Chapter 4123-6 Health Partnership Program

4123-6-01 Definitions.

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 medical 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 under section 4121.442 of the Revised Code 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 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:

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; a doctor of chiropractic who holds a current, valid certificate of licensure to practice chiropractic under Chapter 4734. 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 his or her 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 medicare or medicaid to provide medical services or supplies, including, but not limited tor a qualified rehabilitation provide.

(H) "Credentialing" or "recredentialing" means:

A process by which the bureau validates or reviews the application of a provider for certification or recertification.

(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 the provider.

(K) "Recertification application and agreement" means:

A bureau form sent to bureau certified providers as part of the provider recredentialing and recertification process which requests background information and documentation necessary for recredentialing and which, if completed and signed by the provider and approved by the bureau, constitutes a written, contractual agreement between the bureau and the provider.

(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..

(N) "Employee" means:

As used in the rules ofthis 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 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 for the resolution of 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" means:

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 (D) of section 4729.01 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.

(CC) "Hospital" means:

An institution that provides facilities for surgical and medical diagnosis and treatment of bed patients under the supervision of staff physicians and furnishes twenty-four hour-a-day care by registered nurses.

(1) For the purposes of the rules of this chapter of the Administrative Code relating to hospitals, "inpatient" means:

An injured worker is considered to be an inpatient when he or she has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. An injured worker is considered an inpatient if there is a formal order for admission from the physician. The determination of an inpatient stay is not based upon the number of hours involved. If it later develops during the uninterrupted stay that the injured worker is discharged, transferred to another inpatient unit within the hospital, transferred to another hospital, transferred to another state psychiatric facility or expires and does not actually use a bed overnight, the order from the attending physician addressing the type of encounter will define the status of the stay.

(2) For the purposes of the rules of this chapter of the Administrative Code relating to hospitals, "outpatient" means:

The injured worker is not receiving inpatient care, as "inpatient" is defined in paragraph (CC)(1) of this rule, but receives outpatient services at a hospital. An outpatient encounter cannot exceed seventy-two hours of uninterrupted duration.

(DD) "Urgent care facility" means:

A facility where ambulatory care is provided outside a hospital emergency department and is available on a walk in, non-appointment basis.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 02/01/2015
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: 2/16/96, 9/5/96, 1/1/99, 1/1/01, 3/29/02, 2/14/05

4123-6-01.1 Applicability of medical rules.

Unless specifically stated otherwise, the rules of this chapter governing payment of medical services and supplies shall apply to payments to health care providers in all claims for industrial injuries and/or occupational diseases before the bureau, self-insuring employers, MCOs, OHPs, and the industrial commission.

However, nothing in these rules shall inhibit or diminish the commission's right to establish adjudicatory policy under Chapters 4121., 4123., 4127., and 4131. of the Revised Code, or otherwise prevent the full adjudication of claims properly before the commission or its hearing officers.

Effective: 03/05/2010
R.C. 119.032 review dates: 02/01/2015
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

4123-6-02 Provider access to the HPP - generally.

(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 injured workers if the provider is a direct service provider; meets and maintains basic credentialing criteria under rule 4123-6-02.2 of the Administrative Code; meets and maintains all other applicable criteria under the workers' compensation statutes and rules; and as established by the bureau; and completes and signs a provider application and agreement or recertification application and agreement with the bureau.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and02/01/2015
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.121 , 4121.31 , 4123.05
Rule Amplifies: 4121.121 , 4121.44 , 4121.441 , 4123.66
Prior Effective Dates: 2/16/96, 1/5/99, 1/1/01, 3/29/02

4123-6-02.1 Rescinded.

Effective: 2/1/2010
R.C. 119.032 review dates: 11/17/09
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

4123-6-02.2 Provider access to the HPP - provider credentialing criteria.

(A) The bureau shall establish minimum credentialing criteria for provider certification.

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. However, if an individual provider's professional license is under revocation or suspension in any state, or is subject to disciplinary restrictions in any state that affect the provider's ability to treat patients or that compromise patient care, the provider shall be ineligible to participate in the health partnership program.

(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 (including, but not limited to, disciplinary restrictions related to chemical dependency or substance abuse) that affect the provider's ability to treat patients or that compromise patient care.

(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 involving moral turpitude, 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) Attest to and maintain adequate, current professional malpractice and liability insurance, and provide proof of such coverage to BWC upon request. 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) Adult day care facility: Ohio department of aging PASSPORT adult day care provider agreement.

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

(3) Ambulance, ambulette, or air ambulance service: license from Ohio medical transportation board if private; approved by the centers for medicare and medicaid services (CMS) for medicare if government/public.

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

(5) Anesthesiologist assistant: certificate of registration from Ohio state medical board.

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

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

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

(9) 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.

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

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

(12) Comprehensive pain management services program: (free standing) CARF accreditation; (hospital based) CARF or joint commission accreditation.

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

(14) Dialysis center: license from Ohio department of health and approved by the centers for medicare and medicaid services (CMS) for medicare .

(15) Durable medical equipment supplier (excludes orthotics, prosthetics and pedorthics): state vendors license; approved by the centers for medicare and medicaid services (CMS) for medicare ; and Ohio respiratory care board home medical equipment certificate of registration .

(16) 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).

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

(18) Home health agency: approved by the centers for medicare and medicaid services (CMS) for medicare , joint commission accreditation, or community health accreditation program (CHAP) accreditation, or accreditation through an organization that has been granted deeming authority by the centers for medicare and medicaid services (CMS).

(19) Hospital: approved by the centers for medicare and medicaid services (CMS) for medicare or obtained national accreditation (joint commission accreditation, or American osteopathic association healthcare facilities accreditation program (HFAP), or commission on accreditation of rehabilitation facilities (CARF) for rehabilitation hospitals). The following facility types shall be credentialed and certified as hospitals: short-term general and specialty hospitals; long-term care hospitals; rehabilitation hospitals; psychiatric hospitals; hospital (provider) based urgent care facilities or clinics as designated on the hospital's medicare cost report.

(20) Independent diagnostic testing facility (IDTF): approved by the centers for medicare and medicaid services (CMS) for medicare.

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

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

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

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

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

(26) Nursing home: license from Ohio department of health or approved by the centers for medicare and medicaid services (CMS) for medicare .

(27) Occupational rehabilitation-comprehensive programs (work hardening): CARF accreditation.

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

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

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

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

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

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

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

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

(36) Psychologist: license from Ohio state board of psychology.

(37) Radiology services (free-standing) state licensing, registration or accreditation; (mobile) state, county or city registration, or approved by the centers for medicare and medicaid services (CMS) for medicare or medicaid certification.

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

(39) Sleep laboratory: certified by the American academy of sleep medicine and approved by the centers for medicare and medicaid services (CMS) for medicare.

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

(41) Telemedicine: telemedicine certificate from Ohio state medical board.

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

(43) Urgent care facility (free standing): approved by the centers for medicare and medicaid services (CMS) for medicare .

(44) Vocational rehabilitation case managers: certification for American board of vocational experts (ABVE), occupational health nursing (COHN(S)), certified rehabilitation counselor (CRC), certified disability management specialist (CDMS), certified vocational evaluator (CVE), certified rehabilitation nurse (CRRN), or certified case manager (CCM).

(45) 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)(44) 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)(44) 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.

Effective: 12/11/2012
R.C. 119.032 review dates: 03/16/2012 and 02/01/2015
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.121 , 4121.30 , 4121.31 , 4121.44 , 4121.441 , 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, 4/1/07, 2/1/10

4123-6-02.21 Provider access to the HPP - non-certified provider enrollment.

(A) The bureau may enroll non-certified providers eligible under rule 4123-6- 06.2 or 4123-6-10 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. 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 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.

(D) The enrollment of a non-certified provider, person, or entity pursuant to paragraph (A) or (B) of this rule shall expire, on a schedule determined by the bureau, if the non-certified provider, person, or entity has had no billing activity with the bureau for a period of two years or longer.

(E) Expiration of provider certification or enrollment pursuant to paragraph (C) or (D) of 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: 02/01/2010
R.C. 119.032 review dates:11/17/2009 and 02/01/2015
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:4/1/07

4123-6-02.3 Provider access to the HPP - provider application and credentialing.

(A) The bureau shall make available to each provider via the bureau's internet site 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 shall permit the bureau 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) By signing the provider application and agreement or recertification application and agreement, the provider agrees to, and the bureau may refuse to certify or recertify or may decertify a provider for failure 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) Acknowledge and treat injured workers in accordance with bureau recognized treatment guidelines.

(3) Acknowledge and treat injured workers in accordance with the vocational rehabilitation hierarchy.

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

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

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

(7) 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 as required in the event that the provider's certification is terminated for reasons pertaining to the provider's professional conduct or competence.

(8) Practice in a managed care environment and adhere to MCO and bureau procedures and requirements concerning provider compliance, outcome measurement data, peer review, quality assurance, utilization review, bill submission, and dispute resolution.

(9) Adhere to the bureau's confidentiality and sensitive data requirements, and use information obtained from the bureau by means of electronic account access for the sole purpose of facilitating treatment and no other purpose, including but not limited to engaging in advertising or solicitation directed to injured workers.

(10) Comply with the workers' compensation statutes and rules and the terms of the provider application and agreement or recertification application and agreement.

(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.

Effective: 02/01/2010
R.C. 119.032 review dates:11/17/2009 and 02/01/2015
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
Prior Effective Dates: 2/16/96, 1/15/99, 3/29/02, 2/14/05

4123-6-02.4 Provider access to the HPP - provider recredentialing and recertification.

(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 submitted to the bureau if the provider wishes to be considered for recertification.

(B) Except as otherwise provided in paragraph (E) of this rule, if the bureau receives a completed and signed recertification application and agreement from a provider, the provider's certification 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 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 has lapsed pursuant to paragraph (D) of this rule, the provider's certification shall remain lapsed 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.

Effective: 02/01/2010
R.C. 119.032 review dates:11/17/2009 and 02/01/2015
Promulgated Under: 119.03
Statutory Authority: RC 4121.12 , 4121.121 , 4121.30 , 4121.31 , 4123.05
Rule Amplifies: RC 4121.121 , 4121.44 , 4121.441 , 4123.66
Prior Effective Dates: 3/29/02

4123-6-02.5 Provider access to the HPP - provider not certified.

(A) A provider not certified or recertified shall cure any defects in the provider application and agreement or 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 where the provider has failed to comply with the workers' compensation statutes or rules, or the terms 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, or the provider is convicted of or pleads guilty to a violation of sections 2913.48 or 2923.31 to 2923.36 if the Revised Code or any other criminal offense related to the delivery of or billing for health care benefits, the administrator may immediately 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 or the terms 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.

Effective: 02/01/2010
R.C. 119.032 review dates:11/17/2009 and 02/01/2015
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.121 , 4121.30 , 4121.31 , 4121.44 , 4121.441 , 4123.05 , 4123.66
Rule Amplifies: 4121.12 , 4121.121 , 4121.30 , 4121.31 , 4123.05
Prior Effective Dates: 2/16/96, 1/15/99, 3/29/02, 2/14/05

4123-6-02.51 Provider access to the HPP - Denial of provider, entity or MCO certification based on criminal conviction or civil action.

(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) Is owned directly, or indirectly, by an individual or entity who has engaged in specific conduct which demonstrates financial irresponsibility. Such conduct shall include, but not be limited to:

(a) Specific examples of insolvency of businesses owned or controlled by the individual or entity;

(b) Specific examples of failures to pay debts or judgments;

(c) Specific examples of activity which has defrauded any person, entity or organization, regardless of whether such activity has resulted in criminal prosecution;

(d) Any finding of fraud in a civil or administrative proceeding related to any compensation or benefits payable under Chapter 4121., 4123., 4127., or 4131. of the Revised Code or the equivalent laws of another state.

(4) 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 this rule shall be subject to rule 4123-6-17 of the Administrative Code.

Effective: 09/01/2013
R.C. 119.032 review dates: 05/08/2013 and 02/01/2015
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
Prior Effective Dates: 4/1/07

4123-6-02.6 Provider access to the HPP - selection by an MCO.

(A) The bureau shall maintain a public list of bureau certified providers. The bureau shall make the list of bureau certified providers available via the bureau's internet site.

(B) An MCO may, but is not required to, retain a panel of bureau certified providers. A bureau certified provider is eligible 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 .

(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 or with whom they enter into arrangements, 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 follow the medical management and return to work management approaches of the MCO medically managing an employee's claim, whether or not the provider is on the MCO's provider panel, or has an arrangement with the MCO.

Effective: 03/05/2010
R.C. 119.032 review dates: 11/17/2009 and 02/01/2015
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, 1/1/01

4123-6-02.7 Provider access to the HPP - provider decertification procedures.

(A) Except as otherwise provided in paragraph (C) of this rule, the administrator of workers' compensation shall follow the procedures set forth in this rule to terminate the enrollment of and decertify an individual provider who has failed to comply with a workers' compensation statute or rule, or a term of the provider application and agreement or recertification application and agreement.

