Chapter 4123-6 Health Partnership Program

As used in the rules of this chapter and Chapter 4123-7 of the Administrative Code:

(A) “Health partnership program” or “HPP” means:

The bureau of workers’ compensation’s comprehensive managed care program under the direction of the chief of injury management services as provided in sections 4121.44 and 4121.441 of the Revised Code.

(B) “Qualified health plan” or “QHP” means:

A health care plan sponsored by an employer or a group of employers which meets the standards for qualification developed by the health care quality advisory council and is certified as a qualified health care plan with the bureau.

(C) “Managed care organization” or “MCO” means:

A vendor as defined under section 4121.44 of the Revised Code who has contracted with the bureau to provide medical management and cost containment services as part of the HPP as provided in sections 4121.44 and 4121.441 of the Revised Code. As used in these rules, a managed care organization is not a health care provider.

(D) “Physician” means:

As defined in division (B) of section 4730.01 of the Revised Code, 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 under Chapter 4731. of the Revised Code; as provided in section 4734.09 of the Revised Code, a doctor of chiropractic who holds a current, valid certificate of licensure to practice chiropractic under Chapter 4734. of the Revised Code; as provided in section 4731.151 of the Revised Code, a doctor of mechanotherapy who holds a current, valid certificate of licensure to practice mechanotherapy under Chapter 4731. of the Revised Code and who was licensed prior to November 3, 1985; a psychologist who holds a current, valid certificate of licensure to practice psychology under Chapter 4732. of the Revised Code; or a dentist who holds a current, valid certificate of licensure to practice dentistry under Chapter 4715. of the Revised Code. A physician licensed pursuant to the equivalent law of another state shall qualify as a physician under this rule.

(E) “Physician of record” or “attending physician” means:

For the purposes of Chapters 4121. and 4123. of the Revised Code, the authorized physician chosen by the employee to direct treatment.

(F) “Practitioner” means:

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.

(G) “Health care provider” or “provider” means:

A physician or practitioner, or any person, firm, corporation, limited liability corporation, partnership, association, agency, institution, or other legal entity licensed, certified, or approved by a professional standard-setting body or by a regulatory agency under title XIII or XIX of the Social Security Act to provide particular medical services or supplies, including, but not limited to: a hospital, qualified rehabilitation provider, pharmacist, or durable medical equipment supplier.

(H) “Credentialing” or “recredentialing” means:

A process by which the bureau validates or reviews the application of a provider for eligibility for participation in the HPP.

(I) “Certification” or “recertification” means:

A process by which the bureau approves a provider or MCO for participation in the HPP.

(J) “Provider application and agreement” means:

A bureau form which requests background information and documentation necessary for credentialing and which, if completed and signed by the provider and approved by the bureau, constitutes a written, contractual agreement between the bureau and a provider. The provider application and agreement may include a provider statement or affirmation that the statements made in the application and agreement are true.

(K) recertification application and agreement” means:

A provider application and agreement sent by the bureau to bureau certified providers as part of the provider recredentialing and recertification process.

(L) “Bureau certified provider” means:

A credentialed provider who has completed and signed a provider application and agreement or recertification application and agreement with the bureau and is approved by the bureau for participation in the HPP.

(M) “Non-bureau certified provider” means:

A provider who has not completed and signed a provider application and agreement or recertification application and agreement with the bureau and is not approved by the bureau for participation in the HPP, or whose certification has lapsed and has not been reinstated pursuant to rule 4123-6-02.4 of the Administrative Code. A non-bureau certified provider may participate in the HPP pursuant to rule 4123-6-027 of the Administrative Code.

(N) “Employee” means:

As used in the rules of this chapter, the term “employee” includes the terms “injured worker” and “claimant” and all employees of employers covered under HPP.

(O) “Emergency” means:

Medical services that are required for the immediate diagnosis and treatment of a condition that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death, or that are immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency, but is necessary to determine whether an emergency exists.

(P) “Medical management and cost containment services” means those services provided by an MCO pursuant to its contract with the bureau, including return to work management services, that promote the rendering of high-quality, cost-effective medical care that focuses on minimizing the physical, emotional, and financial impact of a work-related injury or illness and promotes a safe return to work.

(Q) “Medically necessary” means:

Services which are reasonably necessary for the diagnosis or treatment of disease, illness, and injury, and meet accepted guidelines of medical practice. A medically necessary service must be reasonably related to the illness or injury for which it is performed regarding type, intensity, and duration of service and setting of treatment.

(R) “Authorization” or “prior authorization” means:

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: caregiver services, home and van modifications, and return to work management services pursuant to paragraph (D) of rule 4123-6-04.6 of the Administrative Code.

(S) “Dispute resolution” means:

Procedures developed by the MCO or the bureau to resolve medical disputes prior to filing an appeal under section 4123.511 of the Revised Code.

(T) “Provider outcome measurement” means:

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 including, but not limited to, demographics, diagnosis allowances return-to-work and remain-at-work statistics, and other data regarding treatment, to evaluate a health care provider on the basis of cost, utilization and treatment outcomes efficiency and compliance with bureau requirements.

(U) “Utilization review” means:

The assessment of an employee’s medical care by the MCO. This assessment typically considers medical necessity, the appropriateness of the place of care, level of care, and the duration, frequency or quality of services provided in relation to the allowed condition being treated.

(V) “Treatment guidelines” mean:

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.

(W) “Formulary” means:

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.

(X) “Medication” means:

The same as drug as defined by division (C) of section 4729.02 of the Revised Code.

(Y) “Injury” means:

For the purposes of the rules of this chapter and Chapter 4123-7 of the Administrative Code only, an injury as defined in division (C) of section 4123.01 of the Revised Code or an occupational disease as defined in division (F) of section 4123.01 of the Revised Code.

(Z) “Return to work services” means:

Services to support an injured worker in returning to employment where the injured worker is experiencing difficulty as a result of conditions related to an allowed lost time claim.

(AA) “Remain at work services” means:

Services to support an injured worker or employee in continued employment where the injured worker is experiencing difficulties performing a job as a result of conditions related to an allowed medical only claim.

(BB) “Transitional work” means:

A work-site program that provides an individualized interim step in the recovery of an injured worker with job restrictions resulting from the allowed conditions in the claim. Developed in conjunction with the employer and the injured worker, or with others as needed, including, but not limited to the collective bargaining agent (where applicable), the physician of record, rehabilitation professionals, and the MCO, a transitional work program assists the injured worker in progressively performing the duties of a targeted job.

HISTORY: Eff 2-16-96; 9-5-96; 1-1-99; 1-1-01; 3-29-02; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

(A) The bureau is authorized to credential and certify a provider who wishes to participate in the HPP. The bureau is authorized to recredential and recertify a provider at least every two years. The bureau may, but is not required to, recredential and recertify providers on a staggered basis, in order of the provider’s initial certification date.

(B) A provider shall be certified or recertified by the bureau to treat employees under the HPP if the provider agrees to provide care to injured workers; participate in provider outcome measurement, peer review, quality assurance and utilization reviews; meet and maintain basic credentialing criteria under rule 4123-6-02.2 of the Administrative Code and as established by the bureau; and completes and signs a provider application and agreement or recertification application and agreement with the bureau.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/15/99, 1/1/01, 3/29/02

(A) The bureau shall establish an initial enrollment period to identify and contact providers for participation in the HPP upon inception of the HPP. The bureau shall contact all providers currently enrolled or providing services in the workers’ compensation system, and may contact providers through state boards and provider associations.

(B) After the initial provider enrollment period at the inception of the HPP, the bureau shall continue to credential and certify providers and shall periodically, at least annually, update its list of bureau certified providers.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96

(A) The bureau shall establish minimum credentialing criteria for providers to qualify for participation in the HPP. Providers must meet all licensing, certification, or accreditation requirements necessary to provide services in Ohio. A provider licensed, certified or accredited pursuant to the equivalent law of another state shall qualify as a provider under this rule in that state.

(B) The minimum credentials for a provider, where applicable based upon the type of provider, are as follows. The provider shall:

(1) Be currently licensed to practice, as applicable, without disciplinary restrictions that affect the provider’s ability to treat patients, that compromise patient care, or that are related to chemical dependency or substance abuse.

(2) Meet other general certification requirements for the specific provider type, as provided in paragraph (C) of this rule.

(3) Possess a current and unrestricted drug enforcement agency registration, unless it is not required by the provider’s discipline and scope of practice.

(4) Be currently eligible for participation in medicare, medicaid or the Ohio workers’ compensation system.

