The Ohio BWC Writable C-9 form is a crucial document used to request medical service reimbursement or recommend additional conditions for an industrial injury or occupational disease. Properly completing this form ensures that injured workers receive the necessary medical services and that their claims are processed efficiently. For assistance with filling out the form, please click the button below.
The Ohio BWC Writable C-9 form plays a crucial role in the workers' compensation system, specifically for those dealing with industrial injuries or occupational diseases. This form is designed to facilitate the request for medical service reimbursement or to recommend additional conditions related to an injury. It is important for both injured workers and healthcare providers to understand its components to ensure a smooth process. The form must be filled out accurately, including details such as the injured worker's name, claim number, and the nature of the requested medical services. Providers must specify the diagnosis, treatment dates, and any relevant medical documentation to support the request. If additional conditions are being recommended, thorough explanations and supporting documentation are necessary. The form also includes sections for physician information and the managed care organization's decision, which can significantly affect the authorization of services. Timely submission and accurate completion of the C-9 are essential, as delays or omissions may hinder the processing of requests. Understanding these aspects can help injured workers receive the care they need without unnecessary complications.
Completing the Request for Medical Service
Reimbursement or Recommendation for Additional
Conditions for Industrial Injury or Occupational
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 bwc.ohio.gov, or call BWC at 1-800-644-6292, 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 at bwc.ohio.gov or by calling BWC at 1-800-644-6292 and listening to the options.
Section I – Injured worker
1Enter the injured worker’s name, BWC claim number, the date the injured worker was injured or contracted an occupational disease.
Section II – Requested services
2Treating diagnosis for this request to include body part/levels.
3Indicate the beginning and ending date of the requested service. Indicate the last exam or treatment date.
4List 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.
5Provide the two-digit facility site of service code as used by the Centers for Medicare and Medicaid Services (CMS), if applicable.
Section III – Additional conditions
6Complete 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.
7This 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
8Identify the provider who will render the requested services and the address where he or she will provide the services (required). Travel reimbursement may not be authorized when the service provided is available within 45 miles round trip from the injured worker’s residence.
9Print, type or stamp requesting physician/provider name and address.
10Physician/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. Dec. 11, 2023)
C-9 (Combines C-1-A & C-161)
Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease
• Instructions for completing the C-9 on reverse side.
Fax note
IW
1 Injured worker name
To
From
Toll-free fax number
Phone number
Fax number
⁜Claim number
⁜Date of injury
IV. Physician/providerinformation III. Additional conditions II. Requested services
V. MCO/Self-insuring employer decision
2
Treating diagnosis for this request to include body part/levels.
3 Date service begins
⁜Date service ends ⁜Date of last exam or treatment
4
Requested services with CPT/HCPCS codes (required)
Frequency
Duration
1.
2.
⁜3.
4.
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.
6Provide diagnosis (narrative description only), and location and site for conditions you are requesting.
7In 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.
8Identify the provider who will render the requested services and the address where he or she will provide the services (required).Travel reimbursement may not be authorized when the service provided is available within 45 miles round trip from the injured worker’s residence.
9
Requesting physician/provider name and address (please print, type, or
10 Physician/provider/authorized signature (required)
n POR
stamp)
n Not POR — but treating
physician/provider
Individual BWC provider number (required)
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.
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.
nApproved 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).
n Approved
Date service begins
Date service ends
nAmended approval:
nDenied explanation:
You may file disputes to the decision in writing with supporting documentation to the MCO.
nPending: The documentation requested must be submitted to n Claim inactive: MCO cannot make a decision on this request,
the MCO case manager within 10 business days to allow for a
further investigation required. BWC will issue a decision in writing
treatment decision. Failure to respond may result in denial.
within 28 days.
n Withdrawn
n Dismissed
BWC claim status: n Allowed n Denied n Pending
MCO company/Self-insuring employer name
MCO name and signature (print, type or stamp and sign)
(please print, type or stamp)
MCO number
Telephone number
Date
Self-insuring employer
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
BWC-1113 (Rev. Dec. 11, 2023) C-9 (Combines C-1-A & C-161)
Filling out the Ohio BWC Writable C-9 form is an essential step for those seeking reimbursement for medical services related to an industrial injury or occupational disease. Completing this form accurately ensures that the request is processed efficiently. Below are the steps to guide you through the process of filling out the form.
After completing the form, review it for accuracy and completeness. This will help to prevent any processing delays. Once submitted, the appropriate parties will be notified of the decision regarding the request.
The Ohio BWC Writable C-9 form is used to request medical service reimbursement or to recommend additional conditions for an industrial injury or occupational disease. This form is essential for ensuring that injured workers receive the medical services they need. It helps to communicate the specifics of the request to the appropriate managed care organization (MCO) or self-insuring employer, streamlining the process for obtaining necessary medical care.