(1) If the bureau determines a provider has committed three or more violations of the same workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement in a six month period, or five or more violations of any workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement in a six month period, the provider shall receive written notification from the bureau of the violations.

(2) If the bureau determines the provider has committed two or more subsequent violations of any workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement for which the provider previously received notice pursuant to paragraph (A)(1) of this rule, and the subsequent violations occurred any time within the twelve month period following the calendar month in which the provider received notice pursuant to paragraph (A)(1) of this rule, the provider shall receive written notification from the bureau of the violations, which shall include a thirty day implementation period for the provider to submit a correction plan to the bureau and correct the behavior. The correction plan shall be entered into the provider's certification file and the provider's certification file shall have the notation "under correction plan" during the twelve month period following the calendar month in which the provider's thirty day implementation period provided above expires.

If the provider fails to submit a correction plan within the thirty day implementation period satisfactory to the bureau, which satisfaction shall not be unreasonably withheld, the provider shall receive written notification from the bureau of the failure, which shall include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(3) If the bureau determines the provider has committed two or more subsequent violations of the same workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement for which the provider previously received notice pursuant to paragraph (A)(2) of this rule and submitted a correction plan satisfactory to the bureau, and the subsequent violations occurred any time within the twelve month period following the calendar month in which the provider's thirty day implementation period provided in the notice sent pursuant to paragraph (A)(2) of this rule expires, the provider shall receive written notification from the bureau of the violations, which shall include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(4) If the bureau determines a provider who has twice received written notice pursuant to paragraph (A)(1) of this rule for violation of the same workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement has committed a subsequent violation of the same workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement within three years of the date written notification was first sent to the provider by the bureau pursuant to paragraph (A) of this rule, the provider shall receive written notification from the bureau of the violation, which shall include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(5) The bureau may, in its discretion, waive strict application of the procedures set forth in paragraphs (A)(1) to (A)(4) of this rule with regard to an individual provider based on the presence of mitigating circumstances, which may include but are not limited to:

(a) The violations related to the provision of emergency treatment;

(b) At the time the violations occurred, the provider was not aware a workers' compensation claim was involved;

(c) The provider was initially bureau certified within six months prior to the violations;

(d) The violations were due to bureau or MCO error;

(e) The provider billed the bureau for goods or services in fewer than five workers compensation claims in the twelve months prior to the violations;

(f) Other documented justification as deemed sufficient by the bureau.

(B) Providers whose enrollment is terminated and who are decertified pursuant to paragraph (A)(3) or (A)(4) of this rule shall be eligible to apply for and be considered for recertification and reenrollment at any time after two years from the date of the final administrative or judicial order of enrollment termination and decertification.

(C) The procedures set forth in paragraphs (A)(1) to (A)(5) of this rule do not apply to, and the administrator may proceed directly to enrollment termination and/or decertification of a provider for, violation of the following:

(1) The minimum provider credentialing criteria set forth in rule 4123-6-02.2 of the Administrative Code.

(2) Acts of misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, fraud, or deceit on the provider's provider application and agreement or recertification application and agreement.

(3) Acts involving breach of the bureau's confidentiality and sensitive data requirements, including but not limited to failure to maintain the confidentiality of injured worker medical or claim information.

(4) Acts involving misuse of information obtained from the bureau by means of electronic account access for a purpose other than facilitating treatment, including but not limited to engaging in advertising or solicitation directed to injured workers.

(5) Acts involving advertising or solicitation directed to injured workers in violation of rule 4123-6-02.9 of the Administrative Code.

Replaces: Replacing 4123-6- 02.7

Effective: 01/01/2013
R.C. 119.032 review dates: 02/01/2015
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: 2/16/96, 2/14/05, 2/1/10

4123-6-02.8 Provider requirement to notify of injury.

(A) HPP: Within one working day of initial treatment or initial visit of an injured worker, a provider must report the employee's injury or occupational disease in accordance with either paragraph (A)(1) or (A)(2) of this rule.

(1) A provider may report an injury to the MCO responsible for medical management of the employee's treatment. When reporting the injury to the MCO, the provider shall do so in accordance with procedures established by the bureau.

(2) 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.

(B) QHP: Within one working day of initial treatment or initial visit of an injured worker, a provider must report the employee's injury or occupational disease to the QHP or employer.

(C) Self-insuring employer (non-QHP): Within one working day of initial treatment or initial visit of an injured worker, a provider must report the employee's injury or occupational disease to the self-insuring employer.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 02/01/2015
Promulgated Under: 119.03
Statutory Authority: RC 4121.12 , 4121.121 , 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

4123-6-02.9 Provider access to the HPP - provider marketing.

(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: 11/17/2009 and 11/01/2014
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

4123-6-03 MCO participation in the HPP - generally.

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.

Effective: 04/01/2007
R.C. 119.032 review date: 11/17/2009
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: 2/19/96, 1/1/99

4123-6-03.2 MCO participation in the HPP - MCO application for certification or recertification.

(A) Upon request by a managed care organization, the bureau shall send the managed care organization an MCO application for certification for the managed care organization to complete and submit to the bureau.

(B) The MCO application submitted to the bureau by the managed care organization shall include a list of bureau certified providers in its provider panel and/or bureau certified providers with which the managed care organization has arrangements.

(C) The MCO application submitted to the bureau by the managed care organization shall include the following, whether the managed care organization elects to retain a provider panel or enters into provider arrangements:

(1) A description of the managed care organization's health care provider panel or provider arrangements, which shall include a substantial number of the medical, health care professional and pharmacy providers currently being utilized by injured workers. The provider panel or provider arrangements shall cover the geographic area in which the managed care organization determines it shall compete, and may include out-of-state providers.

(2) A description of how the managed care organization's provider panel or provider arrangements shall provide timely, geographically convenient access to a full range of medical services and supplies for injured workers, including access to specialized services.

(3) A description of the managed care organization's process and methodology for credentialing providers in the managed care organization's provider panel, if applicable, and the managed care organization's process and methodology for assisting non-bureau certified providers in the managed care organization's provider panel or with which the managed care organization has provider arrangements in applying for bureau provider credentialing and certification.

(4) A description of the managed care organization's process and methodology for payment of providers in the managed care organization's provider panel or under a provider arrangement.

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

(6) A description of the managed care organization's methodology for distributing provider panel and provider arrangement directories and directory updates to employers and employees.

(D) The MCO application for certification submitted to the bureau by the managed care organization shall include, at a minimum, the following information and 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 representations involving dishonesty, fraud, or deceit.

(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. 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, together with historical and current data. 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, or business trust; provide any trade names or 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; identify other states in which the managed care organization is doing business or has done business; provide a table of organization with the number of employees; and identify any banking relationships, including all account information with any financial institutions.

(4) A description of the managed care organization's business continuation plan.

(5) A description of the bureau approved treatment guidelines used by the managed care organization, including a description of how the managed care organization shall implement 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 administrative and bill payment grievance processes.

(10) A description of the managed care organization's information system platforms, capabilities and capacities; a description of the managed care organization's system for reporting necessary data elements, including but not limited to those required for performance measurements; and the managed care organization's measures in place to ensure data security, including back-up systems.

(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 protection of confidential and sensitive 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 provider bill payment processes including, but not limited to, clinical editing software (including review criteria, process and methodology).

(17) Attestation of intent to obtain and maintain insurance coverage as required by the MCO contract, with proof of such coverage to be submitted to the bureau prior to execution of the contract, and current workers' compensation coverage.

(18) Attestation of intent to obtain and maintain professional accreditations as required by the MCO contract, with proof of such accreditations to be submitted to the bureau prior to execution of the contract.

(19) A description of any and all individuals and entities the managed care organization is affiliated with (including, but not limited to, a subcontractor or subcontractee, vendor or vendee, joint venture or other arrangement), and a copy of the MCO's contract or agreement with each individual or entity. For purposes of this rule, "affiliated with the MCO" shall have the same meaning as defined in paragraph (B) of rule 4123-6- 03.9 of the Administrative Code.

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

(E) For MCO recertification, prior to the expiration of an MCO's certification, the bureau shall send the certified MCO an application for recertification, which must be completed and returned to the bureau. The MCO must be able to provide proof of delivery of the completed application to the bureau upon request. The MCO application for recertification may be amended from time to time at the bureau's discretion.

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

(G) During the bureau's review of the application for certification or recertification, the managed care organization shall provide to the bureau any additional documentation requested and shall permit the bureau, upon request and with reasonable notice given, to conduct an onsite review of the managed care organization.

(H) A managed care organization may cure any defects in its application for certification or recertification within thirty days of notice by the bureau of such defect in its application.

(I) The bureau may require that the application be accompanied by an application fee, which shall not exceed the amount sufficient to cover the cost of processing the application.

(J) The bureau shall hold as confidential and proprietary information contained in a managed care organization's application for certification or recertification, and other information furnished to the bureau by a managed care organization for purposes of obtaining certification or to comply with performance and auditing requirements established by the administrator, in accordance with divisions (H)(1) and (H)(2) of section 4121.44 of the Revised Code.

(K) The bureau shall not accept or approve any MCO applications for certification or recertification in which the managed care organization proposes to subcontract or outsource medical case management services.

Effective: 06/09/2014
R.C. 119.032 review dates: 02/01/2015
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: 2/16/96, 1/1/99, 1/1/01, 2/14/05, 2/1/10, 7/16/12

4123-6-03.3 [Rescinded]MCO participation in the HPP - MCO participation based on MCO capacity.

Effective: 06/09/2014
R.C. 119.032 review dates: 03/24/2014
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.121 , 4121.30 , 4121.31 , 4123.05 , 4123.66
Rule Amplifies: 4121.121 , 4121.44 , 4121.441 , 4123.66
Prior Effective Dates: 2/16/96, 1/1/99, 2/1/10

4123-6-03.4 MCO participation in the HPP - MCO certification.

(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 contract with the bureau to provide medical management and cost containment services for injured workers and employers.

(B) MCO certification by the bureau 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 certification 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.

(E) An MCO may apply to the bureau for recertification beyond the first two years of certification.

Effective: 02/01/2010
119.032 review dates: 11/17/2009 and 2/21/15
Promulgated Under: 119.03
Statutory Authority: RC 4121.12 , 4121.121 , 4121.30 , 4121.31 , 4123.05
Rule Amplifies: RC 4121.121 , 4121.44 , 4121.441 , 4123.66
Prior Effective Dates: 2/16/99, 1/1/99

4123-6-03.6 [Rescinded]MCO participation in the HPP - administrator's authority to terminate MCO contracts.

Effective: 06/09/2014
R.C. 119.032 review dates: 03/24/2014
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: 2/16/96, 1/1/99, 2/14/05, 2/1/10

4123-6-03.7 MCO participation in the HPP - bureau's authority to decertify, to refuse to certify or recertify an MCO.

(A) Should the administrator determine that sufficient evidence exists that an MCO has failed to maintain any of the requirements set forth in division (F) of section 4121.44 of the Revised Code, or to reasonably comply with or to perform in accordance with the terms of a contract between the bureau and the MCO entered into pursuant to division (B)(4) of section 4121.44 of the Revised Code, or has violated a rule adopted under section 4121.441 of the Revised Code, the administrator has the authority to decertify, or refuse to certify or recertify an MCO, in accordance with rule 4123-6-17 of the Administrative Code and Chapter 119. of the Revised Code.

(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.

Effective: 06/09/2014
R.C. 119.032 review dates: 02/01/2015
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, 1/1/99, 2/1/10

4123-6-03.8 MCO participation in the HPP - marketing of services by MCO. [Rescinded].

Rescinded eff 2-14-05

4123-6-03.9 MCO participation in the HPP - MCO disclosure of relationship.

(A) If an MCO is affiliated with another individual, corporation, or entitythat 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 individual, corporation, or entity, the MCO 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.

(B) For purposes of this rule, an individual, corporation, or entity is "affiliated with an MCO" when it:

(1) Owns, is owned by, or is under common ownership with an MCO, directly or indirectly through one or more intermediaries;

(2) Controls, is controlled by, or is under common control with an MCO, directly or indirectly through one or more intermediaries;

(3) Has a contractual or other business arrangement with an MCO;

(4) Has one or more owners, shareholders, partners, members, officers, directors or other persons who exercise operational or managerial control in common with the MCO.

Effective: 06/09/2014
R.C. 119.032 review dates: 02/01/2015
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, 10/26/00, 2/1/10

4123-6-03.10 Conflict of interest.

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 .

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 02/01/2015
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: 1/1/01

4123-6-04 [Rescinded]MCO scope of services - generally.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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, 1/1/01

4123-6-04.2 [Rescinded]MCO scope of services - management of medical treatment of provider selected by employee.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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, 1/1/01

4123-6-04.3 MCO scope of services - MCO medical management and claims management assistance.