(5) Not have a history of a felony conviction in any jurisdiction, a conviction under a federal controlled substance act, a conviction for an act involving dishonesty, fraud, or misrepresentation, a conviction for a misdemeanor committed in the course of practice, or court supervised intervention or treatment in lieu of conviction pursuant to section 2951.041 of the Revised Code or the equivalent law of another state.

(6) Provide proof of and maintain adequate, current professional malpractice and liability insurance. The bureau shall establish the appropriate amount of such insurance coverage for each provider type. In establishing the appropriate amount of insurance coverage for out of state providers, the bureau may consider the regulations or the community standards of the provider’s state of practice.

(7) Provide documentation of the provider’s malpractice history for the previous five years.

(8) Not have any outstanding provider overpayment or other indebtedness to the bureau which has been certified to the attorney general for collection.

(9) Provide proof of and maintain workers’ compensation coverage to the extent required under Ohio law or the equivalent law of another state, as applicable.

(10) Not have been excluded or removed from participation in other health plans for cause, or have lost hospital privileges for cause.

(C) The following minimum credentials apply to the providers listed below as provided in this rule.

(1) Ambulance, ambulette, or air ambulance service: license from Ohio medical transportation board if private; medicare participation if government/public.

(2) Ambulatory surgical center: license from Ohio department of health and medicare participation.

(3) Athletic trainer: license from Ohio occupational therapy, physical therapy, and athletic trainer board.

(4) Audiologist: license from Ohio board of speech-language pathology and audiology.

(5) Alcohol and drug counseling clinic: certified by Ohio department of alcohol and drug addiction services to administer outpatient counseling.

(6) Dentist: license from Ohio state dental board.

(7) Dialysis center: license from Ohio department of health and medicare participation.

(8) Durable medical equipment supplier, excludes orthotics, prosthetics and pedorthics state vendors license, medicare participation, or joint commission on accreditation of healthcare organization (JCAHO) accreditation.

(9) Ergonomist: certification for certified professional ergonomist (CPE), certified human factors professional (CHFP), associate ergonomics professional (AEP), associate human factors professional (AHFP), certified ergonomics associate (CEA), certified safety professional (CSP) with “ergonomics specialist” designation, certified industrial ergonomist (CIE), certified industrial hygienist (CIH), assistive technology practitioner (ATP), or rehabilitation engineering technologist (RET).

(10) Hearing aid dealer: license from Ohio hearing aid dealers and fitters licensing board.

(11) Home health agency: medicare participation, joint commission on accreditation of healthcare organization (JCAHO) accreditation, or community health accreditation program (CHAP) accreditation.

(12) Hospital: approved by the centers for medicare and medicaid services (CMS) for medicare, title XVIII of the Social Security Act; obtained national accreditation (joint commission on accreditation of healthcare organization (JCAHO), or American osteopathic association healthcare facilities accreditation program (HFAP), or commission on accreditation of rehabilitation facilities (CARF) for rehabilitation hospitals).

(13) Licensed social worker or licensed independent social worker (LSW) or (LISW): license from Ohio counselor and social worker board.

(14) Laboratory: valid licensing from clinical laboratory improvement amendment (CLIA).

(15) Massage therapist: certified by Ohio state medical board.

(16) Non-physician acupuncturist: certificate of registration from Ohio state medical board.

(17) Certified registered nurse anesthetist (CRNA): certified by national council on certification of nurse anesthetists or other certifying agency recognized by the Ohio board of nursing.

(18) Certified nurse practitioner: certified by American nurses credentialing center or other certifying agency recognized by the Ohio board of nursing.

(19) Clinical nurse specialist: certified by American nurses credentialing center or other certifying agency recognized by the Ohio board of nursing.

(20) Nursing home: license from Ohio department of health.

(21) Occupational therapist: license from Ohio occupational therapy, physical therapy, and athletic trainer board.

(22) Optician: license from Ohio optical dispensers board.

(23) Optometrist: license from Ohio board of optometry.

(24) Orthotist, prosthetist or pedorthist: license from Ohio state board of orthotics, prosthetics and pedorthics.

(25) Physical therapist: license from Ohio occupational therapy, physical therapy, and athletic trainer board.

(26) Physician assistant: certified by national commission on certification of physician assistants and certified by Ohio state medical board.

(27) Physician (M.D. or D.O.): license from Ohio state medical board.

(28) Chiropractic physician (D.C.): license from Ohio state chiropractic board.

(29) Podiatric physician (D.P.M.): license from Ohio state medical board.

(30) Licensed professional clinical counselor (LPCC) or licensed professional counselor (LPC): license from Ohio counselor and social worker board.

(31) Psychologist: license from Ohio state board of psychology

(32) Radiology services (free-standing) state licensing, registration or accreditation: (mobile) state, county or city registration, or medicare participation or medicaid certification.

(33) Residential care/assisted living facility: license from Ohio department of health.

(34) Speech pathologist: license from Ohio board of speech pathology and audiology.

(35) Traumatic brain injury (TBI) program: CARF accreditation for brain injury services (acute or post-acute).

(36) Vocational rehabilitation case managers: certification for occupational health nursing (COHN), certified rehabilitation counselor (CRC), certified disability management specialist (CDMS), certified vocational evaluator (CVE), certified rehabilitation nurse (CRRN), or certified case manager (CCM).

(37) Vocational rehabilitation case management interns:

(a) Vocational rehabilitation case management may be provided by a bureau-certified intern. An intern is a non-credentialed individual who provides vocational case management services and is supervised by a credentialed vocational case manager, as identified in paragraph (C)(36) of this rule.

(b) To become eligible for bureau certification and provide service as an intern, the intern must:

(i) Enroll with the bureau as an intern.

(ii) Qualify to take one of the examinations to become credentialed, as identified in paragraph (C)(36) of this rule.

(c) Bureau certification of vocational rehabilitation case management interns shall be for a period of four years.

(d) Vocational rehabilitation case management interns may not be recertified for additional four-year periods.

(38) Comprehensive pain management services program: (free standing) CARF accreditation; (hospital based) CARF or JCAHO accreditation.

(39) Occupational rehabilitation programs: CARF accreditation.

Effective: 04/01/2007

R.C. 119.032 review dates: 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96; 1/15/99; 3/29/02; 7/14/03; 9/12/04

(A) The bureau may enroll non-certified providers eligible under rule 4123-6-06.3 or 4123-6-12 of the Administrative Code or division (J) of section 4121.44 of the Revised Code to receive reimbursement for goods and services provided to injured workers, and for this purpose may require such non-certified providers to complete and sign an enrollment application and agreement as the bureau deems appropriate, provided such non-certified providers meet the minimum qualifications for their provider category as set forth in paragraph (C) of rule 4123-6-02.2 of the Administrative Code.

(B) Persons or entities who do not fall within the provider categories set forth in paragraph (C) of rule 4123-6-02.2 of the Administrative Code are not eligible for certification as providers in the HPP. The bureau may enroll such persons or entities to receive reimbursement for goods and services provided to injured workers, and for this purpose may require such persons or entities to complete and sign an enrollment application and agreement as the bureau deems appropriate.

(C) The certification of persons or entities certified as providers in the HPP prior to the effective date of this rule who do not fall within the provider categories set forth in paragraph (C) of rule 4123-6-02.2 of the Administrative Code shall expire on a schedule determined by the bureau, and such persons or entities shall not be eligible for recertification as providers in the HPP.

(D) Expiration of provider certification pursuant to this rule does not constitute an adjudication order and is not subject to appeal pursuant to rule 4123-6-17 of the Administrative Code.

Effective: 04/01/2007

R.C. 119.032 review dates: 03/01/2012

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

(A) Pursuant to rules 4123-6-02.1 and 4123-6-02.4 of the Administrative Code, the bureau shall mail each provider a provider application and agreement or recertification application and agreement, as applicable, which shall require the provider to furnish credentialing documentation as provided in rule 4123-6-02.2 of the Administrative Code.

(B) The provider application and agreement or recertification application and agreement may require the provider to make statements that the provider is without impairments that would interfere with the provider’s ability to practice or that would jeopardize a patient’s health, and a statement that the application is without misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, fraud, or deceit. The provider shall provide to the bureau any additional documentation requested, and must permit the bureau, upon reasonable notice, to conduct a review of the provider’s practice or facility. The provider shall notify the bureau within thirty days of any change in the provider’s status regarding any of the credentialing criteria of paragraph (B) or (C) of rule 4123-6-02.2 of the Administrative Code.

(C) The bureau shall review the application and agreement and all credentialing documentation submitted by the provider. The bureau may cross-check data with other governmental agencies or licensing bodies. The bureau may refer issues relating to malpractice history for review by the bureau’s stakeholders health care quality assurance advisory committee as provided under rule 4123-6-22 of the Administrative Code.

