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) Upon receipt of notification of a workers’ compensation claim, the bureau will determine the compensability of the claim and the allowed conditions of the claim pursuant to the provisions of section 4123.511 of the Revised Code. The bureau will notify all parties and the MCO of the allowed conditions in the claim.

(B) The employer or employee or representative may appeal the bureau’s order to the industrial commission pursuant to section 4123.511 of the Revised 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. The bureau will notify all parties and the MCO of its determination.

The employer or employee or representative may appeal the bureau’s order to the industrial commission pursuant to section 4123.511 of the Revised Code.

(C) 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. The bureau shall notify all parties and the MCO when a claim or conditions are allowed or disallowed and indicate whether treatment rendered therefore may or may not be paid.

(D) 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 will not pay the MCO for medical services in a disallowed claim or for disallowed conditions. If the claim is disputed the MCO shall notify the claimant that continued treatment may be at the claimant’s expense.

(E) The bureau will provide ongoing indemnity and disability claims management on allowed claims.

Effective: 11/01/2004

R.C. 119.032 review dates: 03/01/2004

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) An employer may select any bureau certified MCO that has contracted with the bureau, and has not been placed at capacity pursuant to rule 4123-6-03.3 of the Administrative Code, during an open enrollment period as provided in this rule. The bureau shall develop a process for verifying an employer’s MCO selection.

(B) The bureau shall select an MCO for a state fund employer that fails to select an MCO,as necessary.

(C) If an MCO merges into or is acquired by another MCO, the bureau shall assign the employers formerly assigned to that MCO to the surviving MCO.

(D) If the administrator decertifies an MCO or terminates any agreement or contract between the bureau and an MCO, the bureau shall randomly assign the employers formerly assigned to the decertified or terminated MCO to all remaining, eligible MCOs.

(E) Selection of an MCO by an employer or selection by the bureau shall be until the next open enrollment period. At the bureau’s discretion or upon the employer’s request, 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, the employer shall notify all employees of the selection.

(G) The bureau shall establish an open enrollment period during which time an employer may change its selection of an MCO at least once every two years, but no more than once in a year. During an open enrollment period, an employer may:

(1) Select a new MCO; or

(2) Continue with the employer’s current MCO. In such case, the employer is not required to notify the bureau during the open enrollment period.

(H) The bureau shall maintain and make available to employers via the bureau’s internet site the list of all MCOs contracting with the bureau, and shall provide adequate notice to employers in writing of the deadline for new MCO selection.

(I) An MCO may not refuse to accept an employer once that has selected it or has been assigned to it by the bureau, unless the MCO has placed itself at capacity pursuant to rule 4123-6-03.3 of the Administrative Code.

Effective: 10/16/2008

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: 4121.44, 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 administrator of workers’ compensation, with the advice and consent of the bureau of workers’ compensation board of directors, shall develop, maintain, and publish a provider fee schedule for the various types of billing codes. The administrator hereby adopts the fee schedule indicated in appendix A to this rule, developed with provider and employer input, effective February 19, 2009.

(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.

See Appendix at http://www.registerofohio.state.oh.us/pdfs/4123/0/6/4123-6-08_PH_FF_A_APP1_20090209_1308.pdf

and http://www.registerofohio.state.oh.us/pdfs/4123/0/6/4123-6-08_PH_FF_A_APP2_20090209_1308.pdf

Effective: 02/19/2009

R.C. 119.032 review dates: 10/16/2008 and 02/01/2014

Promulgated Under: 119.03

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

Rule Amplifies: 4121.44, 4121.441, 4123.66

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

(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 MCO contract, the bureau may return the dispute to the MCO for completion. The return of a dispute to the MCO pursuant to this rule does not toll the MCO’s time frame for completing disputes. Within fourteen days after receipt of a completed, unresolved medical dispute from the MCO, the bureau shall conduct an independent review of the unresolved medical dispute received from the MCO and enter a final bureau order pursuant to section 4123.511 of the Revised Code. The bureau order may include a determination that the employee be scheduled for an independent medical examination. This determination shall toll the bureau’s time frame for completing the dispute, and in such cases the bureau shall enter a final bureau order within seven days after receipt of the independent medical examination report. This order shall be mailed to all parties and may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Neither the provider nor the MCO is a party entitled to file an appeal under section 4123.511 of the Revised Code.

(E) If an MCO receives a medical treatment reimbursement request relating to the delivery of medical services for a condition or part of the body that is not allowed in the claim, the MCO may deny the request for the reason that the condition or part of the body is not allowed in the claim. The provider may recommend an additional allowance on a recommendation for additional conditions form (Form C-9 or equivalent) with supporting medical evidence, or the claimant may file a motion requesting an additional allowance. The bureau shall review the recommendation or motion and shall consider the additional allowance. If a party has requested medical dispute resolution of the issue under this rule while the motion or issue on the allowance of the additional condition is pending before the bureau, the MCO may defer consideration of the dispute until the issue of the allowance of the additional condition is resolved, notwithstanding the time limits for resolution of the dispute as provided in paragraph (C) of this rule. Once the bureau has made a decision on the additional allowance, the MCO shall resume the dispute resolution process under this rule. If a dispute is filed where the claimant has not filed a motion for allowance of the condition or the bureau has not allowed the condition as recommended by the provider on the treatment plan form, the MCO may refer the matter directly to the bureau for an order under paragraph (D) of this rule.

(F) If the MCO receives a dispute where the requested treatment relates to the delivery of medical services that have been approved by the MCO pursuant to standard treatment guidelines, pathways, or presumptive authorization guidelines, the MCO may refer the matter directly to the bureau for an order under paragraph (D) of this rule.

(G) A written request to initiate the medical dispute resolution process under paragraph (A) of this rule or to refer the dispute to the bureau for an independent review under paragraph (C) of this rule (written appeal request) must contain, at a minimum, the following elements (form C-11 or equivalent):

(1) Injured worker name.

(2) Injured worker claim number.

(3) Date of initial medical treatment reimbursement request (form C-9 or equivalent) in dispute.

(4) Specific issue(s) in dispute, including description, frequency/duration, beginning/ending dates, and type of treatment/service/body part.

(5) Name of party making written appeal request.

(6) Signature of party making written appeal request or their authorized representative.

Only one medical treatment reimbursement request (form C-9 or equivalent) may be addressed in a single written appeal request under paragraph (A) or paragraph (C) of this rule.

Written appeal requests that do not contain the minimum elements set forth in this paragraph may be dismissed without prejudice by the MCO or bureau.

Effective: 09/25/2008

R.C. 119.032 review dates: 07/09/2008 and 09/01/2013

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; 6/6/97; 1/1/99; 11/8/99; 1/1/01; 1/1/03, 4/1/07

In conducting an independent review of a medical dispute referred to the bureau by an MCO pursuant to rule 4123-6-16 of the Administrative Code, the bureau shall refer to the most recent editions of the work loss data institute’s official disability guidelines: treatment in workers’ compensation, the Milliman and Robertson, Inc. healthcare management guidelines, the American accreditation healthcare commission/URAC national workers’ compensation utilization management standards, the American college of occupational and environmental medicine’s treatment occupational medicine practice guidelines, the McKesson Health Solutions LLC’s InterQual workers’ compensation and disability management guidelines, the agency for health care policy and research’s low back pain guidelines, the guidelines for chiropractic quality assurance and practice parameters, and the mercy center consensus conference’s synopsis of the guidelines for chiropractic quality assurance and practice parameters. In the event of a conflict between these standards or guidelines and any provision of Chapter 4123-6 of the Administrative Code, the provisions contained in the Administrative Code shall control.

HISTORY: Eff 4-29-98; 9-12-04

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

RC 119.032 Review Dates: 06/28/2004 and 03/01/2009

(A) Medical treatment reimbursement requests must be submitted by the physician of record or eligible treating provider (on form C-9 or equivalent) to the MCO responsible for medical management of the claim prior to initiating any non-emergency treatment.

(B) Medical treatment reimbursement requests shall be evaluated by the MCO using the following three-part test (all parts must be met to authorize treatment reimbursement):

(1) The requested services are reasonably related to the industrial injury (allowed conditions);

(2) The requested services are reasonably necessary for treatment of the industrial injury (allowed conditions);

(3) The costs of the services are medically reasonable.

(C) Medical treatment reimbursement requests in claims which have not had activity or a request for further action within a period of time in excess of thirteen months shall be processed in accordance with the provisions of rule 4123-3-15 of the Administrative Code.

(D) The MCO may dismiss without prejudice medical treatment reimbursement requests submitted by providers who are not enrolled with the bureau and who refuse to become enrolled, or who are enrolled but non-certified and are ineligible for payment as a non-certified provider 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.

(E) The MCO may dismiss without prejudice medical treatment reimbursement requests that are not accompanied by supporting medical documentation that the submitting physician of record or eligible treating provider has seen and examined the injured worker within thirty days prior to the request, or that the injured worker requested a visit with the provider, and such evidence is not provided to the MCO upon request (via form C-9A or equivalent).

(F) The MCO may dismiss without prejudice a medical treatment reimbursement request that duplicates a previous medical treatment reimbursement request that has been denied in a final administrative or judicial determination where the new request is not accompanied by supporting medical documentation of a new and change in circumstances impacting treatment, and such evidence is not provided to the MCO upon request (via form C-9A or equivalent).

(G) The MCO may dismiss without prejudice a medical treatment reimbursement request when the underlying claim has been settled, and the dates of service requested are on or after the effective date of the settlement. If the medical treatment reimbursement request includes both dates of service on or after the effective date of the settlement and dates of services prior to the effective date of the settlement, the MCO may dismiss without prejudice only that portion of the request relating to dates of service on or after the effective date of the settlement.

(H) If the MCO determines that any approved medical treatment reimbursement request is not medically indicated or necessary, is not producing the desired outcomes, or the injured worker is not responding, the MCO may notify the parties of its decision to discontinue payment of approved treatment that has not already been rendered. This decision shall be subject to medical dispute resolution pursuant to rule 4123-6-16 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: 4121.12, 4121.44, 4121.444, 4123.66

(A) The administrator of workers’ compensation may refuse to certify or recertify or may decertify a provider or MCO from participation in the HPP where the provider or MCO has failed to comply with the workers’ compensation statutes or rules governing providers or MCOs.

(B) The bureau shall monitor and may investigate a provider or MCO, and may participate with other state or federal agencies or law enforcement authorities in gathering evidence for such matters. When the bureau medical services division determines there is sufficient evidence that a provider or MCO has failed to comply with the workers’ compensation statutes or rules governing providers or MCOs, the bureau medical service division shall present this evidence to the administrator with a recommendation for an adjudication order.

(C) Prior to the administrator issuing an adjudication order on the matter, the administrator shall afford the provider or MCO an opportunity for a hearing in accordance with the provisions of Chapter 119 of the Revised Code and as provided in this rule.

(D) Prior to the administrator entering an adjudication order, the administrator shall send written notice to the provider or MCO by certified mail containing the following information:

(1) A statement of the reasons and a summary of the evidence relied upon for the proposed administrative action concerning the provider or MCO;

(2) A citation of statutes or rules forming the basis for the administrative action;

(3) A statement indicating that the provider or MCO is entitled to a hearing, if requested within thirty days of the time of the mailing of the notice;

(4) A notice that the provider or MCO may appear at the hearing in person, and may be represented by an attorney;

(5) A statement that at the hearing the provider or MCO may present evidence and examine witnesses appearing for and against the provider or MCO, and that the provider or MCO may request that the bureau issue subpoenas to compel the attendance of witnesses;

(6) A statement informing the provider or MCO that in the event a hearing is not requested and the request received by the bureau within thirty days of the time of mailing of the written notice, the administrator may proceed with an adjudication order concerning the provider or MCO.

(E) If no timely request for a public hearing is made by the provider or MCO, the administrator may issue an adjudication order concerning the provider or MCO for a period of time as determined by the administrator. Such order shall be sent by certified mail to the provider or MCO.

(F) If the provider or MCO files a timely request for a hearing, the bureau shall immediately set the date, time, and place for such hearing, not less than seven nor more than fifteen days from receipt of the request for hearing. The bureau shall notify the provider or MCO and any representatives of the hearing. The bureau may continue the date of the hearing upon the application of any party or upon its own motion. The hearing shall be held at the bureau central office in Columbus, but if requested by the provider or MCO, the bureau may hold the hearing in the district office closest to the place of business of the provider or MCO .

