CareMark Comp

Precertification Requirements

Please click the following link below for CareMark Comp MCO precertification forms:

CareMark Comp MCO Precertification Forms

Precertifying Physical Medicine:  The CareMark Comp Administrative Manual States:

Physical medicine, including physical therapy, acupuncture therapy, trigger point treatments, massage therapy, manipulative services and passive or active treatments and modalities; for enrolled workers with open claims, after thirty days duration and for every thirty days thereafter.  This requirement may begin on the first day following the worker’s enrollment into CareMark Comp if the worker has received physical medicine services prior to enrollment.

An injured worker can receive physical medicine (PT, OT, OMT, chiropractic manipulations, massage, etc.) without precertification for up to 30 days for the LIFETIME of the claim.  Suppose an injured worker had one chiropractic manipulation or PT visit at the beginning of his/her claim.  Now, 3 months later, the worker is referred to your office.  The 30 day period during which precertification is not required has expired (even if you have never seen this worker before).  Submit a request for precertification.

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Claim Closure & Closing Exams
Oregon statutes and rules place several responsibilities and related time frames on an attending physician and other medical providers regarding claim closure.

MEDICALLY STATIONARY
When an injured worker becomes "medically stationary", their claims will be closed and any permanent disability award due will be paid to the worker.  Medically Stationary means that "no further material improvement would reasonably be expected from medical treatment or the passage of time".

When the injured worker's condition becomes medically stationary, the attending physician must notify the insurer of:

• The date on which the worker became medically stationary: (Note: The medically stationary date cannot be a projected date).

• Whether or not the worker is released to any form of work;

• If the injury related condition has resolved, returning the worker to pre-injury status, the attending physician shall so state.

WHEN IS A CLOSING EXAM NECESSARY?
Attending physicians will be asked to perform a formal closing examination when permanent disability is anticipated.  Claims examiners may also request a closing exam under other circumstances.

WHAT IS THE EXPECTED TIME FRAME FOR COMPLETING A CLOSING EXAM?
The attending physician shall perform a closing examination, measuring and reporting all applicable findings of impairment, and submit the report to the insurer within 14 days of the date the worker was declared medically stationary.

WHAT ITEMS ARE REQUIRED IN A CLOSING EXAM?
Please complete all applicable areas on the "Elements of a Closing Exam".

Note: The use of an inclinometer to measure spinal ranges of motion is required for spine and back injuries.

ARE THERE ALTERNATIVES TO PERFORMING A CLOSING EXAM?
The terms of your Participation Agreement with CareMark Comp require that attending physicians perform closing exams for injured workers under their care.  If you feel you are unable to perform or accurately complete a closing exam, please contact CareMark Comp's Medical Director at (503) 413-5800.  Note: Providers who do not own an inclinometer or have no experience in using one, may refer a worker to a physical therapist to obtain the actual measurements but are still accountable for the final closing exam and report, incorporating the inclinometer values.

HOW SHOULD A CLOSING EXAM BE BILLED?
SAIF Specific CPT Code: 9455 and contracted reimbursement rate of $250.00 should be used for injured workers insured through SAIF.

For other payors use one of the following methods:

• The Oregon Department of Consumer and Business Services, Workers' Compensation Division recommends billing with CPT Code 99455 (treating physician) or 99456 (other than treating physician).  Compute the fee for these codes by multiplying the actual time to complete the exam and write the report by the physician's normal hourly rate for such an exam.

• An alternative way to bill for the closing exam is to use the appropriate Evaluation and Management CPT Code for established patients 99213-99215 and also bill for a report (Oregon Specific Code N0001 or N0002).