The C-9 form should be completed by the treating physician or provider who is responsible for the injured worker's care. If the injured worker is employed by a self-insuring employer, the form must be sent directly to that employer. Conversely, if the worker is with a state-fund employer, the completed form should be mailed or faxed to the appropriate MCO. It's crucial for the provider to fill out all applicable sections to avoid delays in processing the request.
The C-9 form requires several key pieces of information, including:
Completing all sections accurately helps ensure timely processing of the request.
Once the C-9 form is submitted, the MCO or self-insuring employer has specific timelines to respond. If the form is not returned to the submitting physician/provider within three business days, the authorization for the requested services is deemed granted, unless there are retroactive requests. If further investigation is needed, the MCO will notify the provider and issue a decision within 28 days. It is important to follow up if there are any delays or if additional information is requested.
Yes, the C-9 form can be used to recommend additional conditions related to the original claim. However, it’s important to note that this request cannot be made for claims involving self-insuring employers. Supporting medical documentation is required for all additional conditions listed, and the provider must establish a causal relationship between the new conditions and the original industrial accident or exposure. Clear explanations and thorough documentation will help facilitate the approval process.
Incomplete Information: Failing to fill out all applicable sections can lead to delays. Each part of the form is important for processing the request efficiently. Ensure that all required fields are completed.
Missing CPT Codes: Not including the necessary CPT codes can significantly slow down the processing time. Always double-check that these codes are listed accurately.
Incorrect Recipient: Sending the form to the wrong entity can cause confusion. If the injured worker is with a self-insuring employer, the form should be sent to that employer. For state-fund employers, it should go to the appropriate managed care organization (MCO).
Neglecting Supporting Documentation: Failing to attach necessary medical reports and documentation can result in a denial or delay. Include all relevant medical records, referrals, and treatment notes to support the request.
The Ohio Bureau of Workers' Compensation (BWC) uses various forms and documents to manage claims effectively. Among these, the C-9 form is crucial for requesting medical service reimbursements or recommending additional conditions. However, several other documents often accompany the C-9 to ensure that all necessary information is collected and processed efficiently. Below is a list of related forms that play important roles in the claims process.
Understanding these forms is essential for both injured workers and healthcare providers involved in the workers' compensation process. By ensuring that all necessary documentation is submitted, parties can help facilitate a smoother claims process and ensure that injured workers receive the benefits and care they need.
The Ohio BWC Writable C-9 form shares similarities with the C-1 form, which is the "First Report of Injury." Both documents serve essential functions in the workers' compensation process. The C-1 form is used to report an injury or occupational disease to the Bureau of Workers' Compensation (BWC) as soon as it occurs. Similarly, the C-9 form is utilized to request medical service reimbursements or recommend additional conditions related to the injury. Both forms require detailed information about the injured worker, including their name, claim number, and the nature of the injury, ensuring that all relevant details are communicated effectively to facilitate processing and approval of claims.
Another document that resembles the C-9 is the C-84 form, which is the "Application for Temporary Total Compensation." This form is used by injured workers to apply for temporary total disability benefits due to their inability to work as a result of their injury. Like the C-9, the C-84 requires specific information about the injured worker's medical condition and treatment history. Both forms aim to support the injured worker's claims for benefits, though the C-84 focuses more on financial compensation while the C-9 emphasizes medical service requests and additional conditions.
The C-9 form is also comparable to the C-3 form, known as the "Employee's Claim for Compensation." The C-3 form is used by employees to formally initiate a claim for workers' compensation benefits after sustaining an injury. In contrast, the C-9 is utilized primarily for medical service requests and recommendations for additional conditions. Both forms require the injured worker to provide comprehensive details about their injuries and the circumstances surrounding them, ensuring that the BWC has sufficient information to process the claims effectively.
Lastly, the C-9 form is similar to the C-161 form, which is used for requesting additional conditions or services related to an existing claim. The C-161 specifically addresses the need for further medical treatment or services that are not initially covered under the claim. Like the C-9, the C-161 requires supporting medical documentation and detailed descriptions of the requested services. Both forms play a crucial role in the ongoing management of a worker's compensation claim, ensuring that injured workers receive the necessary medical attention as their conditions evolve.
When filling out the Ohio BWC Writable C-9 form, it is essential to follow specific guidelines to ensure a smooth process. Below is a list of ten things to do and not do while completing the form.
This form is specifically designed for requests related to industrial injuries or occupational diseases. It cannot be used for unrelated medical services.
The C-9 form is not applicable for requesting additional conditions for claims involving self-insuring employers. Such requests must follow different procedures.
Always print or type the information on the Ohio BWC Writable C-9 form to ensure clarity and legibility.
Determine the correct recipient for the form based on the injured worker's employer type: self-insuring employers require direct submission, while state-fund employers should send it to the appropriate managed care organization (MCO).
Complete all sections of the form thoroughly. Missing information can lead to delays in processing the request for medical services.
Attach any necessary supporting documentation, such as medical reports, treatment plans, and referrals, to strengthen the request and provide context for the services needed.
Be aware of the timelines: if the MCO does not respond within specific timeframes, the authorization for services may be automatically granted.