(G) The administrator may conduct the hearing personally or may delegate the hearing to a referee, who shall be an attorney at law. The referee may be from the bureau law section or an attorney employed by the administrator especially for such purpose. The burden of proof shall be on the bureau to establish cause for taking action against the provider or MCO, and shall be by a preponderance of the evidence. The bureau shall be represented by the attorney general at the adjudication hearing. A stenographic record of the hearing shall be made. Should the hearing be conducted by a referee, the referee shall issue a report and recommendation, a copy of which shall be mailed to all parties and representatives, and which may be objected to in writing within ten days. The administrator may approve, disapprove, or modify the report and recommendation of the referee, but shall not take such action until the after the expiration of the period for objection to the referee’s report. The administrator may order additional testimony. The administrator shall issue a decision in writing, sent by certified mail, to the provider or MCO and any representative informing the parties of the administrator’s decision in the matter.

(H) Should the provider or MCO prevail in the adjudicating hearing, the provider or MCO may be entitled to attorney fees. The procedure for determining attorney fees shall be in accordance with section 119.092 of the Revised Code.

(I) Should the provider or MCO be adversely affected by the order of the administrator, the provider or MCO may file an appeal of the decision to the court of common pleas of Franklin county as provided in section 119.12 of the Revised Code. The provider or MCO shall file notice of said appeal with the administrator. Within thirty days after receipt of the notice of appeal from an order in any case in which a hearing was required, the bureau shall prepare and certify to the court a complete record of the proceedings in the case.

(J) Any adjudicating order of the administrator to decertify, or to refuse to recertify a provider or MCO from participation in the HPP 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.

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) Pursuant to division (F) of section 4121.44 of the Revised Code and division (A)(6) of section 4121.441 of the Revised Code, the chief of injury management services shall require employees, employers and medical providers, medical vendors, and plans that participate in the workers’ compensation system to report data to be used by the administrator to:

(1) Measure and perform comparison analyses of costs, quality, appropriateness of medical care, and effectiveness of medical care delivered by all components of the workers’ compensation system.

(2) Compile data to support activities of the MCOs and to measure the outcomes and savings of the HPP.

(3) Publish and report compiled data to the governor, the speaker of the house of representatives, and the president of the senate every six months to gauge the measures of outcomes and savings of the HPP.

(B) The chief of injury management services shall compile and distribute annually to each employer in the HPP a report that summarizes the performance of each employer’s MCO pursuant to the performance criteria described in rule 4123-6-13 of the Administrative Code.

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

Promulgated Under: 119.03

Statutory Authority: RC 4121.121, 4121.44, 4121.441, 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) The bureau shall take measures and make expenditures, as it deems necessary, to aid injured workers who have sustained compensable injuries or contracted occupational diseases to remain at work.

(B) Remain at work services.

(1) An injured worker is eligible to participate in a remain at work program when:

(a) The injury results in a medical only claim which is certified by the employer or is allowed pursuant to a bureau or industrial commission order; and,

(b) It is documented by the employer, the injured worker or physician of record that the injured worker is experiencing problems that are work-related and result from the allowed conditions in the claim.

(2) Services provided shall be charged to the employer’s risk. If the claim is subsequently disallowed, the bureau will not be responsible for remain at work services that were provided.

(C) Scope of remain at work services.

(1) Referrals for remain at work.

(a) Any one can refer an injured worker for remain at work services.

(b) The MCO shall determine the need for remain at work services.

(c) An injured worker’s participation in remain at work services is voluntary.

(2) Services provided in a remain at work program.

(a) The MCO shall submit to the bureau a final report at the completion of services within five business days of final services.

(b) The provider shall staff the claim with the MCO and bureau at the initiation of remain at work services.

(c) Remain at work services may include ergonomic study, functional capacity evaluation, job analysis, physical therapy (on site), occupational therapy (on site), physical reconditioning, transitional work, gradual return to work, on the job training, job modification, tools and equipment, and remain at work case management.

(d) The bureau will not reimburse an employer for remain at work services that are provided by the employer (e.g., transitional work, on the job training, gradual return to work).

(3) Remain at work services shall cease upon the occurrence of any of the following:

(a) A bureau, industrial commission or court order subsequently disallowing the claim.

(b) The claim changes to a lost time claim, with the exception of those cases in which the claim becomes lost time due to an award pursuant to division (A) of section 4123.57 of the Revised Code.

(i) A claim receiving an award under division (A) of section 4123.57 of the Revised Code may continue in the services already authorized; however, no additional services shall be authorized under the remain at work program.

(ii) The injured worker may be referred for vocational rehabilitation services as provided under Chapter 4123-18 of the Administrative Code.

(c) The effective date of lump sum settlement.

(4) Audit of the remain at work program.

(a) The bureau may audit the MCO’s remain at work program on a regular basis.

(b) The following issues will be audited: notification process, eligibility criteria, forty five day staffing, completion reports, documentation of services, and services charged to proper fund.

HISTORY: Eff 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) As provided in rules 4123-6-02.8 and 4123-6-71 of the Administrative Code, a provider who undertakes treatment in an industrial case assumes the obligation to notify the bureau, MCO, QHP, or self-insuring employer of the injury within twenty-four hours of the initial treatment or initial visit.

(B) Interim medical reports and medical documentation.

Compensation for temporary total disability is payable upon submission of current supporting medical documentation. Interim reports must be filed, on forms provided by the bureau, at least every thirty days while the claimant remains on temporary total disability. Interim reports must include at least:

(1) The date of the report;

(2) The date of the last examination;

(3) The current “International Classification of Disease” diagnosis code(s), including a primary diagnosis code, with a narrative description identifying the condition and specific areas of the body being treated;

(4) Any reason(s) why recovery has been delayed;

(5) The date temporary total disability began;

(6) The current physical capabilities of the claimant;

(7) An estimated or actual return to work date;

(8) An indication of need for vocational rehabilitation;

(9) Objective findings; and

(10) Clinical findings supporting the above information.

(C) Treatment plan.

(1) Upon allowance of a claim by the bureau, industrial commission, or self-insuring employer, the physician of record and other providers treating the claimant shall provide and continue to update a treatment plan to the MCO, QHP, or self-insuring employer according to the format or information requirements designated by the bureau. A treatment plan should include at least the following:

(a) Details of the frequency, duration, and expected outcomes of medical interventions, treatments, and procedures;

(b) The projected or anticipated return to work date; and

(c) Factors that are unrelated to the work related condition, but are impacting recovery.

(2) Modifications should be made to the initial treatment plan as treatment is extended, changed, completed, added, deleted or canceled. The modification should describe the current prognosis for the injured worker, progress to date, and expected treatment outcomes.

(3) Treatment plans should be updated when significant changes occur in the claim which impact claims management. Changes include:

(a) Additional allowance;

(b) Re-activation;

(c) Authorization of expenditures from the surplus fund;

(d) Return to modified or alternative work;

(e) Maximum medical improvement;

(f) Rehabilitation;

(g) A new injury while receiving treatment in the claim.

(4) Supplemental reports from the attending physician and other providers may be requested by the bureau, industrial commission, employer, MCO, QHP, or by the claimant or representative. These reports shall be used to determine the appropriateness of a benefit or bill payment.

(D) In accepting a workers’ compensation case, a medical provider assumes the obligation to provide to the bureau, claimant, employer, or their representatives, MCO, QHP, or self-insuring employer, upon written request or facsimile thereof and within five business days, all medical, psychological, or psychiatric documentation relating causally or historically to physical or mental injuries relevant to the claim required by the bureau, MCO, QHP, or self-insuring employer, and necessary for the claimant to obtain medical services, benefits or compensation.

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: 1/27.97, 1/15/99, 1/1/01, 1/1/03

(A) The purpose of this rule is to provide parties to a workers’ compensation claim reasonable access to and reasonable charges for medical records necessary for the administration of the claim.

(B) Except as provided in this rule, a medical provider may not assess a fee or charge the claimant, employer, or their representatives for the costs of completing any bureau form or documentation required under rule 4123-6-20 of the Administrative Code which is required by the bureau, MCO, QHP, or self-insuring employer and is necessary for the claimant to obtain medical services, benefits, or compensation.

(C) A medical provider shall provide copies of medical records to the bureau, claimant, employer, or their representatives, MCO, QHP, or self-insuring employer as provided in paragraph (D) of rule 4123-6-20 of the Administrative Code. A medical provider may not assess a fee or charge the bureau, industrial commission, MCO, QHP, or self-insuring employer for the costs of providing medical records or completing any bureau form or documentation which is required by the bureau, MCO, QHP, or self-insuring employer and is necessary for the claimant to obtain medical services, benefits, or compensation.

(1) The bureau shall provide authorized parties to the claim access to all filed medical records without charge through secure electronic access.

(2) Where the bureau has provided access to medical records electronically and a party requests copies of such medical records, the bureau may charge a fee for the copies in accordance with the Ohio public records laws.

(3) Where a provider has filed copies of medical records with the bureau or MCO and the bureau has provided access to such medical records electronically, if a party requests such medical records of the provider, the provider may charge a fee for the copies. Where a provider has filed copies of medical records with the self-insuring employer, if a party requests such medical records of the provider, the provider may charge a fee for the copies. The provider’s fee shall be based upon the actual cost of furnishing such copies, not to exceed twenty-five cents per page.

(D) As provided in division (B) of section 4123.651 of the Revised Code, a claimant shall promptly provide a current signed release of medical information, records, and reports relative to the issues necessary for the administration of the claim when requested by the employer. The employer shall immediately provide copies of all medical information, records, and reports to the bureau and to the claimant or the claimant’s representative upon request.

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

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30

Rule Amplifies: 149.43, 3701.741, 4113.23, 4121.121, 4121.44, 4121.441, 4123.651

Prior Effective Dates: 1/1/03

(A) Medication must be for the treatment of an occupational injury or disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer. The bureau may deny a therapeutic class of drugs as not being reasonably related to or medically necessary for treatment of the allowed conditions in a claim.

(B) Medication must be prescribed by the physician of record in the industrial claim or by the treating physician, or by such other treating provider as may be authorized by law to prescribe such medication.

(C) Drugs covered are limited to those that are approved for use in the United States by the Food and Drug Administration and that are dispensed by a registered pharmacist from an enrolled pharmacy provider.

(D) The bureau may require prior authorization of certain drugs or therapeutic classes of drugs, and shall publish a list of all such drugs or therapeutic classes of drugs for which prior authorization is required.

(E) Drugs which fall into one of the following categories may be approved and reimbursed by an MCO as part of a comprehensive treatment plan submitted by the physician of record or treating physician:

(1) Drugs for the treatment of obesity;

(2) Drugs for the treatment of infertility;

(3) Drug Efficacy Study Implementation (DESI) drugs or drugs that may have been determined to be identical, similar, or related;

(4) Extemporaneous or simple compounded prescriptions;

(5) Injectable drugs not intended for self-administration;

(6) Drugs used to aid in smoking cessation;

(7) Drugs dispensed to a claimant while the claimant is admitted to a hospital during an approved inpatient admission or during the course of an outpatient visit in a hospital. Drugs approved by the MCO under this rule shall not be reimbursed through the bureau’s pharmacy benefits management vendor.

(F) Payment for medications to pharmacy providers shall include a product cost component and a dispensing fee component.

(1) The product cost component shall be the lesser of the following: maximum allowable cost, if applicable, or the average wholesale price of the commonly stocked package size plus or minus a percentage. The percentage amount added or subtracted from the average wholesale price shall be determined by the bureau, and shall be subject to annual review.

(2) The dispensing fee component shall be a flat rate fee, which shall be subject to annual review.

(a) Only pharmacy providers are eligible to receive a dispensing fee.

(b) The dispensing fee may include an additional incentive component for pharmacy providers that accept assignment.

(c) Except as provided below, dispensing fees shall be limited to one dispensing fee per patient per generic code number (GCN) per rolling twenty-five days. Exceptions to the single dispensing fee are:

(i) Cases where the physician has prescribed a second round of medication within the twenty-five day period;

(ii) Cases where the physician has changed the dosage;

(iii) Cases where the medication did not last for the intended days supply;

(iv) Cases where the medication has been lost, stolen or destroyed;

(v) Controlled substances (which are limited to two dispensing fees per twenty-five days).