(A) The MCO shall refer a medical treatment reimbursement request in an inactive claim as provided in rule 4123-3-15 of the Administrative Code, with the MCO's recommendation, to the bureau for a determination of both the causal relationship between the original injury and the current incident precipitating the treatment request and the necessity and appropriateness of the requested treatment.

(B) The MCO, in conjunction with the employer, employee, attending physician, and the bureau claims personnel assigned to the claim, shall provide medical management and cost containment services that provide the injured worker 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 and timely return to work.

(C) 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.

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

(E) 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 assigned to the MCO, 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.

(F) Either the MCO or the bureau may schedule an independent medical examination (IME) of the claimant to assist in the alternative dispute resolution (ADR) process under rule 4123-6-16 of the Administrative Code.

(1) An ADR IME shall be limited to issues relating to medical treatment disputes, and shall not include extent of disability issues. An ADR IME 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 an ADR IME is scheduled under this rule, the parties, and their representatives, if any, shall be promptly notified as to the time and place of the examination, and the questions and information provided to the doctor. An electronic copy of the ADR IME report shall be submitted to the claim file. 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.

(3) If an ADR IME is scheduled under this rule to assist in resolving a medical dispute, the IME and the ADR process shall be completed in accordance with the requirements of rule 4123-6-16 of the Administrative Code.

(4) If a claimant refuses to attend an independent medical examination scheduled by the MCO to assist in the alternative dispute resolution process , the MCO shall refer the issue to the bureau.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 02/01/2015
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, 1/1/99, 3/27/00, 1/1/01, 11/1/04

4123-6-04.4 MCO scope of services - fee bill review and audit process.

(A) The MCO shall review all bills submitted to it for payment by a provider consistent with the MCO's previous treatment reimbursement approval/denial of the service billed, the MCO's utilization standards, the criteria set forth in rule 4123-6-25 of the Administrative Code, applicable industry standards, and the requirements of the MCO contract.

(B) The MCO shall have in place and operating a grievance hearing procedure allowing a provider, employer, or employee to grieve a disputed bill payment.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 02/01/2015
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

4123-6-04.5 MCO scope of services - bureau claims management.

(A) Upon receipt of notification of a workers' compensation claim, the bureau shall assign a claim number and shall notify the employee, employer and MCO of that claim number. The bureau shall 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) Upon referral from an MCO of a medical treatment reimbursement request in an inactive claim as provided in rule 4123-3-15 of the Administrative Code, the bureau will determine, after considering the MCO's recommendation, 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 . 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 or except as provided by the rehabilitation rules of Chapter 4123-18 of the Administrative 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 shall not pay for medical services in a disallowed claim or for disallowed conditions. If the claim or condition is disputed, the MCO shall inform the employee and the provider that the services provided may not be covered by workers' compensation and may be the responsibility of the employee.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 02/01/2015
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, 11/1/04

4123-6-04.6 Thirty-day return to work assessment.

(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: 11/17/2009 and 11/01/2014

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: 1/1/01

4123-6-05.1 [Rescinded]Employer access to the HPP - MCO advertising and solicitation.

Effective: 06/09/2014
R.C. 119.032 review dates: 03/24/2014
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, 1/1/99, 4/5/99, 7/17/00, 1/1/03, 2/1/10

4123-6-05.2 Employer access to the HPP - employer enrollment and selection of MCO.

(A) An employer may select any bureau certified MCO that has contracted with the bureau, and has not been placed at capacity pursuant to the MCO contract, 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 electronically 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 that has selected it or has been assigned to it by the bureau, unless the MCO has placed itself at capacity pursuant to the MCO contract.

Effective: 06/09/2014
R.C. 119.032 review dates: 02/01/2015
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: 4/19/96, 1/20/98, 1/1/99, 4/5/99, 7/17/00, 10/16/08, 2/1/10

4123-6-05.3 Employer access to the HPP; certain solicitation practices by MCOs prohibited.

(A) An MCO, any individual, corporation, or entity affiliated with the MCO as defined in rule 4123-6- 03.9 of the Administrative Code, or any other individual, corporation, or entity 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, 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.

(B) Notwithstanding paragraph (A) of this rule, the MCO may reimburse to a trade or business association certain expenses in accordance with the following requirements:

(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 its actual and reasonable expenses incurred in educating its member employers on bureau and MCO medical management and cost containment services and related rules, policies, and processes.

(3) The MCO may reimburse to the trade or business association only its actual and reasonable expenses incurred in marketing the MCO to its member employers, subject to the limits set forth in paragraph (B)(4) of this rule.

(4) The reimbursement of a trade or business association's actual and reasonable expenses incurred in marketing the MCO to its member employers during a calendar year shall not exceed sixteen one-hundredths of one per cent of the premium of those employers that are members of the trade or business association and that 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.

(5) 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 four years from the date of performance of any such service. The MCO and the trade or business 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, rebate, premium or kickback, or any other valuable consideration or thing of value prohibited under paragraph (A) of this rule.

(D) For purposes of this rule, "affiliated with an MCO" shall have the same meaning as in paragraph (B) of rule 4123-6- 03.9 of the Administrative Code.

(E) Agent of the MCO.

(1) For purposes of this rule, "agent" of the MCO means:

(a) An insurance agent or broker contracted by the MCO and licensed by the Ohio department of insurance pursuant to Title XXXIX of the Revised Code;

(b) A corporation or entity contracted by the MCO to conduct non-telephonic marketing that has not had and does not contemplate having activities of any nature with the Ohio workers' compensation system so as to create a conflict of interest or the appearance of a conflict of interest under rule 4123-6-03.9 of the Administrative Code;

(c) A telemarketer or telemarketing firm contracted by the MCO who has obtained a certificate of registration from the Ohio attorney general in accordance with Chapter 4719. of the Revised Code.

"

(2) "Agent" of the MCO does not include the following:

(a) A third party administrator, group rating sponsor, business or trade association;

(b) An individual, corporation, or entity affiliated with the MCO that has had or contemplates having activities with the Ohio workers' compensation system so as to create a conflict of interest or the appearance of a conflict of interest under rule 4123-6-03.9 of the Administrative Code.

Effective: 06/09/2014
R.C. 119.032 review dates: 02/01/2015
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: 1/30/98 (emer.), 4/29/98, 1/1/99, 10/26/00, 1/1/01, 2/14/05, 2/1/10

4123-6-05.4 Employer access to the HPP; payment for referrals prohibited.

(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 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 MOC 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 a inducement to or in return for the MCO's referral of employers to any individual or entity for the provision of any goods or services.

(C) 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 injured workers to any provider for the provision of any goods or services.

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

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 02/01/2015
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: 1/30/98 (Emer.), 4/29/98, 1/1/99, 1/1/01

4123-6-06 [Rescinded]Employee access to the HPP - generally.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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: 2/16/96, 1/1/01, 2/14/05

4123-6-06.1 Employee access to medical services - employee education by MCO and employer.

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 information regarding MCO panel providers or providers with whom the MCO has arrangements. Education of the employee shall stress, among other things, the need for the employee to report any accident immediately to the employer, the employee's treating provider, and the bureau, and shall inform the employee how to seek care through the MCO. The MCO may, at the request of the employer or upon its own initiative, provide MCO identification cards to the employer for distribution to each employee.

Effective: 06/09/2014
R.C. 119.032 review dates: 11/01/2014
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, 1/1/01, 2/1/10

4123-6-06.2 Employee access to the HPP - employee choice of provider.

(A) HPP.

(1) Except as provided in paragraph (A)(2) of this rule, an injured employee may seek medical care for an industrial injury from:

(a) A bureau certified provider; or

(b) A non-bureau certified provider, subject to an employee's payment responsibilities as delineated below.

(2) Except in cases of emergency, an injured employee may not seek medical care for an industrial injury from himself, herself, or an immediate family member. An injured employee may not select as physician of record, himself, herself, or an immediate family member. The MCO, bureau, employer, and industrial commission shall not reimburse treatment to an injured employee delivered, rendered or directly supervised by the injured employee or an immediate family member. "Immediate family member" shall have the same meaning as in paragraph (A)(3)(b) of rule 4123-6-02.51 of the Administrative Code.

(3) At the time of an injury, the employee may seek medical care directly from a provider or may seek assistance from the MCO in selecting a provider. If the employee has not already sought medical care or selected a provider, the MCO may refer the employee to a provider or list of providers. The employee may, but is not required to, seek medical care from the referred provider or providers. The MCO shall not discriminate against any category of health care provider when referring the employee to a provider.

(4) If the employee seeks medical assistance from a provider, the employee shall inform the provider of the employee's MCO. The provider shall then report the industrial injury in accordance with rule 4123-6-02.8 of the Administrative Code.

(a) If the provider is a non-bureau certified provider, the MCO shall inform the provider that the care for the first visit will be compensated by the MCO if the claim and the treated conditions are subsequently allowed and that, unless otherwise permitted by paragraph (A)(5)(a) or (A)(5)(b) of this rule, no further treatment will be authorized.

(b) If the provider is a non-bureau certified provider, the provider shall inform the employee upon the initial or emergency treatment that the provider is not a participant in the HPP and that payment will not be made by the bureau, MCO, or employer for the cost of further treatment after the initial or emergency treatment

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

(a) The MCO has determined that the treatment to be provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider and has authorized the non-bureau certified provider to continue to provide the treatment, or

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

(6) Notwithstanding any other provision of this rule, 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. However, if the employee changes the physician of record for any reason, the employee shall select a bureau certified provider as physician of record. If the employee selects a physician of record who is a non-bureau certified provider, payment for the provider shall be governed by the provisions of this rule applicable to non-bureau certified providers.

(B) QHP.

(1) 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. If the employee's date of injury is prior to the establishment of the employer's QHP, and the employee's physician of record is not a provider on the 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.

(2) 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 request a change of providers and may select another provider within the QHP, or any bureau certified provider. An employee's request for change of provider does not require notification to the bureau, but shall contain the reasons for the request. The QHP shall approve written requests for a change of provider within the QHP, or to any bureau certified provider, within seven days of receipt

(3) Notwithstanding the provisions contained in paragraph (B)(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) 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.

(5) A provider certified to participate in the HPP shall be eligible to participate in and to treat injured workers under the QHP system.

(C) Self-insuring employer (non-QHP).

(1) In claims with a date of injury on or after November 2, 1959, employees of self-insuring employers have free choice to select licensed physicians for treatment, as well as other medical services, including, but not limited to, hospital and nursing services. In claims with a date of injury prior to November 2, 1959, medical services furnished by the self-insuring employer must be utilized

(2) Emergency treatment shall not constitute an exercise of free choice of physician.

(3) Once an employee of a self-insuring employer goes to a physician for treatment other than on an emergency basis, the employee is deemed to have made a choice of physician and the employee shall notify the employer of a change of physician.

(a) Change of physician requests shall be made to the self-insuring employer in writing, and shall include the name and address of the new physician and the proposed treatment.

(b) Self-insuring employers shall approve written requests for a change of physician within seven days of receipt.

Replaces: Replaces 4123-6- 06.2

Effective: 02/01/2010
R.C. 119.032 review dates: 11/01/2014
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, 1/1/01

4123-6-06.3 [Rescinded]Employee access to the HPP - application of rules to claims.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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, 1/1/01

4123-6-07 Services and supplies never covered.

The following services and supplies are never covered by, and shall not be authorized or reimbursed by, the bureau or MCO:

(A) Services and supplies that are never covered pursuant to other bureau statutes or rules.

(B) The following services and supplies, which are never considered to be durable medical equipment by the bureau:

(1) Home furniture including, but not limited to: reclining chairs, non-hospital beds, water beds, lounge beds (such as adjust-a-sleep adjustable bed, craftmatic adjustable bed, electropedic adjustable bed, simmons beautyrest adjustable bed). The bureau or MCO shall reimburse a seat lift mechanism when medically necessary and appropriate for an injured worker who requires a mobility aid to stand from a seated position due to physical limitations that are reasonably related to the industrial injury (allowed conditions). However, the bureau or MCO shall not reimburse the chair (furniture);

(2) A mattress for a non-hospital bed (including, but not limited to: tempur-pedic, angelbed, memory foam mattresses). Reimbursement of a hospital bed mattress is limited to a twin/single size only. The bureau or MCO will not reimburse for a double, queen or king size mattress for the purpose of accommodating two people;

(3) Home exercise equipment, including but not limited to such equipment as treadmills and exercise bikes;

(4) Home whirlpools, including built-in whirlpools and pumps, portable hydrotherapy pools, jacuzzi tubs, portable saunas and spas, non-portable hot tubs or whirlpools, and therasaunas.

(5) Unsupervised physical reconditioning programs, including but not limited to memberships to or services provided at a health club, YMCA, spa or nautilus facility, except when the criteria have been met for an injured worker who is participating in a vocational rehabilitation or remain at work program.

(C) Self-administered sympathetic therapy/interferential therapy.

(D) Prescription smoking deterrent drugs outside an approved smoking cessation program.

