Ohio C-9 Forms: Treatment Requests and Denials

What does a C-9 request?

A provider can use a C-9 to request services such as diagnostic testing, therapy or surgery. The request identifies the claim, the proposed services and the medical support. The form includes space for service codes, frequency, duration and dates.

For a state-fund claim, Ohio’s treatment-request rule asks whether the proposed care is reasonably related to the allowed conditions, reasonably necessary for those conditions and medically reasonable in cost. A request needs evidence addressing the actual treatment and the conditions recognized in the claim.

A C-9 can also recommend an additional condition. That does not itself add the diagnosis to the claim. In state-fund claims, BWC decides requests for additional conditions, as the form instructions explain.

C-9, MEDCO-14 and C-84: three different jobs

C-9: medical services

The provider requests treatment or recommends additional conditions. Treatment approval does not, by itself, establish entitlement to lost-wage payments.

MEDCO-14: medical work status

The provider reports work abilities, restrictions and supporting medical findings. Read our MEDCO-14 checklist.

C-84: a request for temporary total compensation

The worker requests temporary total disability benefits. The medical support is a separate part of that process. See our Ohio temporary total disability guide.

A claim can have a pending treatment request and a separate work-status or benefit issue at the same time. Ask which decision is holding up the care or payment you need.

Who completes the form, and what can you check?

The provider prepares and signs the medical request. The official instructions call for supporting medical documentation. The worker can help by checking practical facts and obtaining copies, without changing the provider’s medical findings.

• Confirm the request was submitted. Ask the provider for the date, recipient and a copy of the C-9 and attachments.
• Check the service. Does it describe what the provider recommended, including the number of visits or treatment period?
• Identify the condition. Ask whether the request concerns an allowed condition or whether an additional-condition issue remains unresolved.
• Find out whether more information was requested. A missing report may need a different response from a decision that treatment is not medically necessary.
• Keep the response. Save the written decision, any explanation and the date received.

The treatment-request rule distinguishes a request for more evidence, a treatment decision and dismissal in specified circumstances. Do not assume every notice labeled “not approved” presents the same issue.

Treatment denied? First identify who issued the decision

An MCO denied or changed a treatment request

In a state-fund claim covered by the MCO dispute rule, the worker, employer or provider may submit a written dispute to the MCO using a C-11 or an equivalent written request. The deadline is 14 days from receipt of the written initial MCO decision. The current C-11 form asks what service is disputed, why the decision should change and what new medical information supports the request.

This is the MCO’s alternative dispute resolution process. Under Ohio Administrative Code 4123-6-16, it comes before an appeal under the claim-appeal statute. The MCO process leads to a recommendation and a BWC order; that order has its own appeal rights. Keep proof that the dispute was sent to the correct MCO.

BWC issued an order

Read the order to identify what BWC decided. It may concern an allowed condition, a claim issue or a treatment dispute following MCO review. The Ohio appeal statute generally gives the claimant or employer 14 days after receipt to appeal a BWC order. Follow the order’s instructions and identify the correct filing destination. Do not treat an appeal of that order as another initial C-11 request.

A self-insured employer refused treatment

The C-9 instructions direct self-insured requests to the employer. Do not assume the state-fund MCO/C-11 procedure applies. Obtain the employer’s written position, identify the disputed service or condition and review the appropriate filing route for that claim. Contested self-insured claim issues can reach the Industrial Commission under R.C. 4123.511.

If you cannot tell which type of notice you have, send the complete document for review promptly. The sender, decision date, receipt date and appeal instructions matter more than a shorthand description of “the insurance denial.”

Match the response to the reason for refusal

Ask the provider and your representative to identify the precise issue. If the request lacks a recent examination or an explanation of medical necessity, the response should address that missing support. If the treatment is tied to a condition not allowed in the claim, the condition issue may also need attention.

A repeated request with unchanged records may not resolve the problem. Ohio’s treatment-request rule includes circumstances for dismissing a duplicate request after a final denial when there are no new or changed circumstances. Ask what additional evidence or procedural step is needed before simply submitting the same form again.

Keep medical decisions with your treating provider. If your condition worsens or you have an urgent care question, contact the provider; a pending administrative dispute is not medical advice about whether it is safe to wait.

Keep these records together

• The C-9 and supporting medical reports.
• The written response and any request for more information.
• The date you received the decision.
• The claim number, MCO or self-insured employer contact, and allowed conditions.
• Any C-11, appeal or other filing and proof of submission.
• Your next appointment and the treatment that is being delayed.

For help understanding the claim process, read how an Ohio BWC attorney can help. If the claim itself was denied, start with our denied-claim and appeal guide. Bring the treatment request and decision when you contact Cox, Koltak & Gibson.