Presumptive Approval Guidelines

The following procedures require prior authorization. To obtain prior authorization, please submit your request on a C-9 Treatment Plan Form in box 12, side 2 to CHS via fax 1-800-334-4229 or mail to CHS PO Box 1040, Dublin, Ohio 43017.

For a period not to exceed 45 days following the date of injury physicians have presumptive approval for providing the following services when treating soft tissue and musculoskeletal injuries (for example, lumbosacral sprain/strain, contusion head, open wound finger, etc.) for allowed conditions is allowed claims:

10 physical medicine visits including osteopathic, chiropractic, physical therapy and occupational therapy.

• Diagnostic studies, including x-rays, CAT scans, MRI scans and EMG/NCV.
• Injections up to three soft tissue or joint injections (does not include epidural injections).
• E/M services and consultation services.

The following criteria must be met prior to initiating any or all of the aforementioned services:

• The provider shall file the First Report of Injury (FROI) with MCO.
• The provider shall complete and file the C-9 Treatment Plan with the MCO.
• The provider shall notify the MCO within 24 hours of treatment if the injured worker will be off work for more than 2 calendar days.

Important: Except for emergency services, the services listed in the MCO standardized prior authorization table below that do not fall within the presumptive approval parameters still require prior authorization. Providers must submit a C-9 to indicate services to be provided through formal authorization.

Standardized Prior Authorization Table

Service	Requirement
Physical medicine services, including chiropractic/osteopathic manipulative treatment and acupuncture	Prior authorization
Consultation (Phych/chronic pain program)	Prior authorization
Dental	Prior authorization
Diagnostic testing	Prior authorization
DME	PA if > $250.00 total cost of service, supply or device, rental or purchase
Home/auto/van modifications	PA required from BWC
Home health agency service	Prior authorization
Hospital inpatient treatment, including surgery and outpatient/ASC surgery	PA for surgery from date of injury, if not emergency
Injections	Prior authorization
Non-emergency ambulance services	Prior authorization
Orthotic and prosthetic devices and/or repair	PA > $250.00
Skilled Nursing Facility (SNF)/Extended Care Facility (ECF)	Prior authorization
Vision services	Prior authorization
Vocational rehabilitation – All vocational rehabilitation services, including remain at work, in or out of plan.	Prior authorization Note: Chronic pain and stress AND work hardening require CARF accreditation

PA = prior authorization