(D) The provider application and agreement or recertification application and agreement shall include at a minimum the following provisions, as more fully detailed within the provider application and agreement or recertification application and agreement itself. The provider agrees to:

(1) Provide health services that are applicable to a work-related injury, and not to substantially engage in the practice of experimental modalities of treatment.

(2) Provide adequate on-call coverage for patients.

(3) Utilize bureau certified providers when making referrals to other providers.

(4) Timely schedule and treat injured workers to facilitate a safe and prompt return to work.

(5) Release information from the national practitioner data bank, healthcare integrity and protection data bank or the federation of state licensing boards. The bureau may submit a report to the appropriate state licensing board or data bank in the event that the provider’s certification is terminated for reasons pertaining to the provider’s professional conduct or competence.

(6) Practice in a managed care environment and adhere to MCO and bureau administrative procedures, and procedures concerning provider outcome measurement data, peer review, quality assurance, utilization review, billing procedures and dispute resolution, subject to rule 4123-6-16 of the Administrative Code.

(7) Pursuant to procedures developed by the bureau and the MCOs, report injuries of employees to employers and the bureau.

(E) Upon review and determination by the bureau that the provider has met bureau credentialing requirements, the bureau shall certify or recertify the provider as a bureau certified provider eligible to participate in the HPP.

(F) By signing the provider application and agreement or recertification application and agreement, the provider agrees to abide by all bureau HPP and medical rules, the provider billing and reimbursement manual, and the provider application and agreement or recertification application and agreement.

HISTORY: Eff 2-16-96; 1-15-99; 3-29-02; 02-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

(A) The bureau shall initiate the recredentialing process by sending certified providers notice and a recertification application and agreement, which must be completed, signed and returned to the bureau if the provider wishes to be considered for recertification.

(B) Except as otherwise provided in paragraph (C) of this rule, if the bureau receives a completed and signed recertification application and agreement from a provider, the provider’s certification to participate in the HPP shall remain in effect until the bureau issues a final order approving or denying the provider’s application for recertification.

(C) If the bureau does not receive a completed and signed recertification application and agreement from the provider within sixty days from the date of the notice sent in accordance with paragraph (A) of this rule, the bureau shall send a second notice to the provider stating that the provider has thirty days from the date of the second notice to complete, sign and submit the recertification application and agreement to the bureau if the provider wishes to be considered for recertification.

(D) If the bureau does not receive a completed and signed recertification application and agreement from the provider within thirty days from the date of the notice sent in accordance with paragraph (C) of this rule, the provider’s certification to participate in the HPP shall lapse. Such lapse of certification is not an adjudication order and is not subject to appeal pursuant to rule 4123-6-17 of the Administrative Code.

(E) If the bureau receives a completed and signed recertification application and agreement from a provider after the provider’s certification to participate in the HPP has lapsed pursuant to paragraph (D) of this rule, the provider’s certification to participate in the HPP shall be reinstated and shall remain in effect until the bureau issues a final order approving or denying the provider’s application for recertification.

(F) All recertification application and agreements are subject to credentialing review as provided in rule 4123-6-02.3 of the Administrative Code.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 3/29/02

(A) A provider not certified shall cure any defects in the provider application and agreement within thirty days of notice by the bureau. A provider not recertified shall cure any defects in the recertification application and agreement within thirty days of notice by the bureau.

(B) The administrator of workers’ compensation, pursuant to rule 4123-6-17 of the Administrative Code, may refuse to certify or recertify or may decertify a provider from participation in the HPP where the provider has failed to comply with the workers’ compensation statutes or rules governing providers or MCOs, the provider billing and reimbursement manual, or a provision of the provider application and agreement or recertification application and agreement.

(C) Notwithstanding paragraph (B) of this rule, in any case where the administrator finds a serious danger to the public health and safety and sets forth specific reasons for such findings, or, in the case of an individual provider, the bureau receives notice from the appropriate state licensing board that the provider’s professional license has been revoked or suspended, the administrator may immediately revoke or suspend, or provisionally revoke or suspend, the certification of a provider. The order shall be final unless the provider, within seven days of such order, requests a hearing before the administrator where the provider shall show cause why the order should not be final. The order of the administrator shall remain in force during the pendency of the show cause hearing.

(D) The administrator may impose disciplinary sanctions upon a provider where the provider has failed to comply with the workers’ compensation statutes or rules governing providers, the provider billing and reimbursement manual, or a provision of the provider application and agreement or recertification application and agreement. The administrator may impose a disciplinary sanctions without an adjudication order under rule 4123-6-17 of the Administrative Code. In imposing a disciplinary sanction against a provider the administrator may consider, but is not limited to, suspending all reimbursements to a provider.

HISTORY: Eff 2-16-96; 1-15-99; 3-29-02; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

(A) The administrator may refuse to certify or recertify, or may decertify from participation in the HPP, any provider, entity or MCO that:

(1) Is owned, directly or indirectly, by an individual or entity that has a felony conviction in any jurisdiction, a conviction under a federal controlled substance act, a misdemeanor conviction for an act involving dishonesty, fraud, or misrepresentation, a conviction for a misdemeanor committed in the course of practice, a felony or misdemeanor conviction involving dishonesty, fraud, or misrepresentation related to any compensation or benefits payable under Chapter 4121., 4123., 4127., or 4131. of the Revised Code, or court supervised intervention or treatment in lieu of conviction pursuant to section 2951.041 of the Revised Code or the equivalent law of another state.

(2) Has one or more owners, shareholders, members, partners, managing employees, officers or directors, who have a conviction or court supervised intervention or treatment in lieu of conviction as described in paragraph (A) (1) of this rule; and including any provider, entity or MCO that is no longer so described because of a transfer of ownership or interest to an immediate family member or a member of the person’s household in anticipation of or following a conviction or court supervised intervention or treatment in lieu of conviction as described in paragraph (A) (1) of this rule.

(3) For the purposes of this paragraph:

(a) “Entity” means any sole proprietorship, partnership, corporation, professional association, limited liability company or any other business organization doing business in this or any other state.

(b) “Immediate family member” means a person’s spouse; natural or adoptive parent; child or sibling, stepparent, stepchild, stepbrother or stepsister; father-, mother-, daughter-, son-, brother- or sister-in-law; grandparent or grandchild; or spouse of a grandparent or grandchild.

(c) “Managing employee” means an individual (including a general manager, office manager, business manager, administrator or director) who exercises operational or managerial control over the provider, entity or MCO or part thereof, or directly or indirectly conducts the day-to-day operations of the provider, entity or MCO or part thereof, or is involved in the billing functions of the provider, entity or MCO or part thereof.

(d) “Member of household” means, with respect to a person, any individual with whom they are sharing a common abode.

(e) “Owned directly or indirectly” means having an interest that includes ownership, as an individual or through any other entity or entities, of five percent or more in the provider, entity or MCO at issue.

(B) Notwithstanding and in addition to the provisions set forth in this rule, pursuant to division (C)(1) of section 4121.444 of the Revised Code the administrator may terminate any agreement between the bureau and a person or a health care provider or managed care organization or its owner and cease reimbursement to that person, provider, organization, or owner for services rendered if any of the following apply:

(1) The person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization is convicted of or pleads guilty to a violation of sections 2913.48 or 2923.31 to 2923.36 of the Revised Code or any other criminal offense related to the delivery of or billing for health care benefits.

(2) There exists an entry of judgment against the person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization and proof of the specific intent of the person, health care provider, managed care organization, or owner to defraud, in a civil action brought pursuant to section 4121.444 of the Revised Code.

(3) There exists an entry of judgment against the person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization in a civil action brought pursuant to sections 2923.31 to 2923.36 of the Revised Code.

(C) No person, health care provider, or managed care organization that has had its agreement with and reimbursement from the bureau terminated by the administrator pursuant to division (C)(1) of section 4121.444 of the Revised Code, or an owner, officer, authorized agent, associate, manager, or employee of that person, health care provider, or managed care organization shall do either of the following:

(1) Directly provide services to any other bureau provider or have an ownership interest, as an individual or through any other entity or entities, of five percent or more in a provider of services that furnishes services to any other bureau provider;

(2) Arrange for, render, or order services for claimants during the period that the agreement of the person, health care provider, managed care organization, or its owner is terminated as described in division (C)(1) of section 4121.444 of the Revised Code;

(D) The administrator shall not terminate the agreement or reimbursement if the person, health care provider, managed care organization, or owner demonstrates that the person, provider, organization, or owner did not directly or indirectly sanction the action of the authorized agent, associate, manager, or employee that resulted in the conviction, plea of guilty, or entry of judgment as described in division (C)(1) of section 4121.444 of the Revised Code.