(E) Drug screening of injured workers performed by employers or performed in the emergency room at the time of injury at the request of the employer.

Effective: 12/11/2012
R.C. 119.032 review dates: 11/01/2014
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

4123-6-08 Bureau fee schedule.

(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 January 1, 2013.

(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.

Click to view Appendix

Click to view Appendix

Effective: 03/24/2013
R.C. 119.032 review dates: 02/01/2014
Promulgated Under: 111.15
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, 2/19/09, 11/8/09, 10/25/10; 12/30/10 (Emer.), 3/21/11, 3/24/12, 12/27/12 (Emer)

4123-6-09 [Rescinded]Payment during adjudication of claim.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-10 Payment to providers.

(A) HPP.

(1) The MCO shall accumulate medical records and bills for services rendered to employees for provider services 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 a valid, complete bill from the provider.

(2) For a provider in the MCO's panel or with whom the MCO has entered into an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider either the lesser of the bureau fee schedule, the MCO contracted fee, or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(3) For a bureau certified provider who is not in the MCO's panel or with whom the MCO does not have an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider either the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(4) For a non-bureau certified provider who is not in the MCO's panel or with whom the MCO does not have an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider for initial or emergency treatment either the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(5) For a non-bureau certified provider who is not in the MCO's panel or with whom the MCO does not have an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider for subsequent treatment after the initial or emergency treatment either the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee, only under the following circumstances:

(a) Where the treatment provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider and the MCO has authorized the treatment pursuant to rule 4123-6-06.2 of the Administrative Code, or

(b) Where the treatment provided by the non bureau certified provider is reasonably available through a like bureau certified provider, the non-bureau certified provider may only be reimbursed for the treatment if the provider becomes bureau certified. If the provider refuses or fails to become bureau certified, the treatment shall not be reimbursed.

(6) For hospital services, the bureau shall electronically transfer to the MCO for payment to the hospital either the lesser of the applicable amount pursuant to rule 4123-6-37.1 (inpatient) or 4123-6- 37.2(outpatient) of the Administrative Code or the MCO contracted fee, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(7) The MCO shall have authority to negotiate fees with providers, either by contract or on a case-by-case basis, in the following circumstances:

(a) As permitted under rule 4123-6-08 of the Administrative Code(including the appendix to the rule);

(b) As permitted under rule 4123-6-37.1 , 4123-6- 37.2 or 4123-6- 37.3 of the Administrative Code;

(c) As permitted under rule 4123-18-09 of the Administrative Code;

(d) With non-bureau certified providers outside the state, where the treatment provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider;

(e) With bureau certified providers and non-bureau certified providers within the state, where unusual circumstances justify payment above BWC's maximum allowable rate for the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) Level II and Level III coded services/supplies, and such circumstances are documented and approved by the bureau.

(8) The bureau shall not pay for missed appointments or procedures. Bills must only contain descriptions of services that have been actually delivered, rendered, or directly supervised by the provider 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.

(B) QHP.

(1) 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 (K)(5) of rule 4123-19-03 of the Administrative Code.

(2) With the exception that no financial arrangement between an employer or QHP and a provider shall incentivize a reduction in the quality of medical care received by an injured worker, an employer or QHP may pay a QHP panel provider a rate that is the same, is above or, if negotiated with the provider in accordance with rule 4123-6-46 of the Administrative Code, is below the rates set forth in the applicable provider fee schedule rules developed by the bureau. 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.

(3) An employer or QHP shall pay a bureau certified non-QHP panel provider other than a hospital the lessor of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(4) An employer or QHP shall pay a bureau certified non-QHP panel hospital the applicable amount under rule 4123-6-37.1 (inpatient) or 4123-6- 37.2(outpatient) of the Administrative Code, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

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

(6) An employer in the QHP system shall authorize and pay for initial or emergency medical treatment for an injury or occupational disease that is an allowed claim or condition provided by a non-bureau certified provider as follows:

(a) The employer shall pay a non-bureau certified provider only for initial or emergency treatment of an employee for a workers' compensation injury, unless the QHP specifically authorizes further treatment. A non-bureau certified provider shall inform the employee that the provider is not a participant in the QHP and that the employee may be responsible for the cost of further treatment after the initial or emergency treatment, unless payment for further treatment is specifically authorized by the QHP. 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, except as provided above.

(b) An employer or QHP shall pay a non-bureau certified provider that provides initial or emergency medical treatment or further medical treatment that has been specifically authorized by the QHP, other than a hospital, the lessor of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(7) An employer or QHP shall pay a non-bureau certified hospital that provides initial or emergency medical treatment or further medical treatment that has been specifically authorized by the QHP the applicable amount under rule 4123-6-37.1 (inpatient) or 4123-6- 37.2(outpatient) of the Administrative Code, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(8) The employer or QHP shall not pay for missed appointments or procedures. Bills must only contain descriptions of services that have been actually delivered, rendered, or directly supervised by the provider for the actual conditions treated. A provider shall not transmit to the employer or QHP 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.

(C) Self-insuring employer (non-QHP).

(1) Payment for medical services and supplies by self-insuring employers shall be equal to or greater than the fee schedule established by the bureau in state fund claims, unless otherwise negotiated with the provider in accordance with rule 4123-6-46 of the Administrative Code. All payments by the self-insuring employer shall be consistent with the provisions contained in paragraph (K)(5) of rule 4123-19-03 of the Administrative Code.

(2) The self-insuring employer shall not pay for missed appointments or procedures. Bills must only contain descriptions of services that have been actually delivered, rendered, or directly supervised by the provider for the actual conditions treated. A provider shall not transmit to the self-insuring employer 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.

Replaces: Replaces 4123-6-10

Effective: 02/01/2010
R.C. 119.032 review dates: 11/01/2014
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

4123-6-11 [Rescinded]Payment to bureau certified provider.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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, 1/1/01

4123-6-12 [Rescinded]Payment to non-bureau certified provider.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-13 Payment to MCOs.

(A) The bureau shall determine fee payments to an MCO for providing medical management and cost containment services and administrative services.

(B) MCO fee payments may be subject to penalties 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 may evaluate an MCO's performance based upon criteria including, but not limited to:

(1) Quality performance measures including, but not limited to, return to work rates and re-injury rates.

(2) Process performance measures including, but not limited to, first report of injury (FROI) timing. FROI accuracy and bill timing.

(3) Total cost measures including, but not limited to, average total paid cost, average incurred cost, and lost-time claims to total claims ratio.

(4) Change in cost measures including, but not limited to, change in average total paid cost, change in average incurred cost, and change in lost-time to total claims ratio.

(5) Customer satisfaction measures including, but not limited to, MCO network utilization rates and employee, employer, and provider satisfaction surveys.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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, 1/1/99, 1/1/01

4123-6-14 MCO bill submission to bureau.

(A) The MCO shall submit bills electronically to the bureau. The bureau shall review all bills for payment eligibility. The bureau's review may include, but not be limited to, verification of the following:

(1) The services were delivered, rendered, or directly supervised by providers who meet bureau credentialing and licensing criteria;

(2) The bills conform to standard clinical editing criteria in effect on the billed date(s) of service, including but not limited to: the bureau's billing and reimbursement manual, the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS), and the national correct coding initiative (NCCI) guidelines.

The bureau shall electronically transfer funds to the MCO for allowed payments after receipt of a proper invoice and after a final adjudication permitting payment for the bill. Upon receipt of funds from the bureau, the MCO shall pay the provider within seven days or less. The MCO shall pay to providers at least the amount electronically transferred by the bureau to the MCO for reimbursement of provider services.

(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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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

4123-6-14.1 Records to be retained by MCO.

(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 For records that do not relate to a specific claim, including but not limited to monthly bank statements, monthly bank records and reconciliations, and monthly check registers, the MCO shall also create, maintain, and retain for a period of seven 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.

Effective: 09/01/2013
R.C. 119.032 review dates: 05/08/2013 and 02/01/2015
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

4123-6-15 Confidentiality of records.

(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 Ohio, 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, and/or exchanged among the bureau, the MCO, the employer and its representative, the employee and his or her representative, and the provider. All parties receiving and/or exchanging confidential information for use in the HPP shall ensure transmission of confidential information via secured methods, including but not limited to encryption, password protection, transmission over telephone lines (fax to fax), and other secure methods.

(C) All parties receiving and/or exchanging 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. MCOs shall not release any confidential information, other than in accordance with rule 4123-3-22 of the Administrative Code, to any third parties(including, but not limited to, parent, subsidiary, or affiliate companies, or subcontractors of the MCO) without the express prior written authorization of the bureau.

(D) MCOs shall comply with, and shall assist the bureau in complying with, all disclosure, notification or other requirements contained in sections 1347.12 , 1349.19 , 1349.191 and 1349.192 of the Revised Code, as may be applicable, in the event computerized data that includes personal information, obtained by the MCO for use in the HPP, is or reasonably is believed to have been accessed and acquired by an unauthorized person and the access and acquisition by the unauthorized person causes, or reasonably is believed will cause a material risk of identity theft or other fraud.

(E) MCOs shall comply with all electronic data security measures as may be required by Ohio law, Ohio department of administrative services or other state agency directive, executive order of the governor of Ohio, and/or the MCO contract.

Replaces: Replacing 4123-6-15

Effective: 02/01/2010
R.C. 119.032 review dates: 11/01/2014
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

4123-6-16 Alternative dispute resolution for HPP medical issues.

(A) Pursuant to division (A)(1) of section 4121.441 of the Revised Code, this rule shall provide procedures for an alternative dispute resolution (ADR) process for medical disputes between an employer, an employee, or a provider and an MCO arising from the MCO's decision regarding a medical treatment reimbursement request (on form C-9 or equivalent). 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 MCO's decision regarding a medical treatment reimbursement request.

(B) Within fourteen days of receipt of an MCO decision giving rise to a medical dispute, an employee, employer, or provider may submit the dispute in writing (on form C-11 or equivalent) to the MCO. The written medical dispute must contain, at a minimum, the following elements:

(1) Injured worker name.

(2) Injured worker claim number.

(3) Date of initial medical treatment reimbursement request 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 the party's authorized representative. Written medical disputes that do not contain the minimum elements set forth in this paragraph may be dismissed by the MCO or bureau.

(C) Upon receipt of a written medical dispute, the MCO shall initiate the ADR process. The MCO's ADR process shall consist of one independent level of professional review as follows:

(1) If an individual health care provider eligible to be physician of record would be providing the services requested in the dispute, the independent level of professional 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 who would be providing the services requested.

(2) Notwithstanding paragraph (C)(1) of this rule, if the MCO has already obtained one or more peer reviews during previous disputes involving the same or similar treatment, the MCO may obtain a different perspective review from a licensed physician who falls outside the peer review criteria set forth above.

(3) If an individual health care provider not eligible to be physician of record would be providing the services requested in the dispute, the independent level of professional review shall consist of a provider review conducted by an individual or individuals eligible to be physician of record whose scope of practice includes the services requested.

(4) 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 professional review, and the previous treatment request was ultimately denied based on the professional review, the MCO may use the previous professional review to satisfy the independent level of professional review requirement of this paragraph.

(5) The MCO shall submit a copy of the professional review to the bureau, and the bureau shall provide the parties to the claim access to the professional review electronically.

(D) If, upon consideration of additional evidence or after agreement with the party that submitted the written medical dispute, the MCO reverses the decision under dispute or otherwise resolves the dispute to the satisfaction of the party, the MCO may issue a new decision and dismiss the dispute.

(E) Unless the MCO reverses the decision under dispute pursuant to paragraph (D) of this rule, the MCO shall complete the ADR process and submit its recommended ADR decision to the bureau electronically within twenty-one days of the MCO's receipt of the written medical dispute. The MCO may recommend that the employee be scheduled for an independent medical examination. This recommendation shall toll the MCO's time frame for completing the ADR process, and in such cases the MCO shall submit its recommended ADR decision to the bureau electronically within seven days after receipt of the independent medical examination report.

(F) Within two business days after receipt of a recommended ADR decision from the MCO, the bureau shall publish a final order. 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. The provider and the MCO may not file an appeal of the bureau order.

(G) Notwithstanding paragraph (C) of this rule, the MCO may pend a written medical dispute under the following circumstances:

(1) If the MCO receives a written medical dispute involving a medical treatment reimbursement request that appears to be the same as or similar to a previous treatment request for which the MCO conducted a provider review, and the previous treatment request is pending before the bureau or industrial commission, the MCO may pend the new dispute until the previous treatment request has been resolved. Once the previous treatment request has been resolved, the MCO shall resume the ADR process, and may proceed in accordance with paragraph (C)(4) of this rule if appropriate.

(2) If the MCO receives a written medical dispute involving a medical treatment reimbursement request relating to the delivery of medical services for a condition that is not allowed in the claim, and the issue of the allowance of the additional condition is pending before the bureau or industrial commission, the MCO may pend the dispute until the bureau or industrial commissioin has made a decision on the allowance of the additional condition. Once the bureau or industrial commission has made a decision on the allowance of the additional condition, the MCO shall resume the ADR process.

