medical portion of the claim; this includes medical treatment, surgery approvals, payment of medical bills, and rehab referrals.
Next you will need to select a medical provider who is a “BWC Certified Medical Provider” as your Physician of Record (POR) under your claim. If your primary care physician is already a Certified Provider, you can continue treatment with them. If not, you will need to choose a medical provider who is Certified otherwise, you may be responsible for the payment of medical bills. You can obtain a list of approved providers from your employer or from the BWC, and you can always contact one of our Ohio workers’ compensation attorneys for assistance.
- As long as your medical provider is a BWC Certified Provider, you will not have to pay for any approved medical care and unlike health insurance, there are no co-pays or deductibles.
- If your medical treatment or medication has not been approved, or you have received a denial, you may need the help of experienced Ohio workers’ compensation lawyers to fight for coverage.
Follow up Visits
At your next medical appointment provide your POR your BWC ID card which contains your claim number and the name of your MCO. They will need this information to provide to your MCO for reimbursement of treatment. Your POR will request authorization for all medical treatments from your MCO. For diagnostic testing or surgery your medical provider will need to submit a Form C-9 “Physician’s Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease”to your MCO for pre-approval. You will receive a letter from the MCO telling you whether the requested treatment has been approved or denied. Again, if you believe your treatment has been unfairly denied, you should contact a workers’ compensation disability attorney for assistance.
Medical Payments for Additional Conditions
Sometimes your POR will need to request an additional condition be added to your claim. They do so by submitting the same Form C-9 as mentioned in the previous section. The additional condition must be allowed by the BWC before any further medical treatment or testing will be approved or paid.
Keep in mind you and your employer have the right to appeal medical decisions made by your MCO or the BWC. Contact our Ohio workers’ compensation attorneys if you need assistance with appealing an unfavorable medical decision, and we will make sure your rights are being protected.
For Prescriptions to be Covered Under Your Claim
- The medications must be on the BWC’s Pre-Approved List of Medications.
- The medication must be an approved medication for your allowed condition(s).
- You must use a BWC Certified Pharmacy.
- Your claim must be allowed.
If you need a prescription filled before your claim is allowed, you can use the “First Fill Program.” The First Fill Program allows you to fill a 10-day supply of your medication before your claim is allowed or before you have a BWC claim number. Just tell the pharmacy your prescription is for an Ohio Workers’ Compensation Claim and provide them your Social Security number and date of injury. They will include this information when they submit the request as well as write “For Work-Related Injury” on the prescription.
Once your claim is allowed, take your prescriptions to any BWC Certified Pharmacy with your claim number and they will bill the BWC’s Pharmacy Benefits Manager (PBM) directly.
Most common medications, in their generic form, are included in the BWC’s Pre-Approved List of Medications. If your provider prescribes a “Name Brand Medication” over a generic, similar to health insurance coverage, you may have to pay part of the cost, otherwise, on most common medications you will have no co-pay.
If your medication coverage has been denied, contact an Ohio workers’ compensation attorney for assistance with the appeal process.
Reimbursement for prescriptions you paid for out of pocket
There are two ways to get reimbursed:
- Ask your pharmacist to resubmit your prescription to the BWC’s PBM. The PBM will then pay your pharmacy the allowed amount for the prescription and the pharmacy will reimburse you.
- Submit a “Request for Injured Worker Outpatient Medication Reimbursement Form,” Form C-17, along with your prescription label and the amount you paid for the prescription to the BWC.
If you have additional questions concerning medical coverage or medications, contact the experienced Ohio workers’ compensation attorneys at The Bainbridge Firm.
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