GJ KNUX Y Z
Select a letter from the list above to be taken directly to that section.
an option for state fund employers in which an employer can elect to pay the first $15,000 of medical bills for medical only claims.
The patient's ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care.
Statistical calculations used to determine the rates and premiums that managed care companies charge their customers. The calculations are based on projections of utilization and cost for a defined population.
A person who determines insurance policy rates, reserves and dividends, and performs other statistical studies. Rates or contracts should not be developed without an Actuary working for you in some way.
A pattern of health care in which a patient is treated for an acute (immediate and severe) episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Acute care is usually given in a hospital by specialized personnel using primitive equipment and materials. Acute care is typically only short time.
The processing of claims according to contract.
Costs related to utilization review, insurance marketing, medical underwriting, agents' commissions, premium collection, claims processing, insurer profit, quality assurance programs and risk management.
A contract between an insurance company and a self-funded paln where the insurance company performs administrative services only and the self-funded entity assumes all risk.
A medical condition recognized by BWC as a direct result of an industrial injury or occupational disease.
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Bureau of Workers´ Compensation, the administrative branch of the Ohio workers´ compensation systems.
A credentialed provider who signs a provider agreement with BWC and is approved by BWC for participation in the Health Partnership Program (HPP).
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A nine-character number assigned to a claim for identification. With the current numbering scheme, the first two digits represent the year of injury, i.e. 97-300001.
The component of a computer-based patient record (CPR) which accepts, files and stores clinical data over time from a variety of supplemental treatment and intervention systems for such purposes as practice guidelines, outcomes management, and clinical research. Also referred to as Data Warehousing.
The capability of a data system to provide key data to physicians and other clinicians in response to "flags" or triggers which are functions of embedded, provider-created rules.
Preferred treatment/intervention activities. An outline of information needed to make decisions, the timelines for applying that information, and what action needs to be taken by whom. Provides ways to monitor care. The pathways are created by clinicians based on specific diseases or events.
A medical condition that, along with principle diagnosis, exists at admission and is expected to increase hospital stay by at least one day.
A legal agreement between a payer and a subscribing group/individual which specifies rates, performance pledges, relationships among parties, schedule of benefits and other pertinent conditions. Contract length is usually a 12-month period and is subject to renewal afterward. Contracts are not required by statute or regulation and other agreements may be made.
Any hospital, skilled nursing facility, extended care facility, individual, organization or agency licensed that has a contractual arrangement with an insurer for the provision of services under an insurance contract.
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The date an employee suffers an injury or contacts an occupational disease at work.
An alteration of an individual´s capacity to meet personal, social, or occupational demands or statutory or regulatory requirements; assessed by non-medical means.
Under the Health Partnership Program (HPP), procedures developed by the MCO or BWC to resolve medical disputes prior to filing an appeal.
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The science that seeks to adapt work or working conditions to suit the worker.
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In workers´ compensation, an intentional act or series of acts resulting in payments or benefits to a person or entity that is not entitled to receive those payments or benefits.
A comprehensive evaluation of the ability of a worker to perform job tasks. The evaluation can be job-task specific or generic.
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A health plan that satisfies the QHP certification requirements and is certified by the bureau as a QHP to manage medical treatment, direct care or provide services or supplies to or on behalf of an employee for a compensable injury or occupational disease.
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The claims adjudicative branch of the Ohio workers´ compensation system.
Statistical classification system for medical diagnosis of diseases and injuries used by health-care providers to list condition(s) being treated in a workers´ compensation claim.
A medical examination by a specialist in the appropriate field, appointed by BWC to examine the injured worker.
An alteration of an individual´s health status that is assessed by medical means.
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payment to injured worker instead of workers´ compensation benefits while he or she is participating in an approved rehabilitation plan.
in Ohio, a claim filed when an employee loses eight or more calendar days from his or her job due to an industrial injury or occupational disease. Lost time claims remain open for 10 years from the last date of payment of either compensation or medical payment.
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a system of health care delivery that influences utilization and cost of services and measures performance. The goal is a system that delivers value by giving people access to quality, cost-effective health care.
a provider of medical management and cost containment services through provider networks serving injured workers.
BWC certified provider included within the network of an HPP certified MCO.
in Ohio, a claim filed when an employee loses seven or fewer calendar days from his or her job as a result of an industrial injury or occupational disease.
• Medical only claims occurring before 10/20/93 remain open for six years from the date of injury if no compensation has been issued.
• Medical only claims occurring after 10/20/93 remain open for six years from the last date of payment in the claim.
a treatment plateau (static or well stabilized) at which no fundamental functional or physiological change can be expected within reasonable medical probability, In spite of continuing medical or rehabilitative procedures. An injured worker may need supportive treatment to maintain this level of function, and may receive payment for medical services relating to the claim.
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a disease contracted in the course of employment.
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the identification number assigned to an employer by BWC (formerly risk number).
a physician or practitioner, or any person, firm, corporation, limited liability corporation, partnership, association, agency, institution, or other legal entity licensed, certified or approved by a professional standard setting body and approved by BWC, or by a regulatory agency under title XIII or XIV of the Social Security Act and approved by BWC to provide particular medical services or supplies, including but not limited to: a hospital, qualified rehabilitation provider, pharmacist, or durable medical equipment supplier.
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an arrangement implemented by BWC in which a self-insured employer may contract with a managed care organization and pay medical costs directly. State fund employers or groups of state fund employers will soon have this option also.
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return to work.
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a privilege granted to employers with sufficient financial ability to pay workers´ compensation claims directly.
an agreement among the employer, the injured worker and BWC on a specific dollar amount to settle one or more claims or parts of a claim.
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wage replacement compensation paid for a temporary disability that prevents an employee from returning to his or her job at the time of injury. In Ohio, payment continues until the injured worker returns to work; the attending physician states injured worker is capable of returning to work; or the temporary disability has become permanent (MMI); or work within the physical capability of the employee is made available by an employer.
an early return to work strategy involving performance of work tasks for pay. These tasks can be safely performed by a worker whose ability to perform the original job has been compromised.
guidelines of medical practice developed through consensus of practitioner representatives, that assist a practitioner and a patient in making decisions about appropriate health care for specific medical conditions.
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individualized services that promote a permanent, safe, cost effective return to work and where the focus is shifted from medical management (getting the IW better) to vocational management (getting the IW back to work).
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a clinic-based, multidisciplinary program that includes the use of real and/or simulated work tasks along with physical reconditioning to improve the functional capacity of an injured worker to perform a targeted job.
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