(H) Notwithstanding paragraph (C) of this rule, an MCO may submit its recommended ADR decision to the bureau electronically without obtaining an independent level of professional review under the following circumstances:

(1) The MCO receives a written medical dispute involving a medical treatment reimbursement request relating to the delivery of medical services that have been approved by the MCO pursuant to standard treatment guidelines, pathways, or presumptive authorization guidelines.

(2) The MCO receives a written medical dispute involving a medical treatment reimbursement request relating to the delivery of medical services for a condition that is not allowed in the claim, and the issue of the allowance of the additional condition is not pending before the bureau or industrial commission.

Replaces: Replaces prior 4123-6-16

Effective: 11/01/2009
R.C. 119.032 review dates: 11/01/2014
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, 9/25/08

4123-6-16.1 HPP medical treatment guidelines.

In reviewing medical treatment reimbursement requests pursuant to rule 4123-6-16.2 of the Administrative Code and conducting independent reviews of medical disputes pursuant to rule 4123-6-16 of the Administrative Code, the MCO and the bureau shall refer to treatment guidelines adopted by the bureau. In the event of a conflict between these guidelines and any provision of this chapter of the Administrative Code, the provisions contained in the Administrative Code shall control.

Replaces: Replacing 4123-6- 16.1

Effective: 02/01/2010
R.C. 119.032 review dates: 11/01/2014
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: 4/29/98, 9/12/04

4123-6-16.2 Medical treatment reimbursement requests.

(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.

For purposes of this rule, "eligible treating provider" means a physician as defined in rule 4123-6-01 of the Administrative Code and the following non-physician practitioner types: advanced practice nurse, physician assistant, physical therapist, occupational therapist, optometrist, audiologist, licensed independent social worker, licensed professional clinical counselor.

(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) For informational purposes, the bureau may require the provider to include on the medical treatment reimbursement request the applicable codes, from the edition of the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) in effect on the date of the request, for the procedures or services being requested.

However, review of the request shall be directed to the treatment being requested, and shall not be construed as approving or denying payment for the specific codes listed by the provider.

(D) Medical treatment reimbursement requests in inactive claims shall be processed in accordance with the provisions of rule 4123-3-15 of the Administrative Code.

(E) Medical treatment reimbursement requests submitted by a physical therapist or occupational therapist must be accompanied by a prescription as required in paragraph (B) of rule 4123-6-30 of the Administrative Code, and approval of such requests shall be valid for no longer than thirty days unless the approval specifies a longer period and such longer period is supported by the prescription. Approval of all other medical treatment reimbursement requests shall be valid for no longer than six months unless the approval specifies a longer period.

(F) The MCO may dismiss without prejudice medical treatment reimbursement requests under the following circumstances:

(1) The request has been submitted by a provider who is not enrolled with the bureau and who refuses to become enrolled, or who is enrolled but non-certified and is ineligible for payment as a non-certified provider under rule 4123-6- 06.2 or 4123-6-10 of the Administrative Code or division (J) of section 4121.44 of the Revised Code.

(2) The request is 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).

(3) The request duplicates a previous request that has been denied in a final administrative or judicial determination where the new request is not accompanied by supporting medical documentation of new and changed circumstances impacting treatment, and such evidence is not provided to the MCO upon request (via form C-9A or equivalent).

(4) The underlying claim has been settled, and the dates of service requested are on or after the effective date of the settlement. If the 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.

(5) The underlying claim has been disallowed or dismissed in its entirety, or the only allowances in the underlying claim are for substantial aggravation of a pre-existing condition, and the conditions have been determined in a final administrative or judicial determination to be in a non-payable status.

(6) The services or supplies being requested are never covered by the bureau pursuant to other bureau statutes or rules.

(7) The MCO has requested supporting medical documentation from the submitting physician of record or eligible treating provider (via form C-9A or equivalent) necessary to the MCO's evaluation and determination, and such documentation is not provided to the MCO.

(G) 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 alternative dispute resolution pursuant to rule 4123-6-16 of the Administrative Code.

Effective: 07/25/2011
R.C. 119.032 review dates: 05/06/2011 and 07/01/2016
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
Prior Effective Dates: 4/1/07

4123-6-16.3 Reimbursement of retroactive medical treatment reimbursement requests.

(A) Except as otherwise provided in paragraph (D) of this rule, medical treatment reimbursement requests submitted retroactively to the MCO responsible for medical management of claim by an injured worker's physician of record or eligible treating provider, without just cause, for non-emergency treatment delivered, rendered, or directly supervised by the physician of record or eligible treating provider shall, if approved, be reimbursed at seventy-five per cent of the applicable fee schedule amount, and the physician of record or treating provider may not balance bill the injured worker for the difference.

(B) For purposes of this rule, "just cause" includes, but is not limited to:

(1) The treatment requested was emergency treatment;

(2) The provider was not aware that services were for a workers' compensation claim;

(3) The provider was non-bureau certified and had no established relationship with the injured worker;

(4) The provider was initially bureau certified within six months prior to the treatment request;

(5) The treatment requested was for a pending claim allowance or additional allowance with the bureau or industrial commission;

(6) The treatment provided was within the bureau's presumptive authorization guidelines, or does not require prior authorization per the bureau's provider billing and reimbursement manual;

(7) The treatment request was submitted retroactively due to bureau or MCO error;

(8) Other documented justification as deemed sufficient by the bureau.

(C) Determinations that an approved medical treatment reimbursement request shall be reimbursed at seventy-five per cent of the applicable fee schedule amount pursuant to paragraph (A) of this rule shall be subject to the grievance hearing procedure for disputed bill payments provided by rule 4123-6-04.4 of the Administrative Code.

(D) Retroactive medical treatment reimbursement requests submitted within seven calendar days of the initiation of treatment or prior to the date of the physician of record or eligible treating provider's next encounter with the injured worker, whichever is earlier, shall not be subject to payment reduction under paragraph (A) of this rule.

Effective: 01/01/2013
R.C. 119.032 review dates: 11/01/2014
Promulgated Under: 119.03
Statutory Authority: 4123.66 , 4121.441
Rule Amplifies: 4121.12 , 4121.121

4123-6-17 Bureau refusal to certify or recertify, action to decertify a provider or MCO - standards and procedures for adjudication hearings.

(A) The administrator of workers' compensation may refuse to certify or recertify or may decertify a provider or MCO as provided in paragraph (B) of rule 4123-6-02.5 of the Administrative Code and paragraph (A) of rule 4123-6-03.7 of the Administrative Code.

(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 to refuse to certify or recertify or to decertify a provider or MCO, the bureau medical services 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 this rule.

(D) Prior to the administrator entering an adjudication order, the bureau 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 statement indicating that the provider or MCO may appear at the hearing in person, and may be represented by an attorney, or may present its position, arguments or contentions in writing;

(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 . 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 the bureau's 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 legal division 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 sent to all parties and representatives by certified mail, and which may be objected to in writing within ten days of receipt of the report and recommendation. 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 written order and shall send, by certified mail, a certified copy of the order and a statement of the time and method by which an appeal may be perfected to the provider or MCO. The administrator shall also mail a copy of the order to any representative of the provider or MCO.

(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 a notice of appeal of the decision with the administrator, setting forth the order appealed from and the grounds of the provider's or MCO's appeal. The provider or MCO shall also file a copy of the notice of appeal with the court of common pleas of Franklin county. Notices of appeal shall be filed within fifteen days after the mailing of the order of 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 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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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: 2/16/96, 1/1/99, 2/14/05

4123-6-18 Data gathering and reporting.

(A) Pursuant to division (H) of section 4121.44 of the Revised Code and division (A)(6) of section 4121.441 of the Revised Code, the administrator shall require employees, employers, medical providers, medical vendors (MCOs), 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 on the first day of each January and July to gauge the measures of outcomes and savings of the HPP.

(B) The administrator shall compile at least and make available electronically to each employer a report that summarizes the performance of each MCO pursuant to the performance criteria described in rule 4123-6-13 of the Administrative Code.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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: 2/16/96, 1/1/99, 2/14/05

4123-6-19 Remain at work program.

(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.

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

(C) Scope of remain at work services.

(1) 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) 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.

(c) 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).

(2) 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 eight or more days of lost time due to a work related injury.

A claim that changes to a lost time claim with eight or more days of lost time due to a work related injury 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.

(3) The bureau may audit the MCO's remain at work program.

Effective: 07/01/2012
R.C. 119.032 review dates: 12/30/2011 and 07/01/2017
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: 1/1/01, 2/14/05

4123-6-20 Obligation for submitting medical documentation and reports.

(A) A provider is responsible for the accuracy of all reports, information, and/or documentation submitted by the provider, the provider's employees, or the provider's agents to the bureau, industrial commission, claimant, employer, or their representatives, MCO, QHP, or self-insuring employer in connection with a workers' compensation claim. The provider, the provider's employees, and the provider's agents shall not submit or cause or allow to be submitted to the bureau, industrial commission, claimant, employer, or their representatives, MCO, QHP, or self-insuring employer any report, information, and/or documentation containing false, fraudulent, deceptive, or misleading information.

(B) Interim medical reports and medical documentation.

Compensation for temporary total disability is payable upon submission of current supporting medical documentation. While the claimant remains on temporary total disability, interim reports must be filed in accordance with paragraph (D) of rule 4123-5-18 of the Administrative Code. Interim reports must include at least:

(1) The date of the report;

(2) The date of the last examination;

(3) The "International Classification of Disease" diagnosis code(s) recognized in the claim for all conditions and all parts of the body being treated that are affecting the length of disability, including a primary diagnosis code, with a narrative description identifying the condition(s) and specific area(s) 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.

(E) Independent medical examinations.

(1) A provider performing an independent medical examination of a claimant shall create, maintain, and retain sufficient records, papers, books, and documents in such form to fully substantiate the accuracy of the resulting report submitted to the bureau, industrial commission, claimant, employer, or their representatives, MCO, QHP, or self-insuring employer in connection with a workers' compensation claim. The provider, the provider's employees, and the provider's agents shall keep such records in accordance with rule 4123-6-45.1 of the Administrative Code, and such records shall be subject to audit pursuant to rule 4123-6-45 of the Administrative Code.

(2) A provider performing an independent medical examination of a claimant shall keep confidential all information obtained in the performance of the independent medical examination, including but not limited to knowledge of the contents of confidential records of the bureau, industrial commission, claimant, employer, or their representatives, MCO, QHP, or self-insuring employer. The provider, the provider's employees, and the provider's agents shall maintain the confidentiality of such records in accordance with all applicable state and federal statutes and rules, including but not limited to rules 4123-6-15 and 4123-6-72 of the Administrative Code.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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: 1/27/97, 1/15/99, 1/1/01, 1/1/03

4123-6-20.1 Charges for copies of medical reports.

(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 or the 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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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

4123-6-21 Payment for outpatient medication.

(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 drug or therapeutic class of drugs as not being reasonably related to or medically necessary for treatment of the allowed conditions in a claim.

(B) Medication may be prescribed by any treating provider authorized by law to prescribe such medication ; however, reimbursement for medication shall be denied under the following circumstances:

(1) Reimbursement for prescriptions written by providers who are not enrolled with the bureau and who refuse to become enrolled shall be denied.

(2) Reimbursement for prescriptions written by providers who are enrolled but non-certified shall be denied except in the following situations:

(a) The prescription is written by a non-bureau certified provider during initial or emergency treatment of the claimant if the claimant's claim and treated conditions are subsequently allowed.

(b) The prescription is written by a non-bureau certified provider who is outside the state or within the state where no or an inadequate number of bureau certified providers exist and the MCO has determined that the treatment to be provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider and has authorized the non-bureau certified provider to continue to provide the treatment.

(c) The prescription is written by a non-bureau certified provider for a claimant with a date of injury prior to October 20, 1993, the provider was the claimant's physician of record prior to October 20, 1993, and the claimant has continued treatment with that non-bureau-certified provider.

(3) Reimbursement for prescriptions of controlled substances written by Ohio providers who are not enrolled in OARRS and refuse to become enrolled shall be denied if the provider has written prescriptions for controlled substances for the purpose of providing chronic care. For purposes of this rule:

(a) "Controlled substance" has the same meaning as in section 3719.01 of the Revised Code.

(b) "OARRS" means the "Ohio Automated Rx Reporting System" drug database established and maintained pursuant to section 4729.75 of the Revised Code.

(c) "Written for the purpose of providing chronic care" means the provider has written three or more prescriptions for controlled substances for the same injured worker in a twelve week period.

(C) Drugs covered are limited to those that are approved for human use in the United States by the food and drug administration (FDA) 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 prior authorized by and reimbursed through the bureau's pharmacy benefits manager:

(1) Compounded sterile parenteral drug products.

