Glossary of Terms

WORKERS’ COMPENSATION TERMINOLOGY

ALLOWED CONDITION: Condition recognized as reimbursable in a claim which is a direct result of an industrial or occupational injury.

AUTHORIZATION (prior authorization) Notification by an authorized representative of the MCO that a specific treatment, service, or equipment is medically necessary for the diagnosis and/or treatment of an allowed condition, except that the bureau reserves the authority to authorize or prior authorize the following services: caregivers, and home and van.

BUREAU CERTIFIED PROVIDER: A credentialed provider who signs a provider agreement with the bureau and is approved by the bureau for participation in the HPP.

CONSULTATION: Services rendered by a physician at the request of another physician regarding diagnosis, treatment and recommendations for continuing medical care in a particular case.  A consultant is expected to render an opinion only.

COVERED SERVICES: Medical services or supplied which are reimbursable under the Ohio workers’ compensation program.

CREDENTIALING (RECREDENTIALING): A process by which the bureau validates or reviews the application of a participation in the HPP.

DISPUTE RESOLUTION: Procedures developed by the MCO or the bureau to resolve medical disputes prior to filing an appeal.

FORMULARY: A list of medications determined to be safe and effective by the food and drug administration which the bureau shall consider for reimbursement.  The list shall be regularly reviewed and updated by the bureau to reflect current medical standards of drug therapy.

HANDICAPPED EMPLOYEE: An employee who is afflicted with or subject to any physical or mental impairment, or both, whether congenial or due to an injury or disease of such character that the impairment constitutes a handicap in obtaining employment or would constitutes a handicap in obtaining employment or would constitute a handicap in obtaining reemployment if he should become unemployed, and which impairments is due to certain physical conditions or disease.

HEALTH PARTNERSHIP PROGRAM (HPP): The bureau of workers’ compensations comprehensive managed care program under the direction of the chief of medical management and cost containment.

HEAVY WORK: Exerting fifty to one hundred pounds of force occasionally, and/or twenty to fifty pounds of force frequently and/or ten to twenty pounds of force constantly to move objects.  Physical demand requirements are in excess of those for medium work.

INDEPENDENT MEDICAL EVALUATION (IME): An evaluation performed by a physician other than the treating physician.  An IME usually encompasses a study of previous history and medical care information, e.g. x-rays and lab studies, as well as an examination of the injured worker.  This service may be necessary in order to make a judgment regarding the current status of the injured worker or to determine the need for further medical services.

LIGHT WORK: Exerting up to twenty pounds of force occasionally, and/or up to ten pounds of force frequently, and/or a negligible amount of force constantly (constantly: activity or condition exists two-thirds or more of the time) to move objects.  Physical demand may be only a negligible amount, a job should be rated light work: 1. when it requires walking or standing to a significant degree; or 2. when it requires sitting most of the time but entails pushing and/or pulling or arm or leg controls: and /or 3. When the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.

LOST TIME CLAIM: A claim that takes the injured worker off work eight or more calendar days away from work on an industrial or occupational claim.

MAXIMUM MEDICAL IMPROVEMENT: 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.  A claimant may need supportive treatment to maintain this level of function.

MCO PANEL PROVIDER: A bureau certified provider who is a provider included within an HPP certified MCO.

MEDICAL-ONLY CLAIM: The claim filed when seven or fewer calendar days are lost from the job due to an industrial/occupational injury and for which no compensation is paid.

MEDICATION: A drug or a remedy prescribed for treatment of injuries and diseases or for relieving pain.

MEDIUM WORK: Exerting twenty to fifty pounds of force occasionally, and/or ten to twenty five force frequently, and or greater than negligible up to ten pounds of force constantly to move objects.  Physical demand requirements are in excess of those for light work.

OCCUPATIONAL DISEASE: An occupational disease is defined by O.R.C. 4123.68 and is generally a disease contracted in the course of employment, usually occurring over a period of time.

PERMANENT TOTAL DISABILITY: The inability to perform sustained remunerative employment due to the allowed conditions in the claim within reasonable probability, continue for an indefinite period of time without any present indication of recovery there from.

PHYSICIAN: A doctor of medicine, doctor of osteopathic medicine or surgery, or doctor of podiatric medicine who holds a current, valid certificate of licensure to practice medicine or surgery, osteopathic medicine or surgery, or podiatry, a doctor of chiropractic who holds a current, valid certificate of licensure to practice chiropractic , a doctor of mechanotherapy who holds a current, valid certificate of licensure to practice psychology, or a dentist who holds a current, valid certificate of licensure to practice dentistry.

PHYSICIAN OF RECORD (ATTENDING PHYSICIAN): The authorized physician chosen by the injured worker to direct treatment.

PHYSICIAN OF RECORD: The primary care attending physician. BWC permits treatment by only one physician at a time for treatment of the allowed condition(s) in the claim. The injured worker must send a written request to change the physician of record.  The physician of record (attending physician) may be a doctor of medicine, doctor of osteopathic medicine, doctor of chiropractic, and in specific cases, a podiatrist, psychologist, mechanotherapist or dentist.

PRACTITIONER: A physician, or a physical therapist, occupational therapist, optometrist, or any other person currently licensed and duly authorized to practice within their respective health care field.

PROVIDER PROFILING: A medical management analysis tool used by the bureau or MCO which at a minimum utilizes line item detail from a medical bill and employee specific information such a s demographics diagnosis allowances and other data regarding treatment, to evaluate a health care provider on the basis of cost, utilization and treatment outcomes.

REMITTANCE ADVICE: An itemized listing of bills paid or denied during the payment process.

RESIDUAL FUNCTIONAL CAPACITY: The maximum degree to which the claimant has the capacity for sustained performance of the physical-mental requirements of job as these relate to the allowed condition in the claim.

SEDENTARY WORK: Exerting up to ten pounds of force occasionally (occasionally: activity or condition exists up to one-third of the time) and/or a negligible amount of force frequently (frequently; activity or condition exists from one-third to two-thirds of the time) to lift, carry, push, pull or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking and standing are required only occasionally and all other sedentary criteria are met.

TRANSITIONAL WORK:  A program designed to safely bring the injured work back to work in a gradual process within the injured workers restrictions to extend between 7 and 12 weeks.

TREATMENT GUIDELINES: 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.

VERY HEAVY WORK: Exerting in excess of one hundred pounds of force occasionally, and /or in excess of fifty pounds of force frequently, and/or in excess of twenty pounds of force constantly to move objects.  Physical demand requirements are in excess of those for heavy work.

WAGE CONTINUATION: An optional program employers can select to pay the injured worker their normal salary from day one of their injury rather than letting the bureau pay and affecting their premium.