(G) The pharmacy provider is required to bill medication at their usual and customary charge. The amount paid to the provider will be the lesser of the provider’s usual and customary charge or the reimbursement allowed as determined by the bureau. Pharmacy providers are required to submit for billing the national drug code of the stock bottle from which the dispensed medication is obtained. Drugs may be dispensed in unit dose packaging, but the NDC number of the closest comparable bulk package listed in the bureau or vendor payment system must be used for billing purposes.

(H) The bureau may establish a maximum allowable cost for medications which are pharmaceutically and therapeutically equivalent, that is, contain identical doses of the active ingredient and have the same biological effects as determined by the food and drug administration (FDA) and designated by an “A” code value in the FDA publication, “Approved Drug Products With Therapeutic Equivalence Evaluations.” The methodology used to determine a maximum allowable cost for a qualified drug product shall be determined by the medical policy department and shall be subject to annual review. The bureau may choose to utilize the maximum allowable cost list of a vendor or develop its own maximum allowable cost list.

(I) Claimants who request a brand name drug or whose physician specifies a brand name drug designated by “dispense as written” on the prescription for a medication which has an applicable maximum allowable cost price shall be liable for the product cost difference between the established maximum allowable cost price of the drug product and the average wholesale price plus or minus the bureau established percentage of the dispensed brand name drug.

(J) The following dispensing limitations may be adopted by the bureau:

(1) The bureau may publish a list of drugs identifying those drugs that are considered “chronic” medications. Drugs not identified as “chronic” medications shall be considered “acute” medications.

(2) The bureau may publish supply limitations for acute and chronic drugs which represent the maximum number of days supply that may be dispensed at any one time for a single prescription.

(3) The bureau may publish maximum prescription quantities which represent the largest number of units per drug that may be dispensed at any one time for a single prescription

(4) Requests submitted that exceed any published days supply limit or maximum quantity limit shall be denied. Denials may be overridden by the bureau in cases where medical necessity and appropriateness have been determined.

(5) Refills requested before seventy-five per cent of any published days supply limit has been utilized will be denied, except in cases where the dosage of a noncontrolled drug has been increased and has a new prescription number. Denials may be overridden by the bureau for the following documented reasons:

(a) Previous supply was lost, stolen or destroyed;

(b) Pharmacist entered previous wrong day supply;

(c) Out of country vacation or travel;

(d) Hospital or police kept the medication.

(K) Through internal development or through vendor contracts, an on-line point-of-service adjudication system may be implemented. Upon implementation, pharmacy providers may be required to submit bills for medication by an on-line point-of-service authorization terminal or a host-to-host link with the established bill processing system as a condition of provider enrollment or reimbursement. Submission by paper or by tape-to-tape may be refused upon implementation of an on-line point-of-service system.

(L) Claimant reimbursement for medications shall not exceed the bureau’s established rate for the medication regardless of the price paid by the claimant. Upon implementation of a point-of-service system, claimant reimbursement may be limited to the following situations:

(1) Claimants whose claims are not allowed on the date of service;

(2) Emergency situations where an enrolled pharmacy provider with point-of-service capabilities is not available;

(3) Claimants who reside out of the country.

(M) The bureau may formulate medication utilization protocols for select conditions or diseases consistent with one or more of the following

(1) Compendia consistent of the following:

(a) “United States Pharmacopoeia – Drug Information”;

(b) “American Medical Association Drug Evaluations”;

(c) “Drug Facts and Comparisons”; or,

(2) Peer reviewed medical literature. Compliance with the established protocols shall be monitored through the on-line, point-of-service adjudication system. Refusal to comply with the established protocols shall result in refusal of reimbursement for the medications which are not within the established protocols. This rule does not require the discontinuation of treatment with medications that are not within the established protocols, but simply states the bureau’s refusal to reimburse for such medications.

(N) A “pharmacy provider” designation and provider number can be obtained by a provider who meets all the following criteria:

(1) Has a valid “terminal distributor of dangerous drugs” as defined in section 4729.02 of the Revised Code if located within Ohio; or an equivalent state license if located outside of Ohio; and,

(2) Has a valid drug enforcement agency (DEA) number; and,

(3) Has a licensed registered pharmacist in full and actual charge of a pharmacy. ; and,

(4) Has the ability and agrees to submit bills at the point of service. All state and federal laws relating to the practice of pharmacy and the dispensing of medication by a duly licensed pharmacist must be observed.

(O) The bureau may contract with a vendor to perform drug utilization review and on-line bill processing, maintain a pharmacy provider network and prior authorization program for medications, and provide management reports. The bureau or its vendor may also contract rebate agreements with drug manufacturers, and be responsible for maintaining a drug formulary. The bureau may utilize other services or established procedures of the vendor which may enable the bureau to control costs and utilization and detect fraud.

(P) The bureau may identify circumstances under which it may consider reimbursement for pharmacist professional services (also known as cognitive services) when payment for such services results in a measurable, positive outcome. The bureau shall be responsible for developing the criteria which will be used to assess the compensability of billed pharmacist professional services. The bureau shall be responsible for developing the structure of the reporting of the measurable outcomes used to justify the payment of pharmacist professional services. The amount that could be reimbursed for pharmacist professional services shall be determined by the bureau’s medical policy department.

(Q) The bureau shall secure the services of a pharmacist to assist the bureau in the review of drug bills. The bureau may employ a staff pharmacist on a full or part-time basis or may contract for such services. The pharmacist may assist the bureau in determining the appropriateness, eligibility, and reasonableness of compensation payments for drug services. The bureau may consult with a pharmacy and therapeutics committee, which shall be a subcommittee of the stakeholders’ health care quality assurance advisory committee established by rule 4123-6-22 of the Administrative Code, on the development and ongoing annual review of a drug formulary and other issues regarding medications.

(R) The bureau will publish line by line billing instructions in a health care provider billing and reimbursement manual. At least thirty days written notice will be given prior to required changes in billing procedures.

Replaces: 4123-6-21

Effective: 10/01/2005

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

Promulgated Under: 119.03

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

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/27/97, 1/1/03

The bureau of workers’ compensation stakeholders’ health care quality assurance advisory committee is hereby created to advise the administrator and the chief of injury management services of the bureau of workers’ compensation with regard to medical issues.

(A) A list of physicians who have agreed to serve on the committee shall be developed by approval recommendations from the deans of Ohio’s medical and osteopathic schools, presidents of the Ohio state medical association, the Ohio state osteopathic association, the Ohio state chiropractic association, Ohio board specialty associations, the Ohio podiatry association, the Ohio psychology association, the Ohio hospital association, the Ohio pharmacists association, the Ohio dental association, the Ohio state medical board, the Ohio state chiropractic board, the Ohio state psychology board, the Ohio state pharmacy board, the Ohio state dental board, and the industrial commission of Ohio. This list shall be maintained by the bureau’s chief of injury management services and additional names may be added as needed or desired.

(B) The appointing authority for members of this advisory committee shall be the administrator or his designees, and shall appoint members of the committee from the lists of approved physicians.

(C) The bureau’s chief of injury management services shall be the chairman of the advisory committee, and may be self-designated an ad hoc member of any other subcommittees formed by the advisory committee. The chief of injury management services may delegate these duties to a chairperson elected by the voting members. The chief of injury management services shall be a voting member of the advisory and subcommittees only in case of tie votes.

(D) In addition to the bureau’s chief of injury management services, the advisory committee shall consist of at least one M.D., one D.O., one D.C., one clinical psychologist and one pharmacist, each holding a license in good standing in the state of Ohio, and one person representing the Ohio hospital association. The bureau’s medical director, the industrial commission’s medical director, and one physician chosen by the MCOs may participate in discussions; however, they shall not be voting members.

(E) Terms of membership for individual members of the advisory committee shall be for twelve months, subject to review by the administrator. Vacated terms shall be filled in like manner as for the full term appointments.

(F) The advisory committee shall develop and establish bylaws for the organization and operations of the committee and subcommittees, subject to the requirements of this rule and approval by the administrator and the bureau’s chief of injury management services.

(G) The advisory committee may initiate assessment of any medical quality assurance issue impacting the bureau and shall be responsible to respond to requests for assessment of any medical quality assurance issue submitted by the bureau’s chief of injury management services, including:

(1) Reviewing managed care data reporting;

(2) Recommending system-wide non-coverage policies or determinations that MCOs would be required to follow;

(3) Interfacing with MCO quality assurance committees;

(4) Reviewing performance measures;

(5) Addressing problems with MCO treatment guidelines;

(6) Providing ongoing peer review of the bureau’s MCO and provider certification processes, including making recommendations to the bureau for imposing sanctions or granting or denying certification or recertification of a provider based upon a review of the provider’s malpractice history;

(7) Advising the bureau regarding the decertification of providers and MCOs, including making recommendations to the bureau for imposing sanctions or decertification of a provider based upon a review of the provider’s malpractice history; and

(8) Review of medical disputes referred to the bureau pursuant to rule 4123-6-16 of the Administrative Code.

(H) The advisory committee shall hold at least quarterly meetings. The advisory committee and all subcommittees shall keep written records of the agenda and minutes of each meeting. The records of all committees shall remain in the custody of the bureau’s chief of injury management services.

(I) The advisory committee shall submit an annual report of their activities and recommendations to the administrator. In addition to inclusion in the annual report, all recommendations from the advisory committee and subcommittees shall be submitted to the bureau’s chief of injury management services in a timely fashion upon completion and approval by the respective committees.

(J) Each member of the advisory committee and its respective subcommittees may be paid such fees as may be approved by the administrator. The expenses incurred by the advisory committee and its subcommittees and the fees of their members shall be paid in the same manner as other administrative costs of the bureau.

(K) The administrator may request that the advisory committee appoint peer review subcommittees to review and provide recommendations to the administrator on disputes arising over quality assurance issues, determinations that a service provided to a claimant is not covered or is medically unnecessary, or billing adjustments arising from bureau audits or reviews of records involving individual health care providers. For these disputes the appointed panel shall consist of providers licensed pursuant to the same section of the Revised Code and system specialty as the individual health care provider for whom review has been requested. The panel may conduct an informal hearing, and shall advise the administrator, whose decision shall be final.

Effective: 06/01/2005

R.C. 119.032 review dates: 03/03/2005 and 03/01/2009

Promulgated Under: 119.03

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

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/27/97, 1/15/99

Jurisdictional requirements for payment for medical services rendered by a health care provider are as follows:

(A) Bills must be filed within the time provided in rule 4123-3-23 of the Administrative Code.

(B) In claims where the date of injury is on or after December 11, 1967, and prior to October 11, 2006, there is no jurisdiction to consider payment for medical services, if six years or more have elapsed since the date of the last payment of a medical bill and no compensation has been paid, except as provided in the following cases:

(1) A bill filed within the six-year period for services rendered within the period can be paid after the six-year period when, except for the time passage, it would have been paid.

(2) When an application requesting the payment of medical bills and/or compensation is filed within the six-year period, there is justification to act on the application after the period.

(a) Bills for services rendered within the six-year period can be ordered paid and can be paid after the period. However, these bills must be filed no later than two years after the date that services were rendered.

(b) Compensation can be ordered paid provided that evidence in the claim supports an award. If compensation is paid, the claim is opened for an additional ten years for the payment of compensation and bills. When there has been a payment of compensation under section 4123.56, 4123.57, or 4123.58 of the Revised Code, the claim is active for ten years from either the date of the last payment of compensation, or ten years from the last payment of a medical bill, whichever is later.

(3) Payment for medical services can be made when the claimant has received wages paid by the employer, instead of compensation for total disability. Medical services may be reimbursed when wages have been paid within six years of the date of injury with the employer’s knowledge that an allowed claim exists.

(4) When a request for authorization of treatment beyond the six-year period is filed within the six-year period, the authorization for treatment after that period cannot be granted, unless the claim has been opened by the payment of compensation.

(5) There is no jurisdiction to consider the merits of any application filed after the six-year period, even though supporting evidence for the application was on file within the period.

(6) A bill filed within the six-year period that requires reactivation of the claim cannot be paid when an application for reactivation is not filed within the period. This rule also applies to bills filed after the expiration of the six-year period for treatment rendered within that period.