(a) "Parenteral" drugs are injectable medications. They may include those intended for use by the intrathecal, intravenous, intramuscular, or subcutaneous routes of administration.

(b) All compounded sterile parenteral drug products must be prepared and dispensed by a licensed and enrolled pharmacy provider that is able to demonstrate compliance with the standards contained in chapter 797 of the United States pharmacopeia (USP) in effect on the billed date of service.

(2) Drug efficacy study implementation (DESI) drugs or drugs that may have been determined to be identical, similar, or related;

(3) Extemporaneous compounded prescriptions.

(a) Reimbursement for non-sterile compounded prescriptions shall only be considered for preparations that contain not less than one nor more than three FDA approved active pharmaceutical ingredients, and that contain only one prescription drug from any specific therapeutic class of drugs (as defined in the edition of the "American Hospital Formulary Service Drug Information" in effect on the billed date(s) of service).

(b) Reimbursement for non-sterile compounded prescriptions shall only be considered upon the submission of both:

(i) A prior authorization request, and

(ii) A copy of the signed prescription that lists all active pharmaceutical ingredients and indicates the usual and customary cost of the prescription.

(c) Approval for reimbursement of non-sterile compounded prescriptions will be for an initial period of ninety days with subsequent approvals contingent upon clinical documentation of improvement in both pain and function.

(F) 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) Non-compounded injectable drugs not intended for self-administration;

(4) Drugs used to aid in smoking cessation;

(5) 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.

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

(1) Except as provided in this paragraph, product cost component shall be the lesser of the following: maximum allowable cost, if applicable, or the average wholesale price (AWP) of the commonly stocked package size minus nine per cent.

(a) For repackaged brand name medications, the product cost component shall be calculated using the AWP of the original labeler.

(b) For non-sterile compounded prescriptions, the product cost component shall be limited to the lesser of the usual and customary price or the AWP of the commonly stocked package size minus nine per cent for each ingredient.

(c) The maximum reimbursement for any one compunded prescription will be six hundred dollars.

(2) The dispensing fee component for non-compounded prescriptions shall be three dollars and fifty cents.

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

(b) The dispensing fee may include an additional incentive component of two dollars and fifty cents 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).

(3) The dispensing fee component for non-sterile compounded prescriptions shall be twelve dollars and fifty cents.

(4) The dispensing fee component for sterile compounded prescriptions shall be twenty-five dollars.

(H) 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. The bureau shall not reimburse any third-party pharmacy biller that submits pharmacy bills on behalf of a pharmacy provider or that has purchased pharmacy bills from a pharmacy provider for subsequent submission to the bureau for payment. 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 the bureau's pharmacy benefit manager's payment system must be used for billing purposes. The pharmacy provider shall:

(1) Maintain a signature log verifying receipt by the injured worker of applicable covered medications;

(2) Include prescriber information within bills submitted electronically to the bureau or the bureau's pharmacy benefits manager for payment. The prescriber information must include the national provider identifier (NPI) or the drug enforcement administration (DEA) number;

(3) Not 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 medications or other goods or services) as an inducement to or in return for the injured worker ordering or receiving from the provider any medications or other goods or services for which payment may be made by the bureau, the bureau's pharmacy benefits manager, or MCO under Chapter 4121., 4123., 4127., or 4131. of the Revised Code;

(4) Comply with all applicable billing instructions contained in the bureau's provider billing and reimbursement manual in effect on the billed date(s) of service.

(I) The bureau may establish a maximum allowable cost for single source or multi-source 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" in effect on the billed date(s) of service. The methodology used to determine a maximum allowable cost for a qualified drug product shall be determined by the bureau. For multi-source drugs, the bureau may choose to utilize the maximum allowable cost list of a vendor or develop its own maximum allowable cost list. For single source drugs, the maximum allowable cost shall be the drug's average wholesale price minus nine per cent.

(J) 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 for which single source or multi-source medications exist that are pharmaceutically and therapeutically equivalent, as defined in paragraph (I) of this rule, shall be liable for the product cost difference between the established maximum allowable cost price of the drug product and the average wholesale price of the dispensed brand name drug minus nine percent. However, the bureau may approve reimbursement of the dispensed brand name drug at the average wholesale price of the drug minus nine per cent if the following circumstances are met:

(1) The injured worker has a documented, systemic allergic reaction which is consistent with known symptoms or clinical findings of a medication allergy; and

(2) The injured worker has been prescribed, and has tried, other A code drugs in the therapeutic class and the intended therapeutic benefit has not been achieved or an unacceptable adverse event has occurred.

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

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

(2) 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.

(3) 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.

(4) 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 drug has been changed 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;

(e) Pharmacy will be closed for more than two days.

(f) An emergency or disaster, as defined in division (O) of section 4123.511 of the Revised Code, is declared by the governor of Ohio or the president of the United States.

(L) Except as otherwise provided in paragraph (F) of this rule, outpatient medications shall be billed to and reimbursed through the bureau's pharmacy benefits manager. Pharmacy providers must submit bills for medication by an on-line point-of-service authorization terminal or a host-to-host link with the bureau's pharmacy benefits manager's established bill processing system as a condition of provider enrollment or reimbursement. Submission by paper or by tape-to-tape will not be accepted by the bureau or the bureau's pharmacy benefits manager.

(M) Claimant reimbursement for medications shall be in accordance with rule 4123-6-26 of the Administrative Code. Claimant requests for reimbursement shall comply with all applicable billing instructions contained in the bureau's provider billing and reimbursement manual in effect on the billed date(s) of service. Claimant reimbursement may be limited to the following situations:

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

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

(3) Claimants who reside out of the country.

(N) The bureau may formulate medication utilization protocols for select conditions or diseases consistent with current medical texts and 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.

(O) 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 4729.01 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.

(P) The bureau may contract with a pharmacy benefit manager 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. The bureau may utilize other services or established procedures of the pharmacy benefits manager which may enable the bureau to control costs and utilization and detect fraud.

(Q) 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, which may included reimbursement for the dispensing fee component. The amount that could be reimbursed for pharmacist professional services shall be determined by the bureau.

(R) The bureau shall retain a registered pharmacist licensed in the state of Ohio to act as the full-time pharmacy program director to assist the bureau in the review of drug bills. The pharmacy program director may assist the bureau in determining the appropriateness, eligibility, and reasonableness of compensation payments for drug services. The bureau may adopt a drug formulary with the recommendation of the bureau's pharmacy and therapeutics committee established by rule 4123-6-21.2 of the Administrative Code, and may consult with the committee on the development and ongoing annual review of the drug formulary and other issues regarding medications.

Effective: 12/01/2013
R.C. 119.032 review dates: 11/01/2014
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, 10/1/05, 9/1/11, 1/1/12

4123-6-21.1 Payment for outpatient medication by self-insuring employer.

(A) Medication must be for 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.

(B) Medication may be prescribed by any treating provider authorized by law to prescribe such medication.

(C) Drugs covered are limited to those that are approved for human use in the United States by the food and drug administration (FDA) and that are dispensed by a registered pharmacist from an enrolled pharmacy provider.

(D) A self-insuring employer may approve and reimburse for various drugs as a part of a comprehensive treatment plan submitted by the physician of record or a treating physician when reasonably related to and medically necessary for treatment of the allowed conditions in the claim, provided that such approval and reimbursement shall not constitute the recognition of any additional conditions in the claim even if such drugs are used to treat conditions that have not been allowed in the claim.

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

(1) Except as provided in this paragraph, product cost component shall be the lesser of the following: maximum allowable cost established under paragraph (O) of this rule, if applicable, or the average wholesale price (AWP) of the commonly stocked package size minus nine per cent.

(a) For repackaged brand name medications, the product cost component shall be calculated using the AWP of the original labeler.

(b) For non-sterile compounded prescriptions, the product cost component shall be limited to the lesser of the usual and customary price or the AWP of the commonly stocked package size minus nine per cent for each ingredient.

(c) The maximum product cost component reimbursement for any one compounded prescription will be six hundred dollars.

(2) The dispensing fee component for non-compounded prescriptions shall be three dollars and fifty cents, unless the self-insuring employer has negotiated a payment rate with the pharmacy provider pursuant to rule 4123-6-46 of the Administrative Code.

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

(b) The dispensing fee may include an additional incentive component of two dollars and fifty cents 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), or other proprietary code that serves to group together pharmaceutically equivalent products (defined as products that contain the same active ingredients in the same strengths, dosage forms, and routes of administration), 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;

(vi) Cases where the self-insuring employer determines the limitations of this paragraph to be unnecessary under the specific circumstances.

(3) The dispensing fee component for non-sterile compounded prescriptions shall be twelve dollars and fifty cents.

(4) The dispensing fee component for sterile compounded prescriptions shall be twenty-five dollars.

(F) 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 in paragraph (E) of this rule, unless the self-insuring employer has negotiated a payment rate with the provider pursuant to rule 4123-6-46 of the Administrative Code. 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.

(G) The pharmacy provider shall:

(1) Maintain a signature log verifying receipt of applicable covered medications;

(2) Include prescriber information within bills submitted electronically to the self-insuring employer or its vendor for payment. The prescriber information must include the national provider identifier (NPI) or the drug enforcement administration (DEA) number;

(3) Not 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 medications or other goods or services) as an inducement to or in return for the injured worker ordering or receiving from the provider any medications or other goods or services for which payment may be made by the self-insuring employer or its vendor or QHP under Chapter 4121., 4123., 4127., or 4131. of the Revised Code;

(4) Comply with all applicable billing instructions contained in the bureau's provider billing and reimbursement manual in effect on the billed date(s) of service.

(H) Claimant reimbursement for medications shall be in accordance with rule 4123-6-26 of the Administrative Code and shall at least be equal to the bureau's established rate for the medication, unless the self-insuring employer has negotiated a payment rate with the pharmacy provider utilized by the claimant pursuant to rule 4123-6-46 of the Administrative Code, in which case the claimant reimbursement shall be at least the rate negotiated with the provider. Claimant requests for reimbursement shall comply with all applicable billing instructions contained in the bureau's provider billing and reimbursement manual in effect on the billed date(s) of service. Requests for reimbursement must be paid within thirty days of receipt of the request.

(I) Self-insuring employers must obtain a drug utilization review from a physician before terminating payment for current medications, as follows:

(1) Before terminating payment for current medications, the self-insuring employer shall notify all parties to the claim (including authorized representatives) and the prescribing physician, in writing, that a physician drug review is being performed, or has been performed, regarding the necessity and appropriateness of the continued use of current medications (by therapeutic drug class).

(2) The written notice shall inform all parties to the claim (including authorized representatives) and the prescribing physician that they have twenty-one days from receipt of the notice to provide additional information and/or medical documentation to justify the need for continued use of the medications (by therapeutic drug class).

(3) The self-insuring employer shall provide all medically related information regarding the medications to an independent physician reviewer for review and opinion as to the necessity or appropriateness of the medications. If the self-insuring employer has obtained an independent physician reviewer's report prior to sending the notice required by paragraph (I)(1) of this rule and subsequently receives additional information and/or medical documentation pursuant to paragraph (I)(2) of this rule, the self-insuring employer shall provide the additional information and/or medical documentation to the independent physician reviewer and obtain an addendum. The independent physician reviewer's report (and addendum, if applicable) shall address the medical rationale, necessity and appropriateness of the drug treatment in the control of symptoms associated with the allowed conditions in the claim.

(4) When the independent physician reviewer's report (and addendum, if applicable) indicates the drug treatment is not medically necessary or appropriate for treatment or in the control of symptoms associated with the allowed conditions in the claim, the self-insuring employer may terminate reimbursement for the medications (by therapeutic drug class) effective as of the date of receipt of the independent physician reviewer's report, or addendum if one is obtained, However, if the drug is subject to one of the standard dose tapering (weaning) schedules set forth in the appendix to rule 4123-6-21.5 of the Administrative Code, termination of reimbursement must follow the applicable standard dose tapering (weaning) schedule.

(5) In the event the self-insuring employer terminates reimbursement for the medications as set forth in paragraph (I)(4) of this rule, the self-insuring employer or its authorized representative shall provide all parties to the claim (including authorized representatives) and the prescribing physician with a copy of the independent physician reviewer's report (and addendum, if applicable) and the self-insuring employer shall notify the employee and the employee's representative in writing of its decision to terminate. The employer's notification to the employee and employee's representative shall indicate that the employee has the right to request a hearing before the industrial commission.

(6) In the event there is a dispute as to whether the drug treatment is medically necessary or appropriate for treatment of the symptoms associated with the allowed conditions in the claim, the disputed matter shall be adjudicated in accordance with paragraph (K)(5) of rule 4123-19-03 of the Administrative Code.

(J) Self-insuring employers may deny initial requests for a drug or therapeutic class of drugs as not being reasonably related to or medically necessary for the treatment of the allowed conditions in a claim.

(K) Self-insuring employers may utilize medication utilization protocols formulated by the bureau for select conditions or diseases consistent with current medical texts and peer reviewed medical literature.

