Ohio Workers' Compensation C-9 Treatment Authorization: Provider Guide

The C-9 workflow addresses whether proposed care should be authorized and reimbursed. It is not a substitute for allowance of a diagnosis, claim compensability, or a later medical-bill appeal. Provider teams should identify the actual issue before transmitting a form: treatment authorization, an additional condition, a medical-payment dispute, and a legal claim issue can follow different routes.

This guide focuses on Ohio state insurance fund claims operating through a health partnership program MCO. Self-insuring employers administer medical care under different rules and procedures. Confirm the employer's coverage status and the responsible decision-maker at intake rather than assuming every Ohio claim uses the same three-business-day MCO workflow.

Ohio C-9 workflow at a glance

1. Confirm the claim and decision-maker

Before preparing a treatment request, verify the injured worker's name, claim number, date of injury, employer, MCO, physician of record, and the conditions currently allowed in the claim. A request can be clinically reasonable yet procedurally misrouted when staff send it to BWC instead of the MCO, treat a self-insured employer as a state-fund claim, or request care for a diagnosis that has not been allowed.

• Confirm whether the employer participates in the state insurance fund or is self-insured.
• Identify the MCO currently assigned to the employer and claim.
• Reconcile the diagnosis and body part in the request with the allowed claim conditions.
• Identify the physician of record and the rendering provider when they differ.
• Separate a recommendation for an additional condition from the request for a specific service.
• Check whether the requested care qualifies for presumptive approval or another specific rule before treating formal prior authorization as mandatory.

2. Define the requested service precisely

The MCO should not have to infer the proposed course of care from a general treatment plan. Identify the service or procedure, diagnosis, frequency, duration, units, site of service, facility, and proposed start date. When equipment, medication, rehabilitation, or a staged procedure is requested, describe the exact item and requested period rather than using a broad label.

A strong C-9 packet is both clinically persuasive and auditable. Index the records actually relied upon, date the narrative, identify the author, and preserve a copy of the exact submission. If a guideline or MCO criterion is known, address its elements directly without presenting the criterion as controlling law.

3. Submit to the MCO and prove receipt

Ohio BWC directs providers to send the completed and signed C-9 with supporting medical information to the designated MCO. Use the MCO's current submission channel and retain the fax confirmation, portal acknowledgement, electronic receipt, or other reliable evidence showing the date and time received.

1. Verify the MCO and its current authorization address, fax, or portal destination.
2. Confirm that the patient, claim, provider, diagnosis, and proposed service are consistent across the form and attachments.
3. Transmit one indexed packet rather than separate records that cannot be matched to the request.
4. Save the signed C-9, every attachment, and delivery confirmation in the authorization record.
5. Enter the confirmed receipt date and the three-business-day decision target in the work queue.

4. Track the three-business-day MCO decision

Ohio BWC's provider guidance states that the MCO must provide a decision to the physician within three business days. The MCO returns the request as authorized, denied, or pending. Staff should retrieve the actual written determination and compare it with the submitted request; a telephone status update is not an adequate substitute for the document that controls scope and appeal rights.

Do not generalize the three-business-day rule to self-insured employer handling. Also avoid declaring a request approved solely because a response was not visible in the provider's system. Confirm receipt, contact the responsible entity, preserve the timing evidence, and apply the current rule and notice to the claim's facts.

5. Respond to a pending request without losing the record

A pending response should identify the documentation the MCO needs to complete review. The current C-9 instructions state that requested documentation must be submitted to the MCO case manager within 10 business days to allow a treatment decision. Calendar that date from the written request and answer the stated gap directly.

• Record the date the pending request was received and the exact information requested.
• Determine whether the information already appeared in the original packet and point the reviewer to it if so.
• Obtain a focused addendum when the clinical rationale, treatment history, or service scope is genuinely incomplete.
• Transmit the response with the claim number and original C-9 reference.
• Preserve the added records and a second delivery confirmation.
• Escalate internally when the request seeks information unrelated to the stated decision issue.

6. Appeal an initial treatment decision through C-11

Ohio BWC's C-11 instructions state that an appeal of the MCO's initial medical treatment or service decision must be filed with the MCO within 14 days after receipt of the written notice. The C-11 starts the MCO alternative dispute resolution process. The current ADR rule covers disputes among an employer, injured worker, provider, and MCO arising from an MCO decision on a C-9 or equivalent request.

The appeal should identify the disputed decision, specify the medical reason for disagreement, and include the records that answer the denial. Avoid resending an undifferentiated chart. Quote the rationale, correct factual errors, connect objective findings to the allowed condition, and explain why the requested care is reasonably related and medically necessary.

7. Understand the 21-day ADR period and party rights

Ohio BWC states that the MCO's dispute resolution process must be completed within 21 days after written receipt of the dispute unless the MCO reverses its decision. The process can include an independent medical examination or peer review and results in the next formal determination or order. Preserve the reviewer's report, evidence list, dates, and final notice.

Provider participation does not mean the provider holds every statutory appeal right available to the injured worker or employer. The notice and current rule should be reviewed to determine who may pursue the next level, where it must be filed, and the deadline. Provider staff should coordinate the clinical record with the injured worker or authorized representative without assuming authority to prosecute a party's legal appeal.

Provider quality-control checklist

• State-fund versus self-insured status confirmed.
• Correct MCO, claim number, physician of record, and allowed conditions verified.
• Requested service, units, duration, facility, and proposed date are specific.
• Clinical narrative ties objective findings and prior care to the allowed claim.
• Signed C-9, indexed attachments, and receipt evidence retained.
• Three-business-day MCO decision target calendared.
• Any pending-documentation request assigned and tracked for 10 business days.
• Written decision reconciled against the requested scope.
• C-11 appeal filed with the MCO within 14 days when appropriate.
• ADR completion, reviewer materials, and further party rights tracked separately.
• Authorization record carried into scheduling, treatment, coding, and billing.

Related Millennova Legal resources

Use Millennova Legal's workers' compensation dispute support and workers' compensation state-guide hub for broader jurisdiction context. Compare the state-specific authorization sequence with the Texas workers' compensation preauthorization guide and the New York OnBoard PAR guide.

Ohio primary sources