(C) In claims where the date of injury is prior to December 11, 1967, there is no jurisdiction to consider payment for medical services if ten years or more have elapsed since the payment of compensation or benefits, or, when no compensation has been awarded, ten years have elapsed since the date of injury.

(D) In claims where the date of injury is on or after October 11, 2006, there is no jurisdiction to consider payment for medical services if five years or more have elapsed since the payment of compensation or benefits. The provisions of paragraph (B) of this rule shall apply to the payment of medical bills in claims where the date of injury is on or after October 11, 2006, except that where those provisions reference six year and ten year time limits, the time limits shall be five years.

Effective: 04/01/2007

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

Promulgated Under: 119.03

Statutory Authority: 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.52, 4123.66

Prior Effective Dates: 2/12/97

Medical or other services to be approved for payment must be rendered as a direct result of an injury sustained or occupational disease contracted by a claimant in the course of and arising out of employment. The claim must be allowed by an order of either the bureau of workers’ compensation or the industrial commission, or have been recognized by a self-insuring 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: 2/12/97

(A) Medical supplies and services will be considered for payment when they are medically necessary for the diagnosis and treatment of conditions allowed in the claim, are causally related to the conditions allowed in the claim, and are rendered by a health care provider. Payment for services rendered to a claimant shall be paid to a health care provider only when the provider has either delivered, rendered or directly supervised the examination, treatment, evaluation or any other medically necessary and related services provided to the claimant. By submitting any fee bill to the bureau, in either hardcopy or electronic format, the health care provider affirms that medical supplies and services have been provided to the claimant as required by this rule.

(B) Services rendered by health care providers are subject to review for coding requirements outlined in paragraph (C) of this rule. Payments to health care providers may be adjusted based upon these guidelines.

(C) Coding systems.

(1) Billing codes.

(a) Practitioners are required to use the most current edition of the centers for medicare and medicaid services’ healthcare common procedure coding system (HCPCS) to indicate the procedure or service rendered to injured workers.

(b) Inpatient and outpatient hospital services must be billed using the national uniform billing committee’s revenue center codes.

(c) Outpatient medication services must be billed pursuant to the requirements described in the bureau’s provider billing and reimbursement manual.

(d) To insure accurate data collection, the bureau shall adopt a standardized coding structure which shall be adopted by any MCO, QHP, or self-insuring employer.

(2) ICD-9 Diagnosis codes.

Providers must use the most current edition of the “International Classification of Diseases, clinical modification” to indicate diagnoses.

(D) Prior to services being delivered, the provider must make reasonable effort to notify the claimant, bureau, MCO, QHP or self-insuring employer when the provider has knowledge that the services may not be related to the claimed or allowed condition(s) related to the industrial injury or illness, or that a service is non-covered. The provider may not knowingly bill or seek payment from the bureau, MCO, QHP or self-insured employer for services that are not related to the claimed or allowed condition(s) related to the industrial injury or illness. The provider may not knowingly mislead or direct providers of ancillary services to bill or seek payment for services that are not related to the claimed or allowed condition.

The provider may not bill or seek payment from the claimant for services determined as medically unnecessary through the use of bona fide peer review based on accepted treatment guidelines.

Effective: 04/01/2007

R.C. 119.032 review dates: 08/09/2006 and 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

Prior Effective Dates: 2/12/97

When the claimant or any other person making payment on behalf of the claimant, including a volunteer, pays for medical services or supplies directly to a health care provider not participating in the HPP or QHP and the claim or condition is subsequently allowed, the payor shall be reimbursed upon submission of evidence of the receipt and payment for that service or supply. The payor will receive the amount that would have been paid to the health care provider as provided by the rules of this chapter of the Administrative Code. When payment has been made to the health care provider, the payor shall be informed to seek reimbursement from the provider.

The bureau shall inform a claimant or payor whether a health care provider participates in the HPP or QHP.

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: 2/12/97

Medical fees shall not be approved for treatment by more than one physician for the same condition over the same period of time, except where a consultant, anesthetist, or assistant is required, or where the necessity for treatment by a specialist is clearly shown and approved in advance of treatment. This rule does not apply in cases of emergency, or where the physician of record’s approved treatment plan indicates the necessity for multidisciplinary 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: 2/12/97

In claims involving treatment of more than one condition or more than one part of the body, the attending physician must report all conditions and all parts of the body being treated that are affecting the length of disability. The conditions submitted shall include a primary international classification of disease diagnosis code and a description of the condition being treated. This information may be used in the determination of the extent of disability resulting from the industrial injury or occupational disease.

HISTORY: Eff 2-12-97; 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 provider treating an injured worker may, at any time, make a request in writing, fascimile, e-mail, or by telephone for relevant information concerning conditions, treatment or history for the claim. The request for information shall be accompanied by an appropriate patient release of medical information. A prompt response will be given to this request.

HISTORY: Eff 2-12-97; 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) “Physical medicine” is the evaluation and treatment of a claimant by physical measures and the use of rehabilitative procedures, with or without assistive devices, for the purpose of preventing, correcting, or alleviating any work related disability. Physical medicine includes the establishment and modification of physical rehabilitation programs, treatment planning, instruction, and consultative services. “Physical measures” include massage, heat, cold, air, light, water, electricity, sound, manipulation, and the performance of tests of neuromuscular function as an aid to such treatment. Physical medicine does not include the diagnosis of a patient’s disability, the use of roentgen rays or radium for diagnostic or therapeutic purposes, or the use of electricity for cauterization or other surgical purposes. Physical medicine includes chiropractic treatments, physiotherapy, and physical therapy.

(B) Physical medicine must be prescribed by the physician of record or other approved treating physician, who is licensed to practice medicine, osteopathy, chiropratic, mechanotherapy, dentistry, or podiatry. Physical medicine may be provided in the physician’s office or referred to another licensed provider.

(C) Payment for physical medicine used for treatment of the allowed conditions shall be made pursuant to rule 4123-6-25 of the Administrative Code.

(D) Physical medicine treatments must be provided in conjunction with:

(1) In cases of temporary total disability, interim medical reports and medical documentation meeting the requirements specified in paragraph (B) of rule 4123-6-20 of the Administrative Code.

(2) A current, written treatment plan meeting the requirements specified in paragraph (C) of rule 4123-6-20 of the Administrative Code.

R.C. 119.032 review dates: 03/03/2005 and 03/01/2009

Promulgated Under: 119.03

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

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/12/97

(A) Acupuncture is a recognized method of treatment in Ohio and must be administered by a licensed doctor of medicine, doctor of osteopathic medicine and surgery, or doctor of podiatric medicine who has completed a course of study in acupuncture under the administration of an approved college of medicine, college of osteopathic medicine and surgery, or college of podiatric medicine, doctor of chiropractic who holds a certificate to practice acupuncture from the Ohio state chiropractic board or a registered non-physician acupuncturist.

(B) Services provided by a non-physician acupuncturist must be prescribed by persons licensed under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery or podiatry or Chapter 4743. of the Revised Code to practice chiropractic. A registered non-physician acupuncturist shall perform acupuncture under the general supervision of the injured worker’s prescribing physician or chiropractic physician. General supervision does not require that the acupuncturist and the prescribing physician or chiropractic physician practice in the same office.

Effective: 09/22/2008

R.C. 119.032 review dates: 07/03/2008 and 09/01/2013

Promulgated Under: 119.03

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

Rule Amplifies: 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/12/97, 10/10/03

Payment for x-ray examinations (including CT, MRI, and discogram) shall be made when medical evidence shows that the examination is medically necessary either for the treatment of an allowed injury or occupational disease, or for diagnostic purposes to pursue more specific diagnoses in an allowed claim. Providers shall follow all bureau prior authorization policies in effect at the time when requesting authorization and payment for such studies.

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: 2/12/97, 10/14/02

(A) Payment for dental care shall be made in the following cases:

(1) Where an industrial injury or occupational disease either has caused damage or has adversely affected the claimant’s natural teeth.

(2) For industrial injuries or occupational diseases sustained prior to January 1, 1979, artificial teeth or other denture must be in place in the worker’s mouth at the time of damage or loss.

(3) For industrial injuries or occupational diseases sustained on or after January 1, 1979, the requirements of division (A)(2) of this rule do not apply.

(B) Responsibility for injuries or occupational diseases affecting the claimant’s natural teeth is limited to the repair or replacement of those teeth actually injured at the time of the accident, or directly affected by the injury or disease. This responsibility does not include the replacement of teeth which are extracted or repaired for purposes unrelated to the industrial injury or occupational disease.

(C) Replacement of artificial teeth when the injury or occupational disease has resulted in a deformity of the jaw to the extent that artificial teeth cannot be used, is subject to the limitations of paragraphs (A)(2) and (A)(3) of this rule.

(D) Responsibility for the repair of both natural and artificial teeth is limited to the damage done at the time of the accident, or to the damage directly caused by an allowed injury or occupational disease.

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: 2/12/97

(A) Payment is approved to replace eyeglasses or contact lenses when an industrial injury or an industrial accident not only causes an injury, but also results in the damage or loss of the claimant’s eyeglasses or contact lenses.

(1) In the event of injury prior to January 1, 1979, the eyeglasses must be in place on the claimant’s face or the contact lenses shall be in place in the claimant’s eye(s) at the time of injury.

(2) In the event of injury on or after January 1, 1979, the requirements of paragraph (A)(1) of this rule do not apply.

(B) Contact lenses or glasses are reimbursed when loss of vision is the direct result of an allowed injury or occupational disease.

(C) Refractions will be approved in situations described in paragraph (B) of this rule.

(D) Replacement of glasses with contact lenses is approved when medical evidence indicates a direct need due to an allowed injury or occupational disease.

(E) Glasses or contact lenses will be approved for treatment purposes, when necessary, as a direct result of the allowed injury or occupational disease. Any subsequent adjustment, maintenance supplies or change in a claimant’s glasses or contact lenses, if required for treatment of the allowed injury or occupational disease, will also be approved when supported by evidence of a direct causal relationship.

When eyeglasses and/or contact lenses were damaged or broken in an industrial accident in which an injury was sustained by the claimant and have been replaced, no further replacement will be approved due to subsequent breakage or for any other reason, except as provided in this paragraph of this rule.

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: 2/12/97

(A) When an industrial injury or an industrial accident which causes an injury also damages the claimant’s hearing aid(s), payment to replace the hearing aid(s) is approved as follows:

(1) For injuries or accidents sustained prior to January 1, 1979, the hearing aid(s) must be in place in the claimant’s ear(s) at the time of the injury or accident.

(2) For injuries or accidents sustained on or after January 1, 1979, the requirements of paragraph (A)(1) of this rule do not apply.

(3) Once hearing aid(s) have been replaced, no further replacement will be approved.

(B) When a partial loss of hearing is the direct result of an allowed industrial injury or occupational disease, payment for a hearing aid(s) is justified in order to improve the claimant’s ability to hear.

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: 2/12/97

Payment is made only for those orthotic devices prescribed in writing by the physician of record for treatment of an allowed injury or occupational disease. The use of the orthotic device must be directly related to the allowed industrial injury or occupational disease.

(A) Orthotic devices shall be custom fitted or custom fabricated and delivered to the satisfaction of the prescribing physician and the administrative agencies. Repairs, modifications, and adjustments to secure satisfactory application of the orthotic appliance shall be made within sixty days of fitting and application without additional charge by the supplier of the orthotic device.

(B) No charge shall be made for measurement, transportation, or other expenses incurred by the supplier-orthotist, except when the supplier-orthotist is required to travel beyond the limits of the metropolitan community in which he maintains his place of business by reason of the physical incapacity of the claimant or by reason of direct prescription by the attending physician. The supplier-orthotist shall be paid for traveling expenses on a round-trip basis. Additional charges must be separately specified on the supplier-orthotist’s billing, including the points of travel and the name of the physician prescribing the travel. Payment will be made for a maximum of three round-trip calls.

HISTORY: Eff 2-12-97; 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) Direct reimbursement will not be made to members of a hospital resident staff.

(B) Payment for personal comfort items, which include, but are not limited to, telephones, television, and private rooms provided at the patient’s request, are not compensable.

(C) Bureau fees for hospital inpatient services.

(1) Bureau fees for hospital inpatient services will be based on usual and customary methods of payment, such as prospective payment systems, including diagnosis related groups (DRG), per diem rates, rates based on hospital cost to charge ratios or percent of allowed charges.