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 or self-insured employer's refusal to reimburse for such medications.

(L) Through internal development or through vendor contracts, self-insuring employers may implement a point-of-service adjudication system. Upon implementation, a self-insuring employer may require pharmacy providers 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 reimbursement, and may refuse submission by paper or by tape-to-tape. Self-insuring employers utilizing a point-of-service adjudication system may refuse to reimburse any third-party pharmacy biller that submits pharmacy bills on behalf of a pharmacy provider or that has purchased pharmacy bills from a pharmacy provider for subsequent submission to the self-insuring employer for payment.

(M) Self-insuring employers utilizing a point of service adjudication system may require prior authorization of drugs or therapeutic classes of drugs which appear on the bureau's published list of drugs or therapeutic classes of drugs for which prior authorization is required.

(N) Self-insuring employers utilizing a point-of-service adjudication system may apply the following dispensing limitations, adopted by the bureau, to medications approved and reimbursed by the self-insuring employer:

(1) 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.

(2) Requests submitted that exceed either the days supply limit or maximum quantity limit shall be denied; provided, however, that the pharmacy provider may still fill the prescription up to the days supply limit or maximum quantity limit, as applicable. Denials may be overridden by the self-insured employer in cases where medical necessity and appropriateness have been determined.

(3) Refills requested before seventy-five per cent of the days supply has been utilized will be denied, except in cases where the dosage of a drug has been changed and has a new prescription number. Denials may be overridden by the self-insured employer 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;

(e) Pharmacy will be closed for more than two days.

(f) An emergency or disaster, as defined in division (O) of section 4123.511 of the Revised Code, is declared by the governor of Ohio or the president of the United States.

(O) Self-insuring employers utilizing a point-of-service adjudication system may apply the maximum allowable cost list of the point-of-service adjudication system vendor for multi-source 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" in effect on the billed date(s) of service. For single source drugs, self-insuring employers utilizing a point-of-service adjudication system may utilize as a maximum allowable cost the drug's average wholesale price minus nine per cent.

(P) 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 for which single source or multi-source medications exist that are pharmaceutically and therapeutically equivalent, as defined in paragraph (O) of this rule, shall be liable for the product cost difference between the established maximum allowable cost price of the drug product and the average wholesale price of the dispensed brand name drug minus nine per cent. However, the self-insuring employer or its vendor may approve reimbursement of the dispensed brand name drug at the average wholesale price of the drug minus nine per cent if the following circumstances are met:

(1) The injured worker has a documented, systemic allergic reaction which is consistent with known symptoms or clinical findings of a medication allergy; and

(2) The injured worker has been prescribed, and has tried, other A code drugs in the therapeutic class and the intended therapeutic benefit has not been achieved or an unacceptable adverse event has occurred.

(Q) A self-insuring employer has sufficient grounds to refuse to pay for the dispensing of drugs and other medications when a pharmacy provider fails to observe any state or federal law relating to his or her professional licensure or to the dispensing of drugs and other medication.

Effective: 04/10/2014
R.C. 119.032 review dates: 11/01/2014
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.121 , 4121.30
Rule Amplifies: 4121.44 , 4123.66
Prior Effective Dates: 2/1/10, 9/1/11, 1/1/12, 12/1/13

4123-6-21.2 Pharmacy and therapeutics committee.

The bureau of workers' compensation pharmacy and therapeutics (P&T) committee is hereby created to advise the administrator and the chief medical officer with regard to issues involving medication therapy for injured workers. A list of physician and pharmacist providers, each holding a professional license in good standing, who have agreed to serve on the P&T committee and who would add credibility and diversity to the mission and goals of the committee shall be developed and maintained by the chief medical officer. Providers may also be nominated for inclusion on the list by provider associations and organizations including but not limited to: deans of Ohio's allopathic and osteopathic medical schools, deans of Ohio's colleges of pharmacy, presidents of Ohio's various allopathic and osteopathic medical associations, the Ohio pharmacists association, the Ohio state medical board, and the Ohio state pharmacy board.

(A) The P&T committee shall consist of the bureau pharmacy program director and not more than thirteen nor less than five voting members who shall be licensed physicians and licensed pharmacists representing the diverse group of providers that provide care to the injured workers of Ohio as administered through the bureau. The committee may create any subcommittees that the committee determines are necessary to assist the committee in performing its duties. Any subcommittee recommendations shall be submitted to the P & T committee.

(B) P&T committee members must meet the following requirements:

(1) Each provider must be familiar with issues relating to the prescribing or dispensing of medications in the Ohio workers' compensation system.

(2) Physicians must be a doctor of medicine (MD) or doctor of osteopathic medicine (DO).

(3) Providers must possess significant clinical or administrative experience in health care delivery, including but not limited to pain management, pharmacy practice, medical quality assurance, disease management and utilization review.

(4) Providers must have experience with and an understanding of the concepts of evidence based medicine as well as contemporary best practices in appropriate prescribing, dispensing, and monitoring of outpatient medications.

(5) Providers must not be, or within the previous twenty-four months have been, an employee of any pharmaceutical manufacturer, pharmacy benefits manager, or any non-governmental firm or entity administering state purchased health care program benefits or pharmaceutical rebates.

(C) The appointing authority for members of the P&T committee shall be the administrator or the administrator's designee(s), who shall appoint members of the committee from the list of qualified providers developed and maintained by the chief medical officer. Terms of membership for individual members of the P&T committee shall be for one year. Individuals may be reappointed to subsequent terms as determined by the administrator. Vacated terms shall be filled in a like manner as for the full term appointments and shall be for the remaining term of the vacated member.

(D) The pharmacy program director of the bureau shall be the chairperson of the P&T committee and shall provide notice of meetings to the members and be responsible for the meeting agenda. In addition, the pharmacy program director may be self-designated as an ad hoc member of any subcommittees of the P&T committee; however, the pharmacy program director shall be a voting member of the P&T committee and any subcommittees only in the case of tie votes. The bureau chief medical officer and bureau staff pharmacist may participate in discussions; however, they shall not be voting members.

(E) The P&T 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.

(F) The P&T committee may make such recommendations as it deems necessary to address any issue impacting the bureau related to pharmacy or medication therapeutics. The committee shall be responsible to respond to requests for action on any such issue submitted by the bureau's administrator, chief of medical services, chief medical officer or pharmacy director, including but not limited to:

(1) Development, approval and annual review of a formulary of approved medications.

(2) Development, approval and annual review of a list of non-covered, non-reimbursable medications.

(3) Development and approval of prior authorization criteria.

(4) Review and approval of proposed medication treatment guidelines.

(5) Review and approval of bureau policies and procedures related to drug utilization review or specific medication issues.

(6) Review of the bureau's pharmacy providers' professional performance. The P&T committee shall perform peer review according to generally accepted standards of pharmacy practice and may recommend sanctions as well as termination of any pharmacy provider determined to have consistently failed to meet those standards of care.

(7) Review of the performance of the bureau's pharmacy benefit manager and conduct regarding its management of prescription benefit services for the bureau.

(G) The P&T committee shall hold at least three meetings annually. The P&T 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 chief medical officer.

(H) The P&T committee shall submit an annual report of its activities and recommendations to the administrator. In addition to inclusion in the annual report, all recommendations from the P&T committee and subcommittees shall be submitted to the chief medical officer in a timely fashion upon completion and approval by the respective subcommittees and P & T committee.

(I) Each member of the P&T committee and its respective subcommittees may be paid such fees as approved by the administrator or the administrator's designee. The expenses incurred by the P&T committee and its subcommittees and the fees of their members shall be paid in the same manner as other administrative costs of the bureau.

Effective: 02/01/2012
R.C. 119.032 review dates: 11/01/2014
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: 1/10/2011

4123-6-21.3 Outpatient medication formulary.

(A) The administrator hereby adopts the formulary indicated in appendix A to this rule, developed with the recommendation of the bureau's pharmacy and therapeutics committee, effective January 1, 2014.

(B) The formulary indicated in appendix A to this rule shall constitute the complete list of medications that are approved for reimbursement by the bureau for the treatment of an occupational injury or disease in an allowed claim. Except as otherwise provided in paragraph (F) of this rule, drugs not listed in the formulary are not eligible for reimbursement by the bureau.

(C) The formulary indicated in appendix A to this rule also contains specific reimbursement, prescribing or dispensing restrictions that have been placed on the use of listed drugs. The formulary will be reviewed annually and updated as necessary. The most current version will be electronically published by the bureau.

(D) Based upon current medical literature and generally accepted best clinical practices the bureau's pharmacy and therapeutics committee shall evaluate and make recommendations to the administrator regarding the addition, deletion, or modification of coverage of medications listed in the formulary. Requests for pharmacy and therapeutics committee action on a specific drug may be initiated by the bureau's administrator, chief of medical services, chief medical officer, or pharmacy director.

(E) The bureau shall develop policies to perform an expedited review process for clinically or therapeutically unique medications. The bureau shall also develop policies to address the timely review of new drug products.

(F) Notwithstanding paragraph (B) of this rule, in cases of medical necessity supported by clinical documentation and evidence of need the bureau may, with prior authorization, reimburse for new drugs approved for use in the United States by the food and drug administration (FDA) on or after the effective date of the formulary, and for new indications approved by the FDA on or after the effective date of the formulary for existing drugs that are not on the formulary, for a period not to exceed one hundred eighty days from the adjudication date of the first prescription for the requested drug.

(G) Notwithstanding appendix A to this rule, in cases of medical necessity supported by clinical documentation and evidence of need the bureau may, with prior authorization, reimburse for new dosage forms or strengths approved by the FDA on or after the effective date of the formulary for existing drugs that are on the formulary, for a period not to exceed one hundred eighty days from the adjudication date of the first prescription for the requested drug.

Click to view Appendix

Click to view Appendix

Effective: 01/02/2014
R.C. 119.032 review dates: 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.121
Rule Amplifies: 4121.441 , 4123.66
Prior Effective Dates: 9/1/11, 2/1/12, 9/1/12, 4/1/13

4123-6-21.4 Coordinated services program.

The bureau, or a self-insuring employer with a point-of-service adjudication system, may establish a coordinated services program (CSP) that requires an injured worker to obtain prescription medications reimbursed by the bureau or self-insuring employer from a single designated pharmacy and/or prescriber.

(A) Placement in a CSP.

(1) The bureau or self-insuring employer with a point-of-service adjudication system may review an injured worker for possible placement in a CSP if a review of his or her claim indicates the injured worker meets one or more of the following criteria:

(a) Use of three or more different prescribers to obtain prescriptions of the same or comparable medications per three month time frame;

(b) Receipt of prescription drugs from more than two different pharmacies per three month time frame;

(c) Monthly receipt of three or more prescriptions including refills for drugs identified by therapeutic drug class as a narcotic analgesic per three month time frame;

(d) Monthly receipt of more than two concurrent narcotic analgesics in the same therapeutic drug class per three month time frame;

(e) Monthly receipt of more than two narcotic analgesics in the same therapeutic drug class, more than one benzodiazepine, and more than one sedative-hypnotics per three month time frame.

(2) Upon identification of an injured worker meeting one or more of the criteria identified in paragraphs (A)(1)(a) to (A)(1)(e) of this rule, the bureau or self-insuring employer with a point-of-service adjudication system shall obtain a physician review of the injured worker's most recent twelve months history of prescription medications reimbursed by the bureau or self-insuring employer.

(3) If, based on this physician review, the bureau or self-insuring employer with a point-of-service adjudication system determines that the injured worker's utilization of prescription medications during this period was at a frequency or in an amount that was not medically necessary or appropriate under the criteria set forth in paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code, or was potentially unsafe, the bureau or self-insuring employer may place the injured worker in a CSP.

(4) Notwithstanding paragraphs (A)(1) to (A)(3) of this rule, if the bureau or self-insuring employer with a point-of-service adjudication system determines that an injured worker has been convicted of or pled guilty to an offense under Chapter 2925. of the Revised Code or any other criminal offense related to the misuse of drugs, the bureau or self-insuring employer may place the injured worker in a CSP.

(5) Placement in a CSP shall be for an initial period of eighteen months. The bureau or self-insuring employer with a point-of-service adjudication system may place the injured worker in the CSP for additional eighteen month periods in accordance with paragraph (A)(6) of this rule.

(6) The bureau or self-insuring employer with a point-of-service adjudication system may evaluate an injured worker's medication utilization at the conclusion of each eighteen month period in the CSP. If the bureau or self-insuring employer determines that the injured worker's medication utilization continues to meet the criteria set forth in paragraphs (A)(1) to (A)(4) of this rule, the bureau or self-insuring employer may place the injured worker in the CSP for an additional eighteen month period.

(7) If an injured worker placed in the CSP enters a nursing home, residential care/assisted living facility, or hospice program, the injured worker shall be released from the CSP. If the injured worker is subsequently discharged from the nursing home, residential care/assisted living facility, or hospice program during the CSP period, the bureau or self-insuring employer with a point-of-service adjudication system may place the injured worker back into the CSP.