(E) Nothing in division (C) of section 4121.444 of the Revised Code prohibits an owner, officer, authorized agent, associate, manager, or employee of a person, health care provider, or managed care organization from entering into an agreement with the bureau if the provider, organization, owner, officer, authorized agent, associate, manager, or employee demonstrates absence of knowledge of the action of the person, health care provider, or managed care organization with which that individual or organization was formerly associated that resulted in a conviction, plea of guilty, or entry of judgment as described in division (C)(1) of section 4121.444 of the Revised Code.

(F) Actions taken by the administrator pursuant to paragraph (A) of this rule shall be subject to rule 4123-6-17 of the Administrative Code. Actions taken by the administrator pursuant to paragraph (B) of this rule shall include a clear indication of the beginning date of such action and the specific medical services or dates of medical services or supplies that shall be excluded from payment, and shall be final unless the person, provider, managed care organization or owner, within seven days of the action, requests a hearing before the administrator where the person, provider, managed care organization or owner shall show cause why the action should not be final. The action of the administrator shall remain in force during the pendency of the show cause hearing.

Effective: 04/01/2007

R.C. 119.032 review dates: 03/01/2012

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.121, 4121.30, 4123.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4121.444, 4123.66

(A) The bureau shall maintain a public list of bureau certified providers. The bureau shall make the list of bureau certified providers available to a requesting party at cost.

(B) An MCO may, but is not required to, retain a panel of bureau-certified providers. A bureau certified provider is eligible for selection by an MCO to participate on an MCO’s provider panel. A bureau certified provider may participate in a single MCO panel or may participate in more than one MCO panel.

(C) A provider identified by an MCO for temporary privileges in its panel of providers that is not a bureau certified provider shall be assisted by the MCO in applying for bureau provider credentialing and certification.

(D) The bureau or MCO shall not discriminate against any category of health care provider when establishing categories of providers for participation in the HPP. However, neither the bureau nor an MCO is required to accept or retain any individual provider in the HPP.

(E) The MCO shall include in its panel or its arrangements with providers a substantial number of the medical, professional, and pharmacy providers currently being utilized by employees. An MCO may limit the number of providers on its MCO provider panel, but must do so based upon objective data approved by the bureau, such as reasonable patient access, community needs, the potential number of employees the MCO is applying to service, and other performance criteria, without discrimination by provider type.

(F) A bureau certified provider must submit to the medical management and return to work management of the employee’s employer’s MCO as provided in rule 4123-6-042 of the Administrative Code, Whether the provider is, or is not, on the MCO’s provider panel.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/01

Non-bureau certified providers are eligible to treat injured workers subject to the payment restrictions recited in rule 4123-6-12 of the Administrative Code and the management restrictions recited in rule 4123-6-06.3 of the Administrative Code

HISTORY: Eff 2-16-96; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

(A) Within one working day of initial treatment or initial visit of an injured worker, a provider must report the employee’s injury in accordance with either paragraph (B) or (C) of this rule.

(B) When reporting the injury to the MCO, the provider shall do so in accordance with procedures established by the MCO, pursuant to paragraph (E) of rule 4123-6-04.3 of the Administrative Code. The injury shall be reported to the MCO responsible for medical management of the employee’s treatment.

(C) A provider may report an injury to the bureau via the bureau’s internet site pursuant to rule 4125-1-02 of the Administrative Code.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/01

(A) No bureau certified provider shall engage in any advertising or solicitation directed to injured workers which is false, fraudulent, deceptive, or misleading.

(B) No bureau certified provider shall hire, arrange for, or allow any other individual or entity to engage in any advertising or solicitation directed to injured workers on behalf of the provider which is false, fraudulent, deceptive, or misleading.

(C) No bureau certified provider shall pay, allow, or give, or offer to pay, allow, or give, any consideration, money, or other thing of value to an injured worker (including but not limited to free or discounted examinations, treatment, or other goods or services) as an inducement to or in return for the injured worker ordering or receiving from the provider any goods or services for which payment may be made by the bureau, MCO, QHP, or self-insuring employer under Chapter 4121., 4123., 4127., or 4131. of the Revised Code.

(D) A bureau certified provider that violates this rule may be subject to decertification or disciplinary sanctions pursuant to the rules of this chapter of the Administrative Code.

Effective: 04/01/2007

R.C. 119.032 review dates: 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 3/29/02

A managed care organization that satisfies the certification requirements of this chapter shall be certified by the bureau as an MCO eligible to contract with the bureau to provide medical management and cost containment services in the HPP. The bureau shall continue to certify MCOs and shall periodically, at least annually, update its list of MCOs.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/19/96, 1/1/99

No individual who is an officer or employee of an MCO shall represent a claimant or employer in any matter before the industrial commission, the bureau of workers’ compensation, or a court of competent jurisdiction unless the claimant or employer is not assigned to the MCO and no fee is to be received from or charged against the claimant or employer.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/1/01

(A) Upon request by a managed care organization, the bureau shall mail a managed care organization an MCO application for certification.

(B) The MCO application for certification shall include a list of bureau certified providers.

(C) A provider identified by an MCO for inclusion in its panel of providers that is not a bureau certified provider may be assisted by the MCO in applying for bureau provider credentialing and certification.

(D) An MCO shall demonstrate arrangements and reimbursement agreements with a substantial number of medical, professional and pharmacy providers currently being used by injured employees.

(E) The MCO application for certification shall include, at a minimum, the following provisions, as more fully detailed within the MCO application for certification itself:

(1) A statement that the application is without misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, fraud, or deceit. The managed care organization shall provide to the bureau any additional documentation requested and shall permit the bureau, upon reasonable notice, to conduct a review of the managed care organization.

(2) A description of the geographic area of the State of Ohio for which the managed care organization wishes to be certified by the bureau. The minimum geographic area shall be a county. The bureau shall certify MCO participation on a county basis, subject to the provisions in rule 4123-6-03.3 of the Administrative Code. The managed care organization may apply for coverage in more than one county or statewide.

(3) A description of the managed care organization that includes, but is not limited to a profile that includes a disclosure statement regarding the managed care organization’s organizational structure, including subsidiary, parent and affiliate relationships. Historical and current data shall be provided. The managed care organization must identify its principals; provide the managed care organization’s date of incorporation or formation of partnership or limited liability company, if applicable; provide any fictitious names the managed care organization is, or has been, doing business under; provide the number of years the managed care organization has operated in Ohio; provide a table of organization with the number of employees; identify other states in which the managed care organization is doing business or has done business in the last five years, and identify any banking relationships, including all account information with any financial institutions doing business in Ohio.

(4) An explanation of how the managed care organization will provide timely, geographically convenient access to medical care.

(5) A description of the managed care organization’s treatment guidelines, including a description of the rationale underlying the development of the treatment guidelines.

(6) A description of the managed care organization’s utilization review process.

(7) A description of the managed care organization’s quality assurance/improvement standards program and process, including the use of satisfaction surveys.

(8) A description of the managed care organization’s medical dispute resolution process that meets the requirements of rule 4123-6-16 of the Administrative Code.

(9) A description of the managed care organization’s non-medical service grievance process.

(10) A description of the managed care organization’s information system capabilities and capacities.

(11) A description of the managed care organization’s medical case management policies and procedures.

(12) A description of the managed care organization’s policies and procedures regarding the confidentiality and protection of records.

(13) A description of the managed care organization’s policies and procedures regarding retention of information.

(14) A description of the managed care organization’s provider relations and education program.

(15) A description of the managed care organization’s employer and employee relations and education program; including but not limited to a description of methodologies to be used to explain options available to injured workers, including treatment by non-network providers and the dispute resolution process.

(16) A description of the managed care organization’s system for reporting the necessary data elements required for bureau calculation of performance measurements.

(17) Other descriptions and requirements as contained in divisions (C)(1) to (C)(10) of section 4121.44 of the Revised Code.

(18) A description, with at least galley proofs or the equivalent, of the managed care organization’s marketing materials to be used in marketing to employers.

(19) Proof of current public liability insurance, the adequacy of which shall be determined by the bureau.

(F) The MCO’s application shall include the following, both where the MCO elects to retain a provider panel and where the MCO does not retain a provider panel but enters into arrangements with providers:

(1) A description of the structure of the health care provider panel or arrangements with providers to be offered by the managed care organization. The provider panel or arrangements with providers shall cover the geographic area in which the managed care organization determines it shall compete, and may include out-of-state providers.