(2) Except in cases of emergency as defined in this chapter, prior authorization must be obtained in advance of all hospitalizations. The hospital must notify the bureau and/or the injured worker’s MCO of emergency inpatient admissions within one business day of the admission. Failure to comply with this rule shall be sufficient ground for denial of room and board charges by the bureau or MCO from the date of admission up to the actual date of notification. Room and board charges denied pursuant to this rule may not be billed to the injured worker.

(D) Bureau fees for hospital outpatient services.

(1) Bureau fees for hospital outpatient services, including emergency services, will be reimbursed in accordance with usual and customary methods of payment which may include prospectively determined rates, allowable fee maximums, ambulatory payment categories (APC), hospital cost to charge ratios, or a percent of allowed charges, as determined by the bureau.

(2) Treatment in the emergency room of a hospital must be of an immediate nature to constitute an emergency as defined in this chapter. Prior authorization of such treatment is not required. However, in situations where the emergency room is being utilized to deliver non-emergency care, notification will be provided to the injured worker, the hospital, and the provider of record that continued use of the emergency room for non-emergent services will not be reimbursed.

(E) The bureau may establish the same or different fees for in-state and out-of-state hospitals based on the above reimbursement methodologies

(F) Payment will be made for hospital services based on rules 4123-6-11 and 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: 2/12/97, 3/1/04

Unless an MCO has negotiated a different payment rate with a hospital pursuant to rule 4123-6-08 of the Administrative Code, reimbursement for hospital inpatient services with a discharge date of February 1, 2009, or after shall be as follows:

(A) Reimbursement for hospital inpatient services, other than outliers as defined in paragraph (C) of this rule or services provided by hospitals subject to reimbursement under paragraph (D) of this rule, shall be equal to one hundred twenty per cent of the applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system.

(B) In addition to the payment specified by paragraph (A) of this rule, hospitals operating approved graduate medical education programs and receiving additional reimbursement from medicare for costs associated with these programs shall receive an additional per diem amount for direct graduate medical education costs associated with hospital inpatient services reimbursed by the bureau. Hospital specific per diem rates for direct graduate medical education shall be calculated annually by the bureau effective January first of each year, using the most current cost report data available from the centers for medicare and medicaid, according to the following formula:

1.20 x [(total approved amount for resident cost + total approved amount for allied health cost)/ total inpatient days] = direct graduate medical education per diem.

Direct graduate medical education per diems shall not be applied to outliers as defined in paragraph (C) of this rule or services provided by hospitals subject to reimbursement under paragraph (D) of this rule.

(C) Reimbursement for outliers as determined by medicare’s inpatient prospective payment system outlier methodology shall be equal to one hundred seventy-five per cent of the applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system.

(D) Reimbursement for inpatient services provided by hospitals and distinct-part units of hospitals designated by the medicare program as exempt from the medicare inpatient prospective payment system shall be determined as follows:

(1) For Ohio hospitals who submitted a hospital cost report (JFS 02930) to the Ohio department of job and family services for the 2007 state fiscal year, reimbursement shall be equal to the hospital’s allowable billed charges multiplied by the hospital’s reported facility inpatient cost-to-charge ratio (from schedule B, line 101 of the hospital cost report) plus twelve percentage points, not to exceed seventy per cent of the hospital’s allowed billed charges.

(2) For Ohio hospitals who did not submit a hospital cost report (JFS 02930) to the Ohio department of job and family services for the 2007 state fiscal year and for out-of-state hospitals, reimbursement shall be equal to sixty-two per cent of the hospital’s allowed billed charges.

(E) For purposes of this rule, the “applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate” or “value” shall be determined in accordance with the medicare program established under Title XVIII of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1395 as amended, excluding 42 U.S.C. 1395ww(d)(4)(D), as implemented by the following materials, which are incorporated by reference:

(1) 42 C.F.R. Part 412 as published in the October 1, 2008 Code of Federal Regulations;

(2) Department of health and human services, centers for medicare and medicaid services’ “42 C.F.R. Parts 411, 412, 413, 422, and 489 Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Payments for Graduate Medical Education in Certain Emergency Situations; Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Updates to the Long-Term Care Prospective Payment System; Updates to Certain IPPS-Excluded Hospitals; and Collection of Information Regarding Financial Relationships Between Hospitals; Final Rule,” 73 Fed. Reg. 48434-01 (2008);

(3) Department of health and human services, centers for medicare and medicaid services’ “Medicare Program; Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates: Final Fiscal Year 2009 Wage Indices and Payment Rates Including Implementation of Section 124 of the Medicare Improvement for Patients and Providers Act of 2008,” 73 Fed. Reg. 57888-01 (2008).

Effective: 02/01/2009

R.C. 119.032 review dates: 11/06/2008 and 02/01/2014

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: 1/1/07; 4/1/07, 1/1/08

Unless an MCO has negotiated a different payment rate with a hospital pursuant to rule 4123-6-08 of the Administrative Code, reimbursement for hospital outpatient services shall be as follows:

(A) For Ohio hospitals that annually report a total outpatient cost-to-charge ratio to Ohio medicaid, reimbursement shall be equal to the hospital’s allowable billed charges multiplied by the hospital’s reported cost-to-charge ratio as set forth below plus sixteen percentage points, not to exceed sixty percent of the hospital’s allowed billed charges.

In determining reimbursement under this paragraph, the bureau shall initially utilize the hospital’s 2005 cost-to-charge ratio as reported to Ohio medicaid. However, as subsequent cost-to-charge ratios are reported to Ohio medicaid by the hospital, the bureau shall thereafter utilize the hospital’s most recently reported cost-to-charge ratio not later than thirty days following the bureau’s receipt of the hospital’s most recently reported cost-to-charge ratio from Ohio medicaid.

(B) For Ohio hospitals that do not annually report a total outpatient cost-to-charge ratio to Ohio medicaid and out-of-state hospitals, reimbursement shall be equal to fifty-six percent of the hospital’s allowed billed charges.

Effective: 09/01/2007

R.C. 119.032 review dates: 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

Unless an MCO has negotiated a different payment rate with an ambulatory surgical center pursuant to rule 4123-6-08 of the Administrative Code, reimbursement for ambulatory surgical center services with a date of service of April 1, 2009 or after shall be equal to the lesser of the ambulatory surgical center’s allowable billed charges or the fee schedule amount indicated in appendix A to this rule, developed with provider and employer input and effective April 1, 2009.

APPENDIX A

2009 Ambulatory Surgical Center (ASC) Fee Schedule

See Appendix at http://www.registerofohio.state.oh.us/pdfs/4123/0/6/4123-6-37$3_PH_FF_N_APP1_20090313_1630.pdf

See Appendix at http://www.registerofohio.state.oh.us/pdfs/4123/0/6/4123-6-37$3_PH_FF_N_APP2_20090313_1630.pdf

Effective: 04/01/2009

R.C. 119.032 review dates: 04/01/2014

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

(A) Employment of nursing service.

(1) The need for nursing services must be the direct result of an allowed injury or occupational disease.

(2) Except as described in rule 4123-6-38.1 of the Administrative Code, home health nursing services shall be provided by registered nurses and licensed practical nurses employed by a medicare certified, joint committee on accreditation of healthcare organizations (JCAHO) accredited, or community health accreditation (CHAP) accredited home health agency.

(B) Fees for home health agency nursing services.

Fees for home health agency nursing services will determined by the bureau. Payment will be made for home health nursing services based on rules 4123-6-11 and 4123-6-12 of the Administrative Code.

(C) Authorization for home health nursing services.

(1) Authorization for home health nursing services shall be considered only in cases where the claimant, as the direct result of an allowed injury or occupational disease, is bedfast or otherwise confined to the home, is mentally incapable of self-care or requires home care services ordered for hospital discharge follow-up.

(2) The request for authorization from the physician of record or treating physician must identify the reason for home health nursing services, the period of time the services will be required, the specific services and the number of hours per day that are required.

(3) In addition to skilled nursing services provided by a registered nurse or licensed practical nurse, the claimant may be approved for home health aide or attendant services. If he/she is unable to independently perform activities of daily living, including, but not limited to, feeding, bathing, dressing, providing personal hygiene, and transferring from bed to chair. Household, personal or other duties such as maintaining a household, washing clothes, preparing meals or running errands are not considered nursing services and will not be reimbursed.

(4) Authorization must be obtained from the MCO prior to rendering home health nursing services, except in cases of emergency or where the claimant’s allowed condition could be endangered by the delay of services.

(D) All covered home health services must be rendered on a part-time or intermittent care basis, in accordance with the written treatment plan and the bureau standard of care. Part-time or intermittent care means that services are generally rendered for no more than eight hours per day. Home health services rendered on a full time or continuous care basis are not covered. More appropriate alternative settings will be considered for claimants requiring more than eight hours per day of care, where medical necessity is documented. Exceptional cases may be reviewed by the bureau.

(E) A review of the claim or assessment of the injured worker will be conducted at lease annually to ensure that nursing services are necessary as a direct result of the allowed injury or occupational disease.

(F) Documentation requirements for home health agencies.

Home health agency providers must maintain records which fully document the extent of services provided to each claimant. All records must be maintained in accordance with the conditions of participation required for medicare certification, joint committee on accreditation of healthcare organizations (JCAHO) accreditation, or community health accreditation (CHAP) accreditation. The provider may be required to furnish detailed hourly descriptions of care delivered to a claimant to review care needs and medical necessity.

HISTORY: Eff 2-12-97; 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) Nursing services provided prior to December 14, 1992.

(1) Registered nurses and licensed practical nurses who are not employed by a medicare certified, joint commission on accreditation of healthcare organizations (JCAHO) accredited, or community health accreditation program (CHAP) accredited home health agency may continue to provide authorized services to a claimant if the services began prior to December 14, 1992.

(2) The need for nursing services must be the direct result of an allowed injury or occupational disease.

(3) In the event the registered nurse or licensed practical nurse is no longer able to provide approved services or if services are stopped and later restarted, nursing services shall be provided only by an employee of a medicare certified, joint commission on accreditation of healthcare organizations (JCAHO) accredited, or community health accreditation program (CHAP) accredited home health agency.

(B) Non-licensed caregiver services.

(1) Requests for extension of caregiver services initially provided prior to December 14, 1992.

(a) Prior to December 14, 1992, caregiver services provided by a non-licensed person including claimant’s spouse, friend or family member were considered for reimbursement in cases where the claimant, as a direct result of an allowed injury or occupational disease, was bedfast, confined to a wheelchair, had a disability of two or more extremities which prevented the claimant from caring for his/her own body needs or was otherwise unable to take care of his/her own bodily functions. Services include, but are not limited to, feeding, bathing, dressing, providing personal hygiene, and transferring from bed to chair. Household, personal or other duties such as maintaining a household, washing clothes, preparing meals, or running errands, are not considered nursing services, and will not be reimbursed.

(b) Requests for an extension of caregiver services approved by the bureau prior to December 14, 1992, delivered by a non-licensed person, other than an attendant, aide, or claimant’s spouse, but including other family members or friends, will be approved only if:

(i) The claimant does not have a spouse because the claimant is not married, or the claimant’s spouse is deceased, or the claimant’s spouse is physically or mentally incapable of caring for the claimant; and,

(ii) The approved home health agency is greater than thirty-five miles from the claimant’s location and the home health agency refuses to provide services to the claimant.

(c) In the event the caregiver is no longer able to provide approved services or if services are stopped and later restarted, services shall be provided only by an employee of a medicare certified, joint commission on accreditation of healthcare organizations (JCAHO) accredited, or community health accreditation program (CHAP) accredited home health agency.

(2) Requests for extension of caregiver services initially provided on or after December 14, 1992 and prior to January 9, 1995.

(a) Requests for approval of caregiver services delivered by a non-licensed person, other than an attendant, aide, or claimant’s spouse were considered for reimbursement only if the claimant did not have a spouse or the spouse was physically or mentally incapable of caring for the claimant, or an approved home health agency was greater than thirty-five miles from the claimant’s location and the home health agency refused to provide services to the claimant.

(b) Criteria for approval of caregiver services were as indicated in paragraph (B)(1)(a) of this rule.

(c) After January 9, 1995, persons who are not home health agency home health aides or attendants, but who are currently approved to provide caregiver services to a claimant, may continue to do so until services are no longer medically necessary or unless services are not authorized. After January 9, 1995, approval of caregiver services shall only be considered when services are rendered by a home health agency home health aide or attendant.