When you submit your bill, it may be audited by the insurer.  Depending on the documentation submitted, the insurer may attempt to change the code based upon what they think the documentation in your report supports.  If you disagree with the insurer, you have the right to submit a Fee Dispute Form to the Department of Consumer and Business Services.  The Fee Dispute Form 2330 and 2330a is available at:

http://www.oregonwcd.org/policy/bulletins/docconv_12544/2330.pdf

http://www.oregonwcd.org/policy/bulletins/docconv_12544/2330a.pdf

For additional information on closing examinations or to request Bulletin 239, "A guide to reporting medical information for disability determination and measuring spinal ranges of motion with inclinometer" please contact:

The State of Oregon
Department of Consumer and Business Services
Workers' Compensation Division
(503) 947-7810
or visit their website: www.oregonwcd.org 

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Disability Prevention Consultation
The Disability Prevention Consultation (DPC) program is a unique program developed by CareMark Comp.  It assists the Attending Physician in treatment planning for the injured worker in order to facilitate a progression of the claim toward recovery and closure.  The DPC program could be of benefit to you if you have a CareMark Comp enrolled injured worker and would like assistance in treatment planning or are presented with one of the following situations:

• Recovery process is not progressing or has plateaued

• Subjective complaints outweigh objective findings

To initiate a DPC for a CareMark Comp enrolled injured worker, please call the CareMark Comp Nurse Case Manager at (503) 413-5800.

THE DPC PROCESS
A DPC may be suggested by the Attending Physician or the claims examiner, although CareMark Comp determines whether such an exam is appropriate.

A Level I DPC consists of a file review by the MCO Medical Director or Physician Advisor and a conversation with the Attending Physician to discuss the findings and develop a treatment plan.

A Level II DPC includes a file review, physical examination of the worker and report by a sub-specialist with development of a treatment plan by the MHN Medical Director or MHN Medical Advisor in consultation with the attending physician.  The Level II may also include an examination by a psychologist with administration of MMPI.

Level III include the components of a Level II in addition to a physical capacities exam (PCE).

All DPC reports are forwarded to the Attending Physician and Insurer.  The Attending Physician is obligated to either comply with or appeal the findings of the DPC process.  If at any time there are questions regarding the DPC process please feel free to contact one of the CareMark Comp Nurse Case Managers at (503) 413-5800 for assistance.

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Definitions

Attending Physician:  A doctor or physician who is primarily responsible for the treatment of a worker's compensable injury.  In general, the physician must be an MD, DO or board certified oral and maxillofacial surgeon.  Chiropractors may treat injured workers for a period of 30 days or 12 visits, whichever is less -- see ORS 656.005 (12)(b)(B).  (In rural areas special rules may apply -- see OAR 436-010-0210(3)).

Aggravation:  An objective and measurable worsening of an original compensable workers' compensation injury which necessitates reopening of a claim.

Palliative Care:  Medical treatment intended to reduce or moderate the intensity of a medically stationary condition which enables the injured worker to continue current employment.  Palliative care does not include those medical services rendered to diagnose, heal or permanently alleviate or eliminate a medical condition.

Objective Findings:  Verifiable indications of injury or disease such as range of motion, atrophy, muscle strength and palpable muscle spasm.  Objective findings do not include physical findings or subjective responses to physical examinations that are not reproducible, measurable or observable.

Medically Stationary:  No further material improvement would reasonably be expected from medical treatment, or the passage of time.

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Missed Appointment Charge
Under the Oregon Administrative Rules (OAR) 436-009-0015 (5): No fee is payable for a missed appointment (except a closing examination or an appointment arranged by the insurer or the department).  When the worker fails to appear without providing the medical provider at least 24 hours notice, the medical provider shall be reimbursed at 50% of the examination or testing fee.

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Workers' Comp Division (WCD) Internet Links

Medical Provider Information
http://www.oregonwcd.org/site_map.html#medprovi

Managed Care Organization (MCO) Information
http://www.cbs.state.or.us/external/wcd/compliance/ioac/mco/mcoweb.html

WCD Rules
http://www.cbs.state.or.us/external/wcd/policy/rules/oarors.html

WCD Forms
http://www.cbs.state.or.us/external/wcd/site_map.html#forms

WCD's Spanish Information
http://www.cbs.state.or.us/external/wcd/site_map.html#espanol

WCD's Employer Index
http://www.cbs.state.or.us/external/wcd/compliance/ecu/empcoverage.html

Physician's Guide for Reporting Oregon On-the-job Injuries
http://www.oregonwcd.org/communications/publications/3248.pdf

WCD Bulletins
www.cbs.state.or.us/external/wcd/policy/bulletins/ab_index.html

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Newsletters for CareMark Comp
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