New BWC Medical Treatment Plan Approval Guidelines

• treatment plan for non-emergency treatment must be submitted to MCO prior to initiating treatment;
• use of C-9 form for presentation of plan is preferred, but another document may be used if it presents at least the same information as the C-9. C-161 Forms will not be sufficient and will be returned with a C-9;
• MCO must review and respond to request within 72 hours or 3 business days. MCO must respond by fax if possible, if MCO cannot respond by fax it must call physician and follow up in writing;
• If MCO needs more information or medical review, MCO has 5 days to make decision from receipt of additional information. If medical review results in decision to alter the plan, such decision must be made within the 5 days;
• If
  1. the MCO does not timely communicate its decision to the physician, AND
  2. the treatment plan was completely and correctly documented on an appropriate document, AND
  3. there is proof of submission to the MCO, AND
  4. the treatment is for the allowed condition(s), AND
  5. the claim is payable
     
     
  Then the treatment plan is considered approved.
• MCO must send copy of treatment plan, including the MCO's decision, to BWC for inclusion in claim file.