(d) In the event the caregiver is no longer able to provide approved services or if services are stopped and later restarted, services shall be provided only by an employee of a medicare certified, joint commission on accreditation of healthcare organizations (JCAHO) accredited, or community health accreditation program (CHAP) accredited home health agency.

(C) All covered home health services must be rendered on a part-time or intermittent care basis, in accordance with the written treatment plan and the bureau standard of care. Part-time or intermittent care means that services are generally rendered for no more than eight hours per day. Home health services rendered on a full time or continuous care basis are not covered. More appropriate alternative settings will be considered for claimants requiring more than eight hours per day of care, where medical necessity is documented. Exceptional cases may be reviewed by the bureau.

(D) A review of the claim or assessment of the injured worker will be conducted at lease annually to ensure that nursing services are necessary as a direct result of the allowed injury or occupational disease.

HISTORY: 2/12/97 Replaces: Part of 4123-6-38 Eff 02/14/2005

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: 03/01/2009

(A) Payment to a nursing home or residential care/assisted living facility for the care of a claimant who sustained an injury or contracted an occupational disease in the course of and arising out of employment shall be made only when the need for such care is the direct result of the allowed conditions in the claim.

(B) Payment will be made only for care provided in state licensed, medicaid certified nursing homes and residential care/assisted living facilities.

(C) In claims managed by an MCO, care must be pre-authorized, except when a nursing home or residential care/assisted living facility is used immediately following an approved or emergency hospitalization.

(1) The allowed per diem rate for a claimant shall be no greater than the bureau’s fee schedule or the rate negotiated between the nursing home or residential care/assisted living facility and the MCO.

(2) Nursing home care shall be provided on a semiprivate or ward bed basis, unless a situation exists when the use of a private room is necessary due to the allowed industrial condition. In these cases, the use of such a private room must be pre-authorized, except in cases of emergency, as defined in rule 4123-6-01 of the Administrative Code, or where claimant’s condition would be endangered by delay.

(3) Fee bills for prescription medication provided to claimants in nursing homes and residential care/assisted living facilities for the treatment of the allowed industrial injury or occupational disease shall be submitted by the providing pharmacy in compliance with rule 4123-6-21 of the Administrative Code.

HISTORY: Eff 02/14/2005

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: 03/01/2009

In all cases arising under division (B) of section 4123.57 of the Revised Code, if a claimant requires the purchase or repair of an artificial appliance, the bureau shall pay the cost of purchasing or repairing the artificial appliance out of the surplus fund. The purchase or repair is made regardless of whether the appliance is part of the claimant’s vocational rehabilitation, or if the claimant has, or will ever be able, to return to work.

HISTORY: Eff 2-12-97; 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, 4121.61, 4123.57, 4123.66

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

(A) A claimant’s travel expenses shall be paid, upon the filing of a proper request, under the following circumstances:

(1) When the claimant has been ordered or authorized to undergo a medical examination outside of the city or community limits where he resides. The claimant shall be reimbursed for travel only if the travel distance exceeds a mileage distance as periodically determined by the bureau. The minimum mileage distance for reimbursement shall be published periodically by the bureau.

(2) When specialized treatment necessary for the allowed industrial condition cannot be obtained within the city or community where the claimant resides, and the treatment has been pre-authorized and approved. The claimant shall be reimbursed for travel only if the travel distance exceeds a mileage distance as periodically determined by the bureau. The minimum mileage distance for reimbursement shall be published periodically by the bureau.

(3) When the claimant has been requested to undergo a medical examination by a physician of the employer’s choice, travel expenses incurred as a result of the examination are to be paid by the employer immediately upon the receipt of the bill. Payment of the bill shall not require an order of the bureau or commission, unless there is a dispute. The employer shall provide the claimant with a proper form to be completed by the claimant for reimbursement of traveling expenses. The minimum mileage provision of paragraphs (A)(1) and (A)(2) of this rule shall not apply for reimbursement of examinations under this paragraph of the rule.

(4) In situations described in paragraphs (A)(1) and (A)(2) of this rule, the following provisions apply:

(a) If the claimant is traveling by automobile, the claimant shall be entitled to a reasonable payment, as established and periodically published by the bureau, on a per mile basis if the mileage exceeds the distance established as provided under paragraph (A) of this rule, portal to portal, using the most direct and practical route.

(b) If the claimant is traveling by airplane, railroad or bus, the claimant shall be entitled to the actual and necessary airplane, railroad or bus fare.

(c) The reasonable cost of necessary meals, based on distance traveled, will be refunded to the claimant. It shall be paid in accordance with a schedule adopted by the bureau and periodically revised.

(d) Necessary hotel bills will be paid at reasonable actual cost. Hotel accommodation must be pre-authorized.

(5) Taxicab fares will be refunded only when the claimant’s physical condition requires such transportation for treatment or examination on account of an allowed injury or occupational disease. Taxicabs or other special transportation shall be pre-authorized.

(6) The payment rates for meals, lodging and travel shall be published periodically by the bureau.

(B) Actual payment or refund shall be made in accordance with requirements outlined in this rule.

(C) This rule applies to all claims for industrial injuries and/or occupational diseases, regardless of whether the employer is part of the state fund, is self-insuring, is non-complying, etc.

Effective: 06/01/2005

R.C. 119.032 review dates: 03/03/2005 and 03/01/2009

Promulgated Under: 119.03

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

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/12/97, 10/14/02

(A) Direct payment to a health care provider or other person by the industrial commission, bureau of workers’ compensation, or their agent, for medical care rendered to a claimant does not imply or create a legal relationship between the provider or person and the commission, bureau, or their agent.

(B) The services rendered to the claimant are the legal obligation of the claimant. The direct payment to the health care provider is a discretionary method by which the award made to the claimant for medical expenses may be discharged.

(C) Except as prohibited by division (K) of section 4121.44 of the Revised Code and rule 4123-6-07 of the Administrative Code, whether payment is made to the claimant, or the claimant’s obligation is discharged by a direct payment to the health care provider through payment to the MCO or QHP, the sole legal recourse of the health care provider is against the claimant.

HISTORY: Eff 2-12-97; 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) Payment is made for equipment, materials, goods, supplies, or services incurred by the claimant in connection with claims against the state insurance fund, pneumoconiosis fund, or marine industry fund based on section 126.30 of the Revised Code. For the purpose of this rule, the required payment date is the date on which payment is due under the terms of a written agreement between the bureau, or its agent, and the provider. Payment will be made either thirty days after the bureau, or its agent, receives a proper invoice for the amount of the payment due, or thirty days after the final adjudication allowing payment of an award to the claimant, whichever is later.

(1) A “proper invoice” includes but is not limited to the claimant’s name, claim number, date of injury or occupational disease, employer’s name, provider’s name and address and assigned payee number, a description of the service provided, the procedure code for the service provided, the date provided, and the amount of the charge. If more than one item has been included in the invoice, each item is to be considered separately to determine if it is a proper invoice.

(2) If the bureau or its agent determines that an invoice is improper, the bureau or its agent shall send notification to the provider through the MCO or QHP at least fifteen days prior to what would be the required payment date if the invoice did not contain an error. The notice shall describe the error and the additional information needed to correct the error. The required payment date shall be redetermined upon receipt of a proper invoice.

(3) If an invoice is for payment of either a condition not allowed in a claim, or for a claim that is not allowed, the payment date is thirty days after final adjudication of allowance of the condition or claim. As defined in section 126.30 of the Revised Code, “final adjudication” is the date that the decision of the bureau, commission, or court becomes final, with no further right of appeal. If any section of the Revised Code contains a faster timetable for payments, however, such provisions shall not be superseded by this rule.

(B) Interest shall be paid based on division (E) of section 126.30 of the Revised Code. Any interest charges payable under section 126.30 of the Revised Code are to be paid by the bureau of workers’ compensation.

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) Payment will be approved for a transcutaneous electric nerve stimulator (TENS) unit for treatment of allowed conditions in a claim directly resulting from an allowed industrial injury or occupational disease, as provided in this rule and in the bureau’s provider billing and reimbursement manual.

(1) Prior authorization may be required to have a prescribed transcutaneous electrical nerve stimulator (TENS) unit and supplies furnished to the claimant. Each claimant who requires a TENS unit will be provided only one unit at a time. For each TENS unit request approved, the unit may be rented for a trial period lasting a minimum of one month but no more than four months before purchase of the TENS unit. This trial period is to evaluate the medical necessity and effectiveness of the TENS treatment. For each TENS unit provided, payment shall be limited to necessary disposable or rechargeable batteries, but not both.

(2) If the rental of the TENS unit is required prior to purchase, all rental payments previously made will be applied to the purchase price of the TENS unit. A TENS unit purchased and furnished to the claimant, is not the personal property of the claimant, but remains the property of the bureau, self-insuring employer, or their agent. At its discretion, the bureau, self-insuring employer, or their agent, reserves the right to reclaim and recover the TENS unit from the claimant at the completion of the course of TENS treatment. Once a TENS unit is purchased, of the bureau, self-insuring employer, or their agent, will reimburse for repair or replacement, at its discretion, upon submission of a request from the physician of record. The request must include medical documentation substantiating the continued medical necessity and effectiveness of the unit.

(B) The TENS provider shall maintain the following records and make them available for audit upon request:

(1) The injured worker’s monthly written requests;

(2) Records of the provider’s wholesale purchase of TENS supplies or equipment; and,

(3) Records of delivery of supplies to injured workers and of the delivery or return of TENS units.

Upon request, the provider shall supply copies of the record information to the requester at no cost. Failure to provide the requested records will result in denial or adjustment of bills related to these records.

(C) Payment will be approved for a neuromuscular electrical stimulator (NMNS) unit for treatment of allowed conditions in a claim directly resulting from an allowed industrial injury or occupational disease, as provided in the bureau’s provider billing and reimbursement manual.

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: 2/12/97

Bureau fees for in-state or out-of-state practitioners will be established by the administrator of workers’ compensation with the assistance of the bureau’s medical management and cost containment division. The bureau may establish different fees for in-state and out-of-state practitioners. The methods of payment may include rates based on resource based relative value scale (RBRVS), percent of allowed charges, or usual, customary and reasonable fee maximas, as determined by the bureau’s medical management and cost containment division. Rates will be reviewed at least annually by the bureau to determine the need for appropriate adjustment.

Payment for practitioner services will be made based on rules 4123-6-11 and 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

(A) Providers’ patient and billing related records, including but not limited to those records described in rule 4123-6-451 of the Administrative Code, may be reviewed by the bureau or the MCO to ensure workers are receiving proper and necessary medical care, and to ensure compliance with the bureau’s statutes, rules, policies, and procedures.

(1) Based on division (B)(16)(c) of section 4121.121 of the Revised Code, provider records may be reviewed before, during, or after the delivery of services. Reviews may be random, with no unreasonable infringement of provider rights, or may be for cause. Reviews may include the utilization of statistical sampling methodologies and projections based upon sample findings. Records reviews may be conducted at or away from the provider’s place of business.

(2) Based on division (B)(17) of section 4121.121 of the Revised Code, legible copies of providers’ records may be requested. Providers shall furnish copies of the requested records within thirty calendar days of receipt of the request. The bureau shall establish a schedule for payment of reasonable costs for copying records, which shall be published in the health care provider billing and reimbursement manual.

(3) Original records shall not be removed from the provider’s premises, except upon court order or subpoena issued by the bureau pursuant to section 4121.15 or 4123.08 of the Revised Code.

(B) Upon any finding of improper or unnecessary medical care, the administrator shall, if requested by the provider, appoint a subcommittee of the stakeholders’ health care quality assurance advisory committee to review and advise the administrator as provided in paragraph (K) of rule 4123-6-22 of the Administrative Code. The administrator may sanction, suspend, or exclude a health care provider from participation in the workers’ compensation system based on rule 4123-6-17 of the Administrative Code.