(2) An explanation of how the managed care organization’s provider panel or arrangements with providers shall provide a full range of medical services and supplies for injured workers and provide access for specialized services.

(3) A description of the process and methodology of credentialing of providers in the managed care organization’s panel.

(4) A description of the managed care organization’s payment process and methodology to providers in the managed care organization’s provider panel or to providers with which the managed care organization has provider arrangements.

(5) A description of the managed care organization’s policies and procedures for sanctioning and terminating providers in the managed care organization’s panel; and a description of the managed care organization’s methodology to notify the bureau, employers and employees of any changes in the provider panel or arrangements with providers.

(6) A description of the managed care organization’s methodology for distributing provider panel directories or directories of arrangements with providers and updated provider panel directories or directories of arrangements with providers to employers and/or employees.

(G) The bureau shall review the application for certification submitted by the managed care organization. The bureau reserves the right to cross-check data with other governmental agencies or licensing or accrediting bodies.

(H) The bureau shall hold as confidential and proprietary the managed care organization’s descriptions of process, methodology, policies, procedures and systems as required for the application for certification.

(I) The bureau shall not accept or approve any applications in which the managed care organization proposes to subcontract or outsource any of the following functions: first report of injury (FROI) intake, medical case management, or bill processing and payment. However, this paragraph does not prohibit the bureau from accepting or approving applications for recertification of managed care organizations who subcontract or outsource one or more of these functions if the managed care organization subcontracted or outsourced the function or functions immediately prior to the effective date of this paragraph.

HISTORY: Eff 2-16-96; 1-1-99; 1-1-01; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

119.032 review date: 10/26/2004 and 03/01/2009

An MCO may establish its own capacity based on objective data, which must include at a minimum bureau data related to past claims history for the geographic area to be covered by the MCO, and accordingly may be conditionally certified by the bureau on a county basis. However, if the aggregate number of MCOs within a county does not meet established bureau targets for sufficient capacity within that county to meet the needs of all employees of employers in that county, all MCOs certified or conditionally certified in that county may be required to expand their capacity to meet the needs of all employees of employers in that county.

The bureau may declare an MCO ineligible to solicit or accept selection of the MCO by an employer or assignment of an employer to the MCO by the bureau by placing the MCO at capacity. The bureau shall base such determination on the failure by the MCO to meet predetermined performance criteria set forth in the MCO agreement.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/99

(A) Upon review by and satisfactory to the bureau that the managed care organization has met bureau certification standards, the bureau shall certify an MCO as eligible to participate in the HPP.

(B) MCO certification by the bureau in the HPP shall be for a period of two years. Upon approval by the bureau, an MCO may expand its coverage area after the first year of participation in the HPP and every year thereafter.

(C) The bureau may certify any number of MCOs for each county or statewide.

(D) The bureau shall maintain a current list of all bureau certified MCOs. The list shall include the name and address of each MCO and the counties in which the MCO is certified for participation in the HPP.

(E) A managed care organization not certified may cure any defects in the MCO application for certification within thirty days of notice by the bureau of such defect in its application.

(F) An MCO that wishes to continue in the HPP beyond the first two years of certification may be recertified by the bureau.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/99

The administrator may terminate any MCO contract with the bureau if the administrator determines that it is in the best interest of the workers’ compensation system to do so. The grounds for termination include, but are not limited to, the following:

(A) The MCO is insolvent.

(B) Any act of fraud or misrepresentation by an MCO of the amount or cost of services or supplies rendered or provided to any injured worker.

(C) Any act of fraud or misrepresentation by an MCO in reporting or submitting data to the bureau that is used by the bureau to calculate or determine payment to the MCO.

(D) The MCO implements an unapproved change in its organizational structure or a material change in its operations.

(E) Substantial failure to perform on the part of the MCO in accordance with the terms and conditions of any contract or agreement between the MCO and the bureau.

HISTORY: Eff 2-16-96; 1-1-99; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

119.032 review date: 10/26/2004 and 03/01/2009

(A) Should the administrator determine that sufficient evidence exists that an MCO has failed to comply with applicable workers’ compensation statutes, rules governing MCOs, or a provision of a contract between the bureau and the MCO, the administrator has the authority to decertify, or refuse to certify or recertify an MCO.

(B) In any case where the administrator finds a serious danger to the public health and safety and sets forth specific reasons for such findings, the administrator may immediately decertify an MCO.

(C) Upon a final order of the administrator to decertify, or refuse to recertify an MCO, employees and employers shall not receive services from such MCO pursuant to the HPP.

(D) Upon a final order of the administrator to decertify or refuse to recertify an MCO, any obligation of a provider to provide services under the HPP pursuant to a contract or agreement with such MCO shall be null and void.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/95, 1/1/99

Rescinded eff 2-14-05

If the managed care organization is related to another corporation or entity that has had or contemplates activities of any nature with the Ohio workers’ compensation system and such relationship creates or presents either the opportunity for a conflict of interest or the appearance of a conflict of interest for the managed care organization and/or the other corporation or entity, the managed care organization shall provide to the bureau a description of the resolution of such opportunity for or the appearance of a conflict of interest satisfactory to the bureau.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 10/26/00

By use of managed care and return to work management strategies, an MCO shall provide medical management and cost containment services that promote the rendering of high-quality, cost-effective medical care that focuses on minimizing the physical, emotional, and financial impact of a work-related injury or illness and promotes a safe return to work.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/01

(A) An employee may select a bureau certified provider. If the MCO selected by or assigned to the employee’s employer has elected to retain a provider panel, the employee may select an MCO panel provider. In either case, the MCO shall manage the medical treatment of all workers’ compensation related injuries or diseases incurred by the employee for that employer.

(B) An employee may select a provider who is not a bureau certified provider. In such case, the MCO for the employee’s employer shall manage only the initial or emergency care to the employee; further treatment shall not be authorized except as provided by rule 4123-6-12 of the Administrative Code.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/01

(A) The bureau shall determine the compensability of all claims as provided in rule 4123-6-04.5 of the Administrative Code. Upon referral from an MCO, the bureau will determine both the causal relationship between the original injury and the current incident precipitating a medical treatment reimbursement request and the necessity and appropriateness of the requested treatment in a claim which has not had activity or a request for further action within a period of time in excess of thirteen months, as provided in rule 4123-3-15 of the Administrative Code.

(B) The MCO, in conjunction with the employer, employee, attending physician, and the bureau claims personnel assigned to the claim, shall seek a course of medical or rehabilitative treatment that promotes a safe return to work.

(C) After the claim has been filed, the bureau shall assign a claim number and shall notify the employee, employer and MCO of that claim number.

(D) The MCO shall comply with bureau procedures for reporting injuries to the bureau and employers, and shall instruct the provider to forward to the MCO and the bureau, subject to the confidentiality provisions contained in rule 4123-6-15 of the Administrative Code, all necessary data to effectuate medical and claims management.

(E) MCO guidelines may not be more restrictive for a non-panel provider than for a panel provider. An MCO may not create a procedure that restricts an employee’s option to change providers.

(F) Except as provided in paragraph (D) of rule 4123-6-04.6 of the Administrative Code, an MCO shall provide medical management and return to work management services for the life of a claim, as long as the employer remains in contract with the MCO. An MCO shall manage all claims of the employer, regardless of the date of injury of the claim. In cases where an employee has multiple claims with different employers, each claim shall remain with the associated employer and shall be managed by that employer’s current MCO.

(G) Pursuant to divisions (A)(1), (A)(5), and (A)(9) of section 4121.441 of the Revised Code, an MCO may schedule an independent medical examination of the claimant to assist the MCO in the alternative dispute resolution process under rule 4123-6-16 of the Administrative Code or in the medical management of a claim with a date of injury prior to October 20, 1993.

(1) An MCO may obtain only one independent medical examination in a claim with a date of injury prior to October 20, 1993 for the purpose of medical management of the claim. An MCO independent medical examination shall be limited to issues relating to the management of medical treatment and medical treatment disputes, and shall not include extent of disability issues. An MCO independent medical examination shall not be conducted at the request of an employer and does not substitute for an examination permitted under section 4123.65.1 of the Revised Code.

(2) If the MCO schedules a medical examination under this rule, the MCO shall promptly inform the bureau and the parties, and their representatives, if any, as to the time and place of the examination, and the questions and information provided to the doctor. A copy of the examination report shall be submitted to the bureau, the parties and their representatives upon the MCO’s receipt of the report from the doctor. The claimant shall be reimbursed for the claimant’s traveling and meal expenses, in a manner and at the rates as established by the bureau from time to time. The MCO shall provide the claimant with a proper form to be completed by the claimant for reimbursement of such expenses. If the MCO schedules a medical examination to assist the MCO in resolving a medical dispute, the MCO shall complete the independent medical examination and dispute resolution within the time limits established under rule 4123-6-16 of the Administrative Code.

