4123-3-36 Immediate allowance and payment of medical bills in claims.

(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