(C) The bureau or the MCO may deny payment for services or declare as overpaid previous payments to providers who fail to provide records or access to records to either the bureau or the MCO. The bureau may decertify a health care provider that fails to provide records requested pursuant to Chapters 2913., 4121., and 4123. of the Revised 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: 2/12/97, 1/15/99

(A) A health care provider shall create, maintain, and retain sufficient records, papers, books, and documents in such form to fully substantiate the delivery, value, necessity, and appropriateness of goods and services provided to injured workers under the HPP or of significant business transactions. The provider shall retain such records for a minimum period of three years from the date of payment for said goods or services, or three years from the date of referral to a certified or non-certified provider, or until any initiated audit or investigation is completed, whichever is longer. The provider shall create and maintain the records at the time the goods or services are delivered or within seven days from the date the service was rendered.

(B) The provider shall retain records documenting the following minimum information concerning the goods or services provided to injured workers:

(1) Date the service was provided;

(2) Description of service, treatment or product provided;

(3) Record of patient appointments, if appropriate;

(4) Dates where injured worker canceled or failed to appear for a scheduled examination, treatment, or procedure;

(5) Treatment plans;

(6) Subjective and objective complaints, if the provider is the practitioner or physician of record;

(7) Injured worker’s progress, if the provider is the practitioner or physician of record;

(8) Wholesale purchase records, if goods, products, or prescriptions are delivered;

(9) Delivery records, if goods, products, or prescriptions are delivered by way of a third party;

(10) The identity and qualifications of any individual involved in the delivery of health care or billing for services to injured workers on behalf of the provider billing for the services.

(C) A provider’s failure to create, maintain, and retain such records shall be sufficient cause for the bureau to deny payment for goods or services, to declare overpaid previous payments made to the provider, or to decertify the provider.

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: 1/15/99

(A) The bureau may negotiate payment rates with health care providers for services and supplies provided in the treatment of workers’ compensation claims.

(B) Volume-based contracts may be made with medical providers for services including, but not limited to, the purchase or rental of durable medical equipment and supplies.

(C) Injured workers may be informed of the availability of services, supplies, or equipment from particular health care providers with whom a contract for services or supplies, a negotiated a payment rate for services or supplies, or a contract for cost-effective payment levels or rates has been made. In each case, access to quality and convenient medical services or supplies must be maintained for claimants.

HISTORY: Eff 2-12-97; 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, 4123.651, 4123.66

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

All self-insured employers that do not participate in the QHP system shall comply with the reporting requirements for participating self-insured employers set forth in rule 4123-6-70 of the Administrative Code. Data collected and stored by the bureau in furtherance of the provisions of this rule and rule 4123-6-70 of the Administrative Code shall be in accordance with section 4123.27 of the Revised Code, paragraph (A) of rule 4121-15-03 of the Administrative Code, and paragraph (A) of rule 4123-15-03 of the Administrative Code for the purpose of ensuring confidentiality and avoiding the appearance of impropriety.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) A health plan that satisfies the QHP certification requirements of this chapter shall be certified by the bureau as a QHP to manage medical treatment, direct care or provide services or supplies to or on behalf of an employee for an injury or occupational disease that is compensable under Chapter 4121., 4123., or 4131. of the Revised Code.

(B) An employer may establish a bureau certified QHP, that shall comply with the thirteen standards set forth in divisions (D)(1) to (D)(13) of section 4121.442 of the Revised Code, Division (K) of section 4121.44 of the Revised Code, and rules 4123-6-53 and 4123-6-54 of the Administrative Code.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) The bureau shall establish an initial QHP certification enrollment period upon inception of the QHP system to allow health plans to seek certification for participation in the QHP system.

(B) After the initial QHP certification enrollment period upon inception of the QHP system, the bureau shall continue to certify health plans and shall periodically, at least annually, update its list of certified QHPS.

(C) QHP certification by the bureau shall be for a period of three years.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) Each QHP shall have a quality assurance program that monitors the operation and measures the effectiveness of peer review, utilization review, and dispute resolution within the QHP. Data collected from the quality assurance program shall be used to assist an employer in determining the quality, efficiency and effectiveness of the employer’s QHP and the QHP system in accordance with division (D) of section 4121.442 of the Revised Code.

(B) Each quality assurance program shall include a mechanism for monitoring and the methodology for measuring and improving the QHP’s compliance with each of the following eleven elements:

(1) Peer review and evaluation of clinical performance;

(2) Credentialing and recredentialing and use of provider profiling;

(3) Utilization management to determine the appropriateness of care;

(4) Evaluation of employee and provider dispute resolution procedures and outcomes;

(5) Evaluation of outcomes of care based on clinical data;

(6) Procedures for remedial action for inappropriate or substandard services;

(7) Evaluation of employee satisfaction with the plan;

(8) Evaluation of provider satisfaction with the plan;

(9) Evaluation of employer satisfaction with the plan;

(10) Periodic evaluation of medical records and office procedures; and

(11) Practice patterns compared to accepted medical criteria.

(C) The quality assurance program shall include a quality assurance committee or other mechanism adequate to evaluate the outcomes of each of the eleven elements listed in paragraph (B) of this rule.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) Upon request by an employer or health plan seeking certification, the bureau shall mail the employer or health plan seeking certification a QHP application for certification.

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

(C) The QHP application for certification shall include, at a minimum, the following provisions, as more fully detailed within the QHP certification application 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;

(2) Proof that a self-insured employer has been granted status as a self-insured employer in accordance with section 4123.35 of the Revised Code;

(3) A description of the geographic or regional area of the state of Ohio to be serviced by the QHP, taking into account the unique circumstances of the individual employer, such as multiple locations, and/or the need for a statewide network;

(4) A description of the role of each vendor that will be a component of the QHP including, but not limited to, the following: if an employer uses or anticipates using company-based providers, a description of the role of company-based providers as distinguished from QHP network providers; if an employer uses or anticipates using a third party administrator, a description of the role of the third party administrator;

(5) If an employer contemplates contracting with a vendor that has been certified by the bureau under Chapter 4123-6 of the Administrative Code to provide services under the employer’s QHP, proof that certification has been granted by the bureau and that such certification is current;

(6) A description of the structure of the medical management component and the health care provider network to be offered by the QHP;

(7) A description of the QHP’s plan and methodology for providing, at least annually, QHP network provider information, by provider type, and updated QHP network provider directories to employees;

(8) A description of the QHP’s quality assurance program, including but not limited to, the proposed structure and operation and a description of the mechanism for monitoring and the methodology for measuring and improving the QHP’s compliance with the elements listed in paragraph (B) of rule 4123-6-53 of the Administrative Code;

(9) A description of the QHP’s employee education program. The description shall include but shall not be limited to: a description of the process to be used to educate employees regarding their rights and responsibilities in the QHP system; a description of the process to be used to explain the time, place and manner of services to be delivered under the QHP; and a description of the process to be used to explain options available to injured workers, including the process for changing providers within the QHP and referral and transfer to the HPP; and

(10) A description of the plan satisfactory to the bureau to be implemented by the QHP in the event a final order to revoke certification, or to refuse to recertify a QHP is issued by the administrator, pursuant to rule 4123-6-55 of the Administrative Code, that includes, but is not limited to, a plan that describes continuation and continuity of care of injured workers; a plan that describes payment of providers for medical services rendered prior to revocation of certification or refusal to certify. The injured worker may continue receiving medical services from the same provider or may choose a provider in a new approved plan for delivery of medical services, both of whom shall accept medical management of the medical services through the employer’s new approved plan.

(D) The bureau shall review the application for certification submitted by the health plan seeking certification. The bureau reserves the right to cross-check data with other governmental agencies or licensing or accrediting bodies.

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

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) The bureau is authorized to revoke certification, to refuse to certify or recertify a QHP from participation in the QHP system.

(B) Should the bureau determine that sufficient evidence exists that an employer or QHP has failed to comply with applicable workers’ compensation statutes or rules governing QHPS, the bureau, shall take one of two courses of action:

(1) The bureau shall notify the employer, employee representative and QHP in writing by certified mail of the facts and issues relating to the bureau’s determination that the employer or QHP has failed to comply with applicable workers’ compensation statutes or rules governing QHPs and has set a period of time for the employer or QHP to resolve or correct the problem. Failure of the employer or QHP to resolve or correct the problem within the time period shall result in notification from the bureau to the employer and QHP in writing by certified mail of administrative action that might result in a bureau determination to revoke certification, refusal to certify or recertify, and the employer’s and QHP’s right to a hearing within thirty days of the notice, if requested by the employer or QHP, pursuant to rule 4123-6-17 of the Administrative Code.

(2) Notify the employer, employee representative and QHP in writing by certified mail of administrative action that might result in a bureau determination to revoke certification, refusal to certify or recertify, and the employer’s and QHP’s right to a hearing within thirty days of the notice, if requested by the employer or QHP, pursuant to rule 4123-6-17 of the Administrative Code.

(3) For the purpose of this rule, “employee representative” does not include the employee’s attorney.

(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, the administrator may immediately revoke or suspend, or provisionally revoke or suspend, the certification of a QHP. The order shall be final unless the employer or QHP, within seven days of such order, requests a hearing before the administrator where the employer or QHP 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) Upon a final order of the administrator to revoke certification of, refuse to recertify or suspend a QHP, employees and employers shall not receive services from such QHP pursuant to the QHP system.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) An employee of an employer that participates in a QHP has freedom of choice of providers within the QHP network of providers established by the employer’s QHP. In all claims that precede the establishment of the employer’s QHP, and where the employee’s physician of record is not a provider on a panel of the QHP when established, the employee may continue treatment with that physician of record. The physician of record shall be subject to and participate in the dispute resolution process as provided in rule 4123-6-69 of the Administrative Code. After the establishment of the QHP, the employer’s QHP shall manage the medical care and treatment in the claim. If an injured worker changes from the physician of record who is not in the QHP for any reason, the employee shall select a QHP panel provider as the physician of record.

(B) An employee of an employer that participates in a QHP, who is dissatisfied with the health care services of a provider in the QHP, after written notice to the QHP, may change providers and select another provider of the employee’s choice within the QHP. An employee’s notice for change of provider within a QHP does not require notification to the bureau. To provide the employer’s QHP with data necessary for QHP tracking of employee choice of provider and to provide the bureau with data necessary for recertification of providers, an employee’s notice for a change of provider within a QHP shall be in a writing that contains the reasons therefore.

(C) An employee who first has chosen and received health care services from a provider in the employer’s QHP, but is dissatisfied with the health care services provided by the employer’s QHP, may request and shall be granted a change of provider to a bureau certified provider. An employee’s notice for a change of provider to a bureau certified provider in the HPP shall be in a writing to both the employer’s QHP and to the administrator of the bureau.

(1) The bureau shall provide all QHPs with a list of bureau certified providers in the employees’ area. The QHP shall provide an employee with a list of bureau certified providers upon request. The bureau shall provide an employee, upon request to the bureau, with a list of bureau certified providers within the employee’s area.

(2) An employee who first has chosen and received health care services from a provider in the employer’s QHP, and who has requested and has been granted a change of provider to a bureau certified provider in the HPP, shall submit a written request to the QHP medically managing the treatment and shall be granted approval to change providers within the HPP. An employee’s request for change of provider within the HPP does not require notification to the bureau of the request. An employee who has requested and has been granted a change of provider from an employer’s QHP to a bureau certified provider in the HPP shall be permitted to return to the employer’s QHP at any time for health care services.

(3) Notwithstanding the provisions contained in paragraph (C)(2) of this rule, an employee who incurs a new medical condition, injury or claim requiring medical treatment, not related to a prior medical condition, injury or claim, shall first seek treatment from a provider on the panel of the injured worker’s employer’s QHP.

(4) To provide the employer’s QHP with data necessary for QHP tracking of employee choice of provider and to provide the bureau with data necessary for recertification of providers, an employee’s request for a change of provider from a QHP to a bureau certified provider in the HPP, or a change of provider within the HPP, shall state a reason for the request.

(D) Medical management of all injured workers’ claims, whether medical services are provided within or without the QHP network of providers, shall be provided by the employer’s QHP.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) A provider who participates in the QHP system shall be certified by the bureau, pursuant to rules 4123-6-02 to 4123-6-025 of the Administrative Code, and credentialed by the QHP.

(B) Notwithstanding rule 4123-6-02 of the Administrative Code, a provider who is an employee or an independent contractor of an employer that participates in the QHP shall have the provider’s credentials reviewed and the bureau shall verify that the provider’s credentials meet bureau standards. Such provider may sign a provider agreement set forth in rule 4123-6-02 of the Administrative Code.