(3) If a claimant refuses to attend an independent medical examination scheduled by the MCO to assist the MCO in resolving a medical dispute in a claim, as part of the alternative dispute resolution process under rule 4123-6-16 of the Administrative Code, or in a claim with a date of injury prior to October 20, 1993, the MCO shall refer the issue to the bureau.

HISTORY: Eff 2-16-96; 1-1-99; 3-27-00; 1-1-01; 11-1-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 4121.12, 4121.30, 4121.31, 4123.05

Rule amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

R.C. 119.032 review dates: 01/01/2004

The MCO shall review all bills submitted to it for payment by a provider for appropriateness consistent with the MCO’s utilization standards and certification requirements. The MCO shall have in place and operating a grievance hearing procedure allowing a provider, employer, or employee to grieve a disputed bill payment.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96

(A) The bureau may perform a return-to-work assessment of an injured worker who has a lost time claim as defined in section 4123.52 of the Revised Code and who has not returned to work within an acceptable timeframe as determined by the bureau.

(B) The assessment may include, but is not limited to, the case management goals, identification of barriers, return to work plan, medical stability and vocational status of the claim.

(C) All findings and conclusions of the assessment and all recommendations for addressing deficiencies shall be documented in writing to the MCO assigned to the claim. The assigned MCO shall have five business days from receipt of the bureau’s findings to initiate or complete the recommended action steps identified by the bureau or propose alternative action steps acceptable to the bureau.

(D) If the assigned MCO does not carry out the recommended action steps or if the MCO fails to propose an acceptable alternative course of action to resolve the return-to-work barriers, the bureau may assume the vocational rehabilitation management of the claim.

(E) For any claim assumed pursuant to paragraph (D) of this rule, the bureau may charge the assigned MCO a financial penalty, to include hourly case management fees, in accordance with rule 4123-6-13 of the Administrative Code and the terms of the MCO contract.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/1/01

(A) Except where the bureau has placed an MCO at capacity pursuant to rule 4123-6-03.3 of the Administrative Code, an employer may be solicited by and may select for its employees’ coverage under the HPP any MCO that has contracted with the bureau. An MCO, or any entity or individual on behalf of the MCO, may directly solicit an employer only during periods of open enrollment as provided in this rule and rule 4123-6-05.2 of the Administrative Code. During such open enrollment direct solicitation, the MCO shall comply with the provisions of rules 4123-6-03.9 and 4123-6-05.3 of the Administrative Code, and with the MCO contract. Each employer may select an MCO, subject to paragraph (B) of rule 4123-6-05.2 of the Administrative Code.

(B) The bureau shall determine an open enrollment period during which time an employer may change its selection of an MCO; however, beginning January 1, 1999, the bureau shall establish an open enrollment period at least once every two years but no more than once in a year.

(C) During employer open enrollment periods, the bureau shall distribute to employers the list of all MCOs contracting with the bureau pursuant to rule 4123-6-03.4 of the Administrative Code.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/99, 4/5/99, 7/17/00, 1/1/03

(A) The bureau shall select an MCO for a state fund employer that fails to select an MCO, or is not solicited by an MCO.

(B) An employer with fixed work SITES in more than one county may select different MCOs certified to provide services in the counties where the employer maintains fixed work SITES.

(C) An MCO selected by an employer or employers shall provide a list of enrolled employers to the bureau.

(D) The bureau shall develop a process for verification of employer selection of an MCO.

(E) Selection of an MCO by an employer or selection by the bureau subject to paragraph (A) or (J) of this rule shall be until the next open enrollment period. The bureau may reassign an employer from the MCO if the bureau determines that the reassignment is in the best interest of both the employer and the MCO.

(F) Once the MCO has been selected by either the employer or the bureau on behalf of an employer that has not made a selection, the employer shall notify all employees of the selection.

(G) Upon expiration of the employer enrollment period, an employer may:

(1) Select a new MCO pursuant to paragraphs (A) to (F) of this rule; or

(2) Continue with an MCO selected during the prior enrollment process. In such case, the employer is not required to notify the bureau during the enrollment process.

(H) Prior to the expiration of the MCO enrollment period, the bureau shall provide adequate notice to employers in writing of the pending deadline for new MCO selection.

(I) An MCO may not refuse to provide services to an employer once selected by that employer or assigned by the bureau, subject to the provisions of rule 4123-6-033 of the Administrative Code.

(J) If an employer selects more than one MCO in the same county, the bureau shall notify the employer in writing. The employer shall have fourteen days from date of written receipt of notification to select one MCO or an MCO will be assigned by the bureau.

(K) In the event of a decision by the administrator to decertify an MCO or to terminate any agreement or contract between the bureau and the MCO, immediately thereafter the bureau shall initiate an employer-MCO reassignment process. The bureau shall randomly assign those employers formerly assigned to the decertified or terminated MCO to all remaining, eligible MCOs for a period of thirty days. Upon expiration of the thirty day period, the employers affected by the decertification or termination shall have a fourteen day open enrollment period, during which they may select another MCO. In the absence of an employer’s selection of another MCO, the employer shall remain with the MCO to which it was randomly assigned.

(L) In the event of the merger or acquisition of an MCO, immediately thereafter the bureau shall assign those employers formerly assigned to that MCO to the merging or acquiring MCO for a period of thirty days. Upon expiration of the thirty day period, the employers affected by the merger or acquisition shall have a fourteen day open enrollment period, during which they may select another MCO. In the absence of an employer’s selection of another MCO, the employer shall remain with the merging or acquiring MCO.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 4/19/96, 1/20/98, 1/1/99, 4/5/99, 7/17/00

(A) In soliciting employers as provided under rule 4123-6-05 of the Administrative Code, an MCO, or any parent, subsidiary, affiliated, or related entity, or any agent or person acting on behalf of an MCO or for the benefit of an MCO, shall not:

(1) Pay, allow, or give, or offer to pay, allow, or give, to any prospective employer or to any other person, firm, or corporation not an employee or agent of the MCO, either directly or indirectly, as an inducement to or in return for an employer’s selection of the MCO for its employees’ coverage under the HPP, any rebate, premium, or kickback, or any special favor or advantage, or any other valuable consideration or inducement not provided for under Chapter 4123-6 of the Administrative Code.

(2) Pay, allow, or give, or offer to pay, allow, or give any commission, consideration, money, or other thing of value to any person, firm, or corporation not an employee or agent of the MCO for soliciting, negotiating, procuring, placing, writing, renewing, forwarding, or transmitting to the bureau an employer’s selection of the MCO for its employees’ coverage under the HPP.

(3) Pay, allow, or give, or offer to pay, allow, or give lead fees to any person, firm, or corporation other than an employee or agent of the MCO. For purposes of this rule, “lead fees” are defined as payments by an MCO to any person, firm, or corporation other than an employee or agent of the MCO for referrals of prospective employers where such payments are:

(a) Conditioned on the prospective employer selecting the MCO for its employees’ coverage under the HPP; and/or

(b) Not reasonably related to actual expense reimbursement by the MCO to the person, firm or corporation referring the prospective employer.

(B) Notwithstanding paragraph (A) of this rule, once an employer has selected an MCO under the HPP, the MCO may reimburse to a trade or business association certain expenses as provided in this paragraph of this rule.

(1) The trade or business association shall meet the requirements for being a sponsoring organization for group rating under section 4123.29 of the Revised Code and rules 4123-17-61 to 4123-17-68 of the Administrative Code.

(2) The MCO may reimburse to the trade or business association only the actual and reasonable expenses incurred by the trade or business association in marketing to or educating its member employers on the HPP and the MCO selection process.

(3) The reimbursement of a trade or business association’s actual and reasonable expenses during a calendar year shall not exceed sixteen one-hundredths of one per cent (.16%) of the premium of those employers which are members of the trade or business association and which have selected the MCO. The premium used in calculating allowable reimbursement under this rule shall be the premium used by the bureau to calculate payments to the MCO under the payment provisions of the MCO contract.

(4) The MCO and the trade or business association shall keep accurate records of all marketing and education services provided to its member employers for a period of two years from the date of performance of any such service. The MCO and the trade association shall provide the bureau with access to such records within a reasonable time after a request for audit of such records by the bureau.

