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Ohio Laws and Rules
(A) In accordance with division (A) of section 4123.511 of the Revised Code the administrator has established a program to immediately allow specific medical conditions which have a historical record of being allowed whenever included in a claim and having low medical costs.
(1) The administrator has identified these medical conditions by ICD code and narrative description.
(2) The administrator used historical statistical criteria to determine the appropriate specific medical conditions to include in the program. The criteria included but was not limited to the following:
(a) Number of claims for the medical condition;
(b) Per cent of claims for the medical condition disputed;
(c) Per cent of claims for the medical condition appealed;
(d) Per cent of claims for the medical condition disallowed; and
(e) Average cost for the medical condition per claim.
(3) The medical conditions that the administrator determined to be included attached as appendix A of this rule.
(B) Upon the initial filing of a claim, the administrator shall investigate the claim and issue an order on the claim as required by section 4123.511 of the Revised Code. The administrator shall consider all of the necessary evidence and relevant laws and rules for the determination of the allowance of a claim. For any medical condition identified in appendix A to this rule, however, the administrator may grant immediate allowance of the medical condition and may make immediate payment of the medical bills relating to that condition, regardless of the receipt of the medical reports for that medical condition or the employer's certification of the claim.
(C) The employer retains the right to contest the immediate allowance and payment of a medical condition in a claim under this rule. If the employer appeals the allowance and payment and the claim is disallowed, the payment for the medical treatment provided prior to the date of the disallowance of that claim shall be charged to and paid from the surplus fund created under section 4123.34 of the Revised Code. The administrator shall not seek reimbursement of the payment from the injured worker or the provider.
Appendix A
ICD Code ICD Description
692.79 Solar dermatitis nec
872.02 Opn wound auditory canal
872.69 Open wound of ear nec
873.21 Open wound nasal septum
873.22 Open wound nasal cavity
873.65 Open wound of palate
878.0 Open wound of penis
878.4 Open wound of vulva
878.8 Open wound genital nec
879.4 Opn wnd lateral abdomen
879.6 Open wound of trunk nec
880.01 Open wound of scapula
880.02 Open wound of axilla
922.33 Contusion of interscapular region
930.2 FB in lacrimal punctum
940.3 acid burn cornea/conjunc
941.13 1st deg burn lip
941.14 1st deg burn chin
941.16 1st deg burn scalp
942.10 1st deg burn trunk nos
942.19 1st deg burn trunk nec
943.14 1st deg burn axilla
943.15 1st deg burn shoulder
943.19 1st deg burn arm-mult
945.11 1st deg burn toe
945.19 1st deg burn leg-mult
877.0 Open wound of buttock
940.1 Burn periocular area nec
941.12 1st deg burn eye
872.01 Open wound of auricle
943.12 1st deg burn elbow
941.11 1st deg burn ear
883.0 Open wound of finger
944.14 1 deg burn fingr w thumb
942.12 1st deg burn chest wall
881.00 Open wound of forearm
879.2 Opn wnd anterior abdomen
881.02 Open wound of wrist
918.0 Superfic inj eyelids
944.15 1st deg burn palm
882.0 Open wound of hand
914.6 Foreign body hand
873.44 Open wound of jaw
921.3 Contusion of eyeball
913.6 Foreign body forearm
873.64 Opn wnd tongue/mouth flr
930.0 Corneal foreign body
930.1 FB in conjunctival sac
890.0 Open wound of hip/thigh
Effective: 02/10/2009
R.C.
119.032 review dates: 11/21/2008
and 02/01/2014
Promulgated Under:
119.03
Statutory
Authority:
4121.12,
4121.121,
4121.30,
4121.31,
4123.05
Rule
Amplifies:
4121.12,
4121.121,
4123.511
Prior
Effective Dates: 12/17/01