(C) A provider who meets the certification requirements as set forth in the administrative code relating to the certification of providers under the HPP, and is certified as a provider eligible to participate in the HPP, shall be eligible to participate in and to treat injured workers under the QHP system.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

A QHP or vendor that provides medical management and cost containment services shall not require a provider to participate in a workers’ compensation network of providers in order to maintain membership in a related health care program.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(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 employer that develops a QHP, a vendor within the QHP system, or a QHP shall develop and implement standards of credentialing of providers in the QHP network that meet but may exceed the bureau credentialing requirements in the HPP.

(C) An employer that develops a QHP may selectively contract with providers or contract with a vendor that selectively contracts with providers.

(D) Only a bureau certified provider is eligible for selection by an employer that develops a QHP, by a QHP as a QHP panel provider or by a vendor as a panel provider to participate in the QHP system. A provider identified by a QHP for inclusion in its panel of providers that is not a bureau certified provider may be assisted by the QHP in applying for bureau provider credentialing and certification.

(E) The bureau, an employer, a QHP or a vendor shall not discriminate against any category of health care provider when establishing categories of providers for participation in the QHP system. However, an employer, a QHP or a vendor is not required to accept or retain any individual provider in the QHP system.

(F) The bureau, an employer, a QHP and a vendor shall comply with state and federal laws prohibiting discrimination based on, but not limited to, race, national origin, or color, and shall not discriminate against any health care provider when establishing categories of providers for participation in the QHP system on the basis of race, religion, national origin, color, gender, sexual orientation or age.

(G) A QHP shall include in its panel a substantial number of the medical, professional, and pharmacy providers currently being utilized by employees. A QHP may limit the number of providers on its provider panel, but shall do so based upon objective data that demonstrates that the fundamental needs of the employer and employees are met based on reasonable standards such as historical claims data or other geographic information approved by the bureau. In addition, a QHP shall include in its application for QHP certification information including reasonable patient access, the potential number of employees the QHP is applying to service, and other performance criteria, without discrimination by provider type. Subject to the provisions of rules 4123-6-67 and 4123-6-68 of the Administrative Code, a QHP seeking QHP certification may select out-of-state providers as members of the QHP panel.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) Providers who treat injured workers who originate in the QHP system shall develop and/or maintain a system that accomplishes efficient transfer of copies of injured workers’ medical records among providers when the following occurs:

(1) An employee changes provider within or without the employer’s QHP network;

(2) An employer terminates a QHP, or

(3) An employer transfers to another QHP or the HPP.

(B) Release or transfer of injured workers’ medical records shall be in accordance with section 4123.651 of the Revised Code and rule 4121-17-30 of the Administrative Code.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

An employer utilizing a QHP is responsible for payment of all goods and services that are medically necessary and appropriate for allowed condition(s) in claims for injured workers under a QHP. Within each QHP, all payments shall be in accordance with consistent billing and payment policies and practices established by the QHP and consistent with the provisions contained in paragraph (L)(5) of rule 4123-19-03 of the Administrative Code.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) No health care provider shall charge, assess, or otherwise attempt to collect from an employee any amount for covered services or supplies that is in excess of the amount reimbursed by the employer, a vendor, or a QHP.

(B) An employer or QHP shall hold an employee harmless for all balanced billing from providers who are members of the employer’s QHP panel or who have signed a provider agreement with a QHP and/or employer.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) With the exception of the restrictions recited in rule 4123-6-65 of the Administrative Code, and with the exception that no financial arrangement between an employer or QHP and a provider shall reduce the quality of medical care received by an injured worker, an employer or QHP may pay a provider a rate that is the same, is above or is below the rates set forth in the provider fee schedule developed by the bureau pursuant to division (A)(8) of section 4121.441 of the Revised Code, and nothing in the rules pertaining to the QHP system shall be construed to inhibit employers or QHPs and providers in their efforts to privately negotiate a payment rate.

(B) An employee, dissatisfied with the medical services provided by the employer’s QHP, may request and shall be granted a change of provider as provided in rule 4123-6-56 of the Administrative Code. The employee’s health care shall be managed by the QHP. In such event, the provider shall be reimbursed by the employer or QHP the lessor of the bureau fee schedule or the billed charges by the provider for services rendered, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider.

(C) Employers’ financial arrangements with company-based providers remain intact, and services provided by company-based providers need not be billed separately through QHP arrangements.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

A vendor retained by an employer shall not benefit financially from the difference between the fee schedule negotiated with the provider and the rate paid to the provider by the employer.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

The bureau shall not interfere with nor impose restrictions upon an arrangement for payment negotiated between an employer and a vendor that provides medical management and cost containment services and/or a QHP under the QHP system, except that no financial arrangement between an employer and a vendor that provides medical management and cost containment services and/or a QHP shall incentivize a reduction in the quality of medical care received by an injured worker.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) An employer in the QHP system shall authorize and pay for initial emergency medical treatment for an injury or occupational disease that is an allowed claim or condition provided by a health care provider who is not part of the employer’s QHP in accordance with the provisions and limitations contained in this rule.

(B) The employer shall pay a health care provider who is not part of the employer’s QHP only for initial-emergency treatment of an employee for a workers compensation injury. The health care provider who is not part of the employer’s QHP shall inform the employee upon the initial emergency treatment that the provider is not a participant in the QHP and that the provider will not be paid nor will the employee be reimbursed by the QHP or employer for the cost of further treatment after the initial emergency treatment, unless authorized otherwise by the employer or QHP.

(C) Subsequent emergency medical treatment by a provider who is not part of the employer’s QHP for the same injury or occupational disease shall be reviewed by the QHP unless payment is otherwise authorized by the QHP. The employee may continue to obtain treatment from the health care provider who is not part of the employer’s QHP, but the payment for the treatment shall be the employee’s sole responsibility, except as provided above.

(D) A provider that provides initial emergency medical treatment or subsequent emergency medical treatment for the same injury or occupational disease authorized by the QHP shall be paid in accordance with the rates established in Ohio workers’ compensation fee schedule or the provider’s billed charges, whichever is less unless an alternate payment arrangement is negotiated between an employer or QHP and a provider.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) Out-of-state providers that are certified by the bureau in states that border Ohio shall accept and be paid as payment in full in accordance with the Ohio workers’ compensation state fee schedule or the amount billed, whichever is less, unless an alternate provider agreement exists between provider, and employer and/or the QHP. No health care provider shall charge, assess, or otherwise attempt to collect from an employee, employer, a vendor, or a QHP, any amount for covered services or supplies that is in excess of the amount reimbursed by the employer, a vendor, or a QHP.

(B) An employer or QHP shall hold an employee harmless for all balanced billing from out-of-state providers in states that border Ohio and who are a member of a QHP panel or who have signed a provider agreement with a QHP and/or employer.

(C) Payment to out-of-state providers in states that border Ohio who are not certified by the bureau, in the absence of a provider agreement with an employer and/or QHP, shall be the sole responsibility of the employee unless otherwise authorized by the employer or QHP.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) A QHP may negotiate all issues with providers in states that do not border Ohio.

(B) Paragraph (A) of this rule notwithstanding, no provider in a state that does not border Ohio shall charge, assess, or otherwise attempt to collect from an employee with an Ohio claim who works in Ohio but who resides in another state any amount for covered services or supplies that is in excess of the amount reimbursed by the employer, a vendor, or a QHP.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) This rule shall provide time frames and procedures for review of requests for the delivery of medical services and for the resolution of disputes that may arise between an employee and an employer, an employee and a provider, or an employer and a provider. This rule applies to, but is not limited to, reviews of records, medical disputes arising over issues such as, but not limited to, quality assurance, utilization review, a determination that a service provided to an employee is not covered, is covered or is medically unnecessary; or disputes involving individual health care providers.

(B) Initial review and decision upon requests for the delivery of medical services that include, but are not limited to, medical treatment, major diagnostic testing, hospitalization, surgery and physical therapy, shall be completed by the QHP. The employee, employer and provider shall be notified verbally of the outcome of the initial review within forty-eight hours of the request. Within seven working days of the verbal notification, the verbal notification shall be committed to writing and mailed to the employee, employer and provider.

(C) A QHP shall have a dispute resolution process beyond initial review that includes a minimum of two levels of peer review of a medical diagnosis or treatment issue if an individual health care provider is involved in the dispute, or a minimum of two levels of dispute resolution if an individual health care provider is not involved in the dispute.

(D) A QHP dispute resolution process shall be completed and the QHP shall notify the parties to the dispute and their initial written notice of a dispute, unless an extension of time is otherwise agreed to by the parties. Any party appealing a decision to a higher level within a QHP’s dispute resolution process shall provide notice of such appeal to all the parties to the dispute within seven working days of notice of decision.

(E) The dispute resolution process shall begin upon written notice of the dispute by the party maintaining the dispute to the parties of the dispute. If an individual health care provider is involved in the dispute, there shall be available at least two levels of peer review if appealed, with at least one level conducted by an individual or individuals licensed pursuant to the same section of the revised code as the health care provider who is a party to the dispute. The other level of peer review shall include, at the discretion of the QHP medical director, one or more of the following: a review conducted by a multi-disciplinary medical panel or board; an independent or agreed upon medical examination; or the use of other resources beneficial to the resolution of the dispute.

(F) A dispute unresolved by a QHP dispute resolution process may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code.

(G) Notwithstanding the requirements set forth in paragraph (F) of this rule, a dispute unresolved by a QHP providing medical management and cost containment services for a state fund employer shall be referred by the QHP to the bureau within seven working days of the final decision rendered within the QHP dispute resolution process. Within fourteen days of receipt of an unresolved medical dispute, the bureau shall conduct an independent review of the unresolved medical dispute received from the QHP and enter a final bureau order pursuant to section 4123.511 of the Revised Code. This order shall be mailed to all parties and may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) To enhance the quality of the QHP system, and pursuant to division (G) of section 4121.44 of the Revised Code, divisions (D)(9) and (G) of section 4121.442 of the Revised Code, and division (D)(2)(d) of section 4121.125 of the Revised Code, the deputy administrator for the division of medical management and cost containment shall require employers and QHPs that participate in the workers compensation QHP system to report data to be used by the administrator to:

(1) Measure and perform comparison analyses of costs, quality, appropriateness of medical care, and effectiveness of medical care delivered by all components of the workers compensation system; and

(2) Publish and report compiled data to the governor, the speaker of the house of representatives, and the president of the senate every six months to gauge the measures of outcomes and savings of the QHP system.

(B) The bureau shall evaluate the effectiveness of the QHP system based on standardized data and reporting requirements developed by the bureau.

(C) The bureau shall receive, define and publish data elements and data collection techniques that meet the thirteen standards set forth in divisions (D)(1) to (D)(13) of section 4121.442 of the Revised Code and are necessary to evaluate the effectiveness of the QHP system. Performance indicators used by the bureau to evaluate the effectiveness of the QHP system may include, but shall not be limited to, the following: customer satisfaction; system cost drivers; improvements in quality, and cost reductions.

(D) QHPs shall submit to the bureau no more than twice per year, on standardized forms developed by the bureau, data that provide the bureau with information enabling the bureau to determine the effectiveness of the QHP system.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

(A) A provider who initially becomes aware of an employee’s injury or occupational disease, at a minimum, shall notify the QHP or employer of the injury or occupational disease in a standard format no later than one working day after the date the provider becomes aware of the injury or occupational disease.

(B) Providers shall abide by current standard state workers’ compensation reporting requirements for treatment of injured workers, pursuant to rule 4123-7-08 of the Administrative Code.

(C) The injured worker, when the injured worker’s medical condition does not prohibit him from doing so, shall notify the QHP or employer of the injury or occupational disease as soon as possible after the date the injured worker becomes aware of the injury or occupational disease.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

Subject to the requirements and protections contained in ohio law pertaining to release of confidential and/or privileged information, in the course of medical management in the QHP system, confidential information may be exchanged among the bureau, the QHPs, an employer and its representative, an employee and his or her representative, and the provider. All parties providing or requiring such confidential information for use in the QHP system shall not provide or use such confidential information for any purpose other than to perform duties required under the QHP system, and shall prevent such information from further disclosure or use by unauthorized persons.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96

The bureau, at least annually, shall develop and make available information that describes employer and employee rights under the QHP system.

R.C. 119.032 review dates: 05/06/2004 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, 4121.442, 4123.66

Prior Effective Dates: 9/5/96