(C) Except as provided in paragraph (B) of this rule, no person, firm, or corporation not an employee or agent of the MCO shall knowingly receive any payment, commission, lead fee, rebate, premium or kickback, or any other valuable consideration or thing of value prohibited under paragraph (A) of this rule.

(D) An MCO that violates this rule may be subject to decertification or termination of its contract pursuant to the rules of this chapter of the Administrative Code.

HISTORY: Eff 1-30-98 (Emer.); 4-29-98; 1-1-99; 10-26-00; 1-1-01; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

119.032 review date: 10/26/2004 and 03/01/2009

(A) An MCO shall not solicit, receive, or accept any payment, commission, consideration, money, or other thing of value, including, but not limited to any rebate, premium, or kickback, as an inducement to or in return for the MCO’s referral of employers who have selected or been assigned to it to any sponsoring organization or group for the purpose of participating in a group experience rating program authorized under section 4123.29 of the Revised Code and rules 4123-17-61 to 4123-17-68 of the Administrative Code.

(B) An MCO that violates this rule may be subject to decertification or termination of its contract pursuant to the rules of this chapter of the Administrative Code.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/30/98 (Emer.), 4/29/98, 1/1/99, 1/1/01

As more fully set forth in rule 4123-6-06.2 of the Administrative Code, an employee may select a physician of record who is: a bureau certified provider; a bureau certified provider who is a member of a panel of a bureau certified MCO selected by the employee’s employer; or a non-bureau certified provider.

HISTORY: Eff 2-16-96; 1-1-01; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

119.032 review date: 10/26/2004 and 03/01/2009

An MCO selected by an employer and the employer shall educate employees regarding access to and use of services offered by the MCO for injuries resulting from an industrial accident, including, if the MCO has elected to retain a provider panel, information regarding MCO panel providers. Education of the employee shall stress, among other things, the need for the employee to report any accident immediately to the employer and the bureau and shall inform the employee how to seek care through the MCO. An MCO card shall be provided to each employee.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/01

(A) An injured employee may seek medical care for an industrial injury from

(1) A bureau certified provider

(2) An MCO panel provider; or

(3) A non-bureau certified provider, subject to an employee’s payment responsibilities as delineated in rule 4123-6-12 of the Administrative Code.

(B) At the time of an injury, the employee may seek medical care directly from A provider or may seek assistance from the MCO. If the employee has not already sought medical care or selected a provider, the MCO may refer the employee to a provider. The MCO shall ask if the employee has any preference as to specialty of provider and shall make any referrals accordingly. The MCO shall not discriminate against any category of health care provider when referring the employee to a provider. The employee may, but is not required to, seek medical care from the referred provider.

(C) If the employee seeks medical assistance from a provider, the employee shall inform the provider of the employee’s MCO. The provider shall then notify the MCO of the contact by the employee. If the provider is a bureau certified provider, the provider must agree to provide treatment pursuant to the MCO’s guidelines. If the provider is a non-bureau certified provider, the provider will be informed by the MCO that the care for the first visit will be compensated by the MCO if the claim and the treated conditions are subsequently allowed. The MCO will inform the non-bureau certified provider that no further treatment will be authorized.

(D) An injured employee may continue treatment with a non-bureau certified provider under two circumstances:

(1) The provider may apply to the MCO for emergency credentialing as necessary for care and services which are unavailable through like MCO panel providers, or

(2) The employee may continue to treat with a non-bureau certified provider, but at the employee’s own expense without recourse against the MCO, employer, or bureau.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/01

(A) The rules of this chapter of the Administrative Code shall apply to all claims with the date of injury on or after October 20, 1993. The employee’s medical care and treatment and return to work services in such claims shall be managed under the HPP by the employer’s MCO as provided in the rules of this chapter.

(B) Notwithstanding rule 4123-6-06.2 of the Administrative Code, if the employee’s date of injury is prior to October 20, 1993 and the employee’s physician of record is a non-bureau certified provider, the employee may continue treatment with that non-bureau certified provider. The employer’s MCO shall manage the medical care and treatment and return to work services in the claim and shall manage medical payment for the provider.

(C) In all claims with a date of injury prior to October 20, 1993, and not withstanding paragraph (B) of this rule, if the employee changes the physician of record for any reason, the employee shall select a bureau certified provider as a physician of record and the claim is thereafter governed by all of the HPP rules of this chapter. If the employee selects a physician of record who is a non-bureau certified provider, payment for the provider shall be governed by rule 4123-6-12 of the Administrative Code.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/01

No health care provider, whether certified or not, shall charge, assess, or otherwise attempt to collect from an employee, employer, a managed care organization, or the bureau any amount for covered services or supplies that is in excess of the allowed amount paid by a managed care organization, the bureau or a qualified health plan.

HISTORY: Eff 2-16-96; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

119.032 Review Date: 10/26/2004 and 03/01/2009

(A) Pursuant to division (A)(8) of section 4121.441 of the Revised Code, the bureau shall develop, maintain, and publish a provider fee schedule for the various types of billing codes. The fee schedules shall be developed with provider and employer input.

(B) Whether the MCO has elected to retain a provider panel or not, an MCO may contract with providers. Every provider contract shall describe the method of payment to the providers. The MCO shall provide an MCO fee schedule to each provider that contracts with the MCO. The MCO fee schedule may be at different rates than the bureau fee schedule. The MCO shall make the MCO fee schedule available to the bureau as part of its application for certification. The bureau shall maintain the MCO fee schedule as proprietary information.

R.C. 119.032 review dates: 07/22/2004 and 07/22/2009

Promulgated Under: 119.03

Statutory Authority: R.C. 4141.06, R.C. 4141.14

Rule Amplifies: R.C. 4141.281

Prior Effective Dates: 5-1-92, 12-6-99

(A) The bureau shall not make medical payments in a disallowed claim or for conditions not allowed in a claim until permitted to do so under the provisions of section 4123.511 of the Revised Code or except as provided by the rehabilitation rules of Chapter 4123-18 of the Administrative Code. If during the adjudication of the claim before either the bureau or the industrial commission the claim or conditions therein are either allowed or disallowed, the bureau shall notify all parties and the MCO that the claim or conditions are allowed or disallowed, and if disallowed, that treatment rendered therefore may not be paid by the bureau.

(B) During the adjudication process, the provider may continue to render or the MCO may continue to manage medical services on behalf of the employee, but the bureau shall not pay the MCO for services in a disallowed claim or for disallowed conditions. The MCO shall inform the employee that the services provided may not be covered by workers’ compensation and may be the responsibility of the employee.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96

The MCO shall pay to providers at least the amount paid by the bureau to the MCO for provider services.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96

(A) All payments by the bureau for the allowed services of a bureau certified provider shall be through the MCO managing the care of the claim, whether for an MCO panel provider or a bureau certified provider who is not a panel provider of that MCO.

(B) The MCO shall accumulate the various medical records and bills for services rendered to employees for allowed conditions by its MCO panel providers and submit the bills electronically to the bureau for payment in a bureau approved format utilizing billing policies defined by the bureau. The MCO shall submit a bill to the bureau within seven business days of its receipt of the bill from the provider.

(C) The MCO shall accumulate the various bills for services rendered to employees for allowed conditions by bureau-certified providers who are not MCO panel providers for that MCO, but whose care is managed by the MCO, and submit the bills electronically to the bureau for payment in a bureau approved format utilizing billing policies defined by the bureau. The MCO shall submit a bill to the bureau within seven business days of its receipt of the bill from the provider.

(D) For an MCO panel provider, the bureau shall reimburse the MCO the least of the bureau fee schedule, the MCO panel provider fee schedule, or the billed charges by the provider for the services rendered.

(E) For a bureau certified provider who is not an MCO panel provider for that MCO but whose care is managed by that MCO, the bureau will reimburse the MCO the lesser of the bureau fee schedule or the billed charges by the provider for the services rendered.

(F) The bureau does not pay for failed or missed appointments or procedures. Bills must only contain descriptions of services that have been actually rendered for the actual conditions treated. A provider shall not transmit to the MCO or bureau any bill containing false or misleading information that would cause a provider to receive payment for services that the provider is not entitled to receive.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/15/99, 1/1/01

(A) The bureau shall pay a non-bureau certified provider only for initial or emergency treatment of an employee for a workers’ compensation injury under the HPP. If the non-bureau certified provider does not obtain further authorization of treatment from the employer’s MCO as provided in paragraph (B) of this rule, the employee may continue to obtain treatment from the non-bureau certified provider, but the payment for the treatment shall be the employee’s sole responsibility. The non-bureau certified provider shall inform the employee upon the initial or emergency treatment that the provider is not a participant in the HPP and that the employee will not be reimbursed by the bureau, MCO, or employer for the cost of further treatment after the initial or emergency treatment.

(B) The bureau shall pay a non-bureau certified provider for subsequent treatment after the initial or emergency treatment in the following circumstances:

(1) Where the services provided by the non-bureau certified provider are unavailable through a like provider in the MCO provider panel, the MCO may allow special authorization for the provider to continue treatment where medically necessary for the employee’s care. The MCO shall notify the bureau accordingly.

(2) Where the services provided by the non-bureau certified provider are available through a like provider in the MCO provider panel, the MCO may authorize the treatment by a non-bureau certified provider only if the provider becomes a bureau-certified provider. In such case, the MCO shall assist the provider in completing the bureau provider application and bureau provider agreement prior to authorization of or payment for additional treatment. Upon application by the non-bureau certified provider and certification by the bureau, the provider shall be paid for service rendered pursuant to rule 4123-6-11 of the Administrative Code.

(3) All payments by the bureau for the allowed services of a non-bureau certified provider shall be through the employer’s MCO.

(C) The MCO shall accumulate the various bills and medical records for services rendered to employees for allowed conditions from non-bureau certified providers who are not MCO panel providers for that MCO, but whose care is managed by the MCO, and shall submit the bills electronically to the bureau for payment in a bureau approved format utilizing billing policies defined by the bureau. The MCO shall submit a bill to the bureau within seven business days of its receipt of the bill from the provider.

(D) For a non-bureau certified provider whose care is managed by the MCO for an initial or emergency visit, the bureau shall pay the MCO the lesser of the bureau fee schedule or the billed charges by the provider for the services rendered.

(E) The bureau does not pay for failed or missed appointments or procedures. Bills must only contain descriptions of services that have been actually rendered for the actual conditions treated. A provider shall not transmit to the MCO or bureau any bill containing false or misleading information that would cause a provider to receive payment for services that the provider is not entitled to receive.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/15/99

(A) The bureau shall determine fee payments to an MCO which is selected by or assigned to employers with zero payroll, noncomplying employers, employers who are no longer in business, new employers, and other employer situations in which the employer’s premium does not adequately account for an MCO’s medical management services.

(B) The bureau shall pay an MCO an administrative fee for its medical management and administrative services in a manner determined by the administrator. The administrative fee may be subject to a disincentive penalty based upon the failure of the MCO to meet predetermined performance criteria set forth in the MCO contract. The bureau may pay an MCO a performance payment and may pay an incentive payment.

(C) In establishing performance measures, the bureau shall evaluate an MCO’s performance based upon but not limited to:

(1) Quality performance measures that may include return to work rates and reinjury rates.

(2) Total cost measures that may include average total paid cost, average incurred cost, and lost-time claims to total claims ratio.

(3) Change in cost measures that may include change in average total paid cost, change in average incurred cost, and change in lost-time to total claims ratio.

(4) Customer satisfaction that may include in-network utilization rate and employee, employer, and provider satisfaction surveys.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/99, 1/1/01

(A) The MCO shall submit bills electronically to the bureau. The bureau shall review all bills for allowed conditions and allowed claims, and shall pay the MCO for allowed payments after receipt of a proper invoice and after a final adjudication permitting payment for the claim. Upon receipt of payment from the bureau, the MCO shall pay the billing provider within seven days or less, if otherwise agreed by contract between the MCO and the provider.

(B) A provider that bills an MCO for services in expectation of payment from the MCO is responsible for the accuracy of all billing data and information the provider transmits to the MCO. The MCO is responsible for the accuracy of translating billing data received from the provider and the accuracy of transmitting billing data to the bureau that results in payment to the MCO or to the provider.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/15/99

(A) An MCO shall retain records received from providers and subcontractors that are utilized by the MCO to develop electronic billings to the bureau. The MCO shall retain any records obtained from the providers and subcontractors that are utilized by the MCO to perform its medical management functions or to substantiate the delivery, value, necessity, and appropriateness of goods and services provided to injured workers. The MCO shall retain records relating to a claim so long as the industrial commission and bureau of workers’ compensation have continuing jurisdiction over the claim pursuant to section 4123.52 of the Revised Code; however, if the MCO is no longer managing the claim in which the services were provided due to transfer of the management of the claim to another MCO or to the bureau, the MCO shall transfer the claim records to the other MCO or bureau. For records that do not relate to a specific claim, the MCO shall also create, maintain, and retain for a period of three years from the date of the transaction records documenting transactions with the injured worker, providers, and subcontractors.

(B) The failure of an MCO to create, maintain, and retain such records shall be sufficient cause for the bureau to deny payment for goods or services, or for performance fees, or for declaring overpaid previous payments made to the MCO, and may be cause for decertification.

(C) As used in this rule, “records” includes, but is not limited to, “record” and “electronic record” as defined in rule 4125-1-02 of the Administrative Code.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/15/99, 1/1/01

(A) Subject to sections 2317.02, 4123.27, and 4123.88, of the Revised Code, certain employer premium, payroll and claim file information is confidential and exempt from the general open records laws of this state, as set forth in section 149.43 of the Revised Code.

(B) In the course of medical management in the HPP, some confidential information may be provided by the bureau to the MCO, the employer and its representative, the employee and his or her representative, and the provider. All parties requiring such confidential information for use in the HPP shall not use such confidential information for any use other than to perform duties required by the HPP, and shall prevent such information from further disclosure or use by unauthorized persons.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96

(A) This rule shall provide for procedures for the resolution of medical disputes that may arise between any of the following: an employer, an employee, a provider, the bureau, or an MCO. This rule applies to reviews of records, medical disputes arising over issues such as, but not limited, to quality assurance, utilization review, determinations that a service provided to an employee is not covered, is covered or is medically unnecessary; or involving individual health care providers. Within fourteen days of receipt of written notice of an MCO determination giving rise to a medical dispute, an employee, employer, or provider may request, in writing, that the MCO initiate the medical dispute resolution process provided for in paragraph (C) of this rule. Such written request must comply with paragraph (F) of this rule.

(B) An employee or employer must exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code on an issue relating to the delivery of medical services.

(C) Any MCO participating in the bureau’s HPP must have a medical dispute resolution process that includes one independent level of review. Except as provided below, if an individual health care provider is involved in the dispute, the independent level of review shall consist of a peer review conducted by an individual or individuals licensed pursuant to the same section of the Revised Code as the health care provider. The MCO must identify the providers performing the peer review. If the MCO receives a dispute where the requested treatment appears to be the same as or similar to a previous treatment request for which the MCO conducted a peer review pursuant to this rule, and the previous treatment request was ultimately denied based on the peer review, the MCO may refer the new dispute to the bureau for a determination as to whether peer review is needed for the independent level of review in the new dispute. If the MCO receives a dispute where the requested treatment appears to be the same as or similar to a previous treatment request for which the MCO conducted a peer review pursuant to this rule, and the previous treatment request is pending before the bureau or industrial commission, the MCO may defer consideration of the new dispute until the previous treatment request is resolved. Once the previous treatment request has been resolved, the MCO shall refer the new dispute to the bureau for a determination as to whether peer review is needed for the independent level of review in the new dispute and shall resume the dispute resolution process under this rule. If, upon consideration of additional evidence or after negotiation with the party requesting dispute resolution, the MCO reverses the determination under dispute or otherwise resolves the dispute to the satisfaction of the party, the MCO may issue a new determination and dismiss the dispute without prejudice. The MCO must complete its internal medical dispute resolution process and must notify the parties to the dispute and their representatives of the decision in writing within twenty-one days of notice of a dispute. The twenty-one days shall be measured from the time the written notice of the medical dispute is received by the MCO. However, if the MCO elects to refer the employee for an independent medical examination as part of the dispute resolution process, the MCO shall have thirty days to complete its internal medical dispute resolution process and notify the parties to the dispute and their representatives of the decision in writing. Upon written notice of the dispute, the MCO shall inform the bureau local customer service team of the dispute. Notice of the medical dispute received by telephone only does not constitute formal notification as described in this paragraph. Within seven days of receipt of written notice of the MCO’s decision, the employer, injured worker or provider may request, in writing, that the dispute be referred to the bureau for an independent review. Such written request must comply with paragraph (F) of this rule. The MCO shall refer the requested dispute to the bureau within seven days of written notice of the request. All disputes shall be referred by the MCO to the bureau within seven days of the expiration of the referral period for tracking purposes.

(D) Upon receipt of an unresolved medical dispute from the MCO, if the bureau determines that the MCO has not satisfactorily completed its internal medical dispute resolution process as set forth in paragraph (C) of this rule and the