(B) Selection of designated pharmacy and/or prescriber.

(1) An injured worker placed into a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule shall be given the opportunity to select a designated pharmacy from a list of participating pharmacies maintained by the bureau or self-insuring employer. If an injured worker fails to select a designated pharmacy, or selects a designated pharmacy that is unable or unwilling to accept the injured worker, the bureau or self-insuring employer may select a designated pharmacy for the injured worker.

(2) An injured worker placed in a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule may only change from one designated pharmacy to another in the following circumstances:

(a) The designated pharmacy becomes inaccessible to the injured worker due to relocation or incapacity of the injured worker or closing of the designated pharmacy,

(b) The designated pharmacy chooses to no longer participate in the CSP or to provide services to the injured worker in accordance with paragraph (D)(4) of this rule.

(c) The injured worker requests to be assigned to another designated pharmacy due to personal preference. Not more than one change due to personal preference shall be approved in a rolling twelve-month period.

(3) An injured worker placed in the CSP pursuant to paragraph (A)(4) of this rule shall be given the opportunity to select a designated prescriber from among those bureau certified providers who meet the definition of physician under paragraph (D) of rule 4123-6-01 of the Administrative Code. If an injured worker fails to select a designated prescriber, or selects a designated prescriber that is unable or unwilling to accept the injured worker, the bureau or self-insuring employer may select a designated prescriber for the injured worker.

(4) An injured worker placed in a CSP pursuant to paragraph (A)(4) of this rule may only change from one designated prescriber to another in the following circumstances:

(a) The designated prescriber becomes inaccessible to the injured worker due to relocation or incapacity of the injured worker or closing of the designated prescriber's practice,

(b) The designated prescriber chooses to no longer provide services to the injured worker,

(c) The injured worker requests to be assigned to another designated prescriber due to personal preference. Not more than one change due to personal preference shall be approved in a rolling twelve-month period.

(5) All requests for change of designated pharmacy or designated prescriber must be submitted in writing to the bureau or self-insuring employer.

(C) Operation of the CSP.

(1) An injured worker placed in a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule must obtain covered prescription medications from the injured worker's designated pharmacy. During the period the injured worker is placed in the CSP, the bureau or self-insuring employer shall deny reimbursement for prescription medications obtained from a pharmacy other than the injured worker's designated pharmacy, except in cases of emergency as set forth in paragraph (C)(2) of this rule.

(2) Emergency prescription fills shall be allowed in the following situations:

(a) The injured worker is unable to get to his or her designated pharmacy,

(b) The injured worker's designated pharmacy does not have the prescribed medication in stock.

(3) Emergency prescription fills shall be limited to a four-day supply. Records of dispensing for emergency prescription fills are subject to review by the bureau.

(4) An injured worker placed in a CSP pursuant to paragraph (A)(4) of this rule must obtain all prescriptions for covered medications from the injured worker's designated prescriber. During the period the injured worker is placed in the CSP, the bureau or self-insuring employer shall deny reimbursement for prescriptions written by providers other than the injured worker's designated prescriber, except:

(a) In cases of emergency as defined in paragraph (O) of rule 4123-6-01 of the Administrative Code;

(b) With prior authorization, prescriptions written by a specialist in cases where the injured worker has been referred to a specialist for care.

(D) Pharmacies participating in the bureau's CSP.

(1) The bureau shall maintain a list of pharmacies participating in the bureau's CSP that are eligible for selection by an injured worker as a designated pharmacy. To participate in the bureau's CSP, a pharmacy must meet the following criteria:

(a) The pharmacy must be enrolled with the bureau and have a signed agreement with the bureau's pharmacy benefits manager.

(b) The pharmacy must enter into a CSP agreement with the bureau.

(2) Pharmacies participating in the bureau's CSP agree to perform the following monitoring activities:

(a) For each injured worker in the bureau's CSP for whom the pharmacy is the designated pharmacy, the pharmacy shall conduct a bimonthly review of the injured worker's OARRS report from the Ohio board of pharmacy (or a similar automated prescription monitoring report from the injured worker's state of residence).

(b) The pharmacy shall notify the injured worker's prescribing physician of any critical findings discovered in the report. Critical findings are indications of any prescription related activity that could cause harm to the patient, including but not limited to:

(i) Duplication of therapy,

(ii) Excessive doses of concurrent medications,

(iii) Potential drug interactions or potentiation of side effects.

(c) The pharmacy shall notify BWC in writing whenever reports are made under paragraph (D)(2)(b) of this rule.

(d) BWC may request quarterly documentation of the pharmacy's monitoring activities under paragraphs (D)(2)(a) to (D)(2)(d) of this rule.

(3) Pharmacies participating in the CSP may receive compensation from the bureau under the CSP agreement for services provided as part of the CSP.

(4) Pharmacies participating in the bureau's CSP may terminate their CSP agreement with the bureau and discontinue their participation in the bureau's CSP at any time upon not less than thirty days written notice to the bureau. Pharmacies participating in the bureau's CSP may discontinue providing services to an individual injured worker at any time upon not less than thirty days written notice to the bureau, the injured worker, and the injured worker's authorized representative.

(5) The bureau may terminate the CSP agreement of a pharmacy participating in the bureau's CSP in accordance with the terms of the CSP agreement.

(E) Pharmacies participating in a self-insuring employer's CSP.

(1) A self-insuring employer with a point-of-service adjudication system who establishes a CSP shall maintain a list of pharmacies participating in the self-insuring employer's CSP that are eligible for selection by an injured worker as a designated pharmacy. The list of participating pharmacies shall cover a geographic area sufficient to provide the self-insuring employer's injured workers with reasonable access to pharmacy providers.

(2) Pharmacies participating in a self-insuring employer's CSP shall provide not less than thirty days written notice to an injured worker and the injured worker's authorized representative prior to discontinuing services to the injured worker.

(F) Disputes.

(1) Decisions by the bureau regarding an injured worker's placement in the bureau's CSP, assignment of a designated pharmacy or designated prescriber, or denial of an injured worker's request for change of designated pharmacy or designated prescriber may be appealed to the industrial commission in accordance with section 4123.511 of the Revised Code.

(2) Decisions by a self-insuring employer regarding an injured worker's placement in the self-insuring employer's CSP, assignment of a designated pharmacy or designated prescriber, or denial of an injured worker's request for change of designated pharmacy or designated prescriber shall indicate that the injured worker has the right to request a hearing before the industrial commission.

Effective: 06/01/2012
R.C. 119.032 review dates: 06/01/2017
Promulgated Under: 119.03
Statutory Authority: 4121.121 , 4121.44 , 4121.441 , 4121.50
Rule Amplifies: 4121.50 , 5111.085 , 5111.179

4123-6-21.5 Standard dose tapering schedules.

The bureau hereby adopts the standard dose tapering (weaning) schedules for the prescription medications indicated in appendices A and B to this rule, developed with the recommendation of the bureau's pharmacy and therapeutics committee to safely implement denials for payment of the indicated medications, effective April 10, 2014.

These weaning schedules shall be applied to all denials for payment of the indicated medications by the bureau, self-insuring employers, MCOs, QHPs, and the industrial commission.

Click to view Appendix

Effective: 04/10/2014
R.C. 119.032 review dates: 11/01/2014
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4123.121, 4123.66 , 4123.441
Rule Amplifies: 4121.12 , 4121.121

4123-6-22 Stakeholders' health care quality assurance advisory committee.

The bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) was created to advise the administrator, the chief of medical services, and the chief medical officer with regard to medical quality issues. A list of medical providers, each holding a professional license in good standing, who have agreed to serve on the HCQAAC, and who would add credibility and diversity to the mission and goals of the HCQAAC shall be developed and maintained by the chief medical officer. Providers may be nominated for inclusion on the list by provider associations and organizations including but not limited to: deans of Ohio's allopathic and osteopathic medical schools, deans of Ohio's colleges of pharmacy, deans of Ohio's dental schools, the dean of the Ohio college of podiatric medicine, the Ohio state medical association, the Ohio state osteopathic association, the Ohio state chiropractic association, specialty board associations of Ohio, the Ohio podiatric medical association, the Ohio psychological association, the Ohio dental association, the Ohio pharmacists association, the Ohio hospital association, the Ohio state medical board, the Ohio state chiropractic board, the Ohio state psychology board, the Ohio state pharmacy board, and the Ohio state dental board.

(A) The HCQAAC shall consist of the bureau's chief medical officer and not more than thirteen nor less than five voting members representing the diverse group of providers that provide medical care to the injured workers of Ohio as administrated through the bureau. The committee may create any subcommittees that the committee determines are necessary to assist the committee in performing its duties. Any subcommittee recommendations shall be submitted to the HCQAAC committee.

(B) HCQAAC members must meet the following requirements:

(1) Providers must be familiar with issues relating to the treatment of injured workers in the Ohio workers' compensation system.

(2) Providers must possess significant clinical or administrative experience in health care delivery, including but not limited to, medical quality assurance, disease management, and utilization review.

(3) Providers must have experience with and an understanding of the concepts of evidence based medicine as well as contemporary best practices in their respective areas of practice.

(C) The appointing authority for members of the HCQAAC shall be the administrator or the administrator's designee(s), who shall appoint members of the HCQAAC from the list of qualified providers developed and maintained by the chief medical officer. Terms of membership for individual members of the HCQAAC shall be for one year. Individuals may be reappointed to subsequent terms as determined by the administrator. Vacated terms shall be filled in a like manner as for the full term appointments and shall be for the remaining term of the vacated member.

(D) The chief medical officer of the bureau shall be the chairperson of the HCQAAC and shall provide notice of meeting to the members and be responsible for the meeting agenda. In addition, the chief medical officer may be self-designated as an ad hoc member of any subcommittees of the HCQAAC; however, the chief medical officer shall be a voting member of the HCQAAC and any subcommittees only in the case of tie votes. 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) The HCQAAC 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 chief medical officer.

(F) The HCQAAC shall be responsible to respond to requests for action on any medical quality assurance issue submitted by the bureau's administrator, chief of medical services, or chief medical officer including, but not limited to:

(1) Review of medical treatment guidelines referred to the bureau;

(2) Review of any of the bureau's policies and procedures related to medical quality assurance issues;

(3) Review of any of the bureau's medical providers' professional performance and conduct, including bureau certification and malpractice issues. The HCQAAC shall perform peer review according to generally accepted standards of medical practice and may recommend sanctions as well as decertification of any provider determined to have consistently failed to meet those standards of care;

(4) Review of any of the bureau's managed care organizations' professional performance and conduct regarding the management of medical services for the bureau. This may include interfacing with any quality assurance committee of any of the individual managed care organizations.

The HCQAAC may make such recommendations as it deems necessary to address any medical quality assurance issue impacting the bureau.

(G) The HCQAAC shall hold at least quarterly meetings. The HCQAAC 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 chief medical officer.

(H) The HCQAAC shall submit an annual report of its activities and recommendations to the administrator. In addition to inclusion in the annual report, all recommendations from the HCQAAC and subcommittees shall be submitted to the chief medical officer in a timely fashion upon completion and approval by the respective subcommittees and HCQAAC committee.

(I) Each member of the HCQAAC and its respective subcommittees may be paid such fees as approved by the administrator or administrator's designee. The expenses incurred by the HCQAAC and its subcommittees and the fees of their members shall be paid in the same manner as other administrative costs of the bureau.

Replaces: Replacing 4123-6-22

Effective: 01/10/2011
R.C. 119.032 review dates: 11/01/2014
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, 6/1/05

4123-6-23 Jurisdictional principles applicable to payment of bills for medical services rendered by health care providers.

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 August 25, 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 August 25, 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 August 25, 2006, except that where those provisions reference six year and ten year time limits, the time limits shall be five years.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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, 4/1/07

4123-6-24 [Rescinded]Treatment necessary due to an industrial injury or occupational disease.

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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-25 Payment for medical supplies and services.

(A) 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.

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.

Providers billing for services rendered shall follow the procedures set forth in the bureau's provider billing and reimbursement manual in effect on the billed date of service.

(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 edition of the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) in effect on the billed date of service 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) Diagnosis codes.

Providers must use the appropriate "International Classification of Diseases, clinical modification" codes for the condition(s) treated 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: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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, 4/1/07

4123-6-26 Claimant reimbursement.

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 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 no more than the amount that would have been paid to the health care provider as provided by the rules of this chapter of the Administrative Code. However, in cases where the payor is the claimant's health insurer, if the claimant seeks reimbursement for an out-of-pocket copayment and the claimant's health insurer has already been reimbursed or later seeks reimbursement, the claimant may be reimbursed for the copayment and the claimant's health insurer may be reimbursed up to 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.

Effective: 06/24/2011
R.C. 119.032 review dates: 11/01/2014
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: 2/12/97

4123-6-27 Treatment by more than one physician.

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: 11/17/2009 and 11/01/2014

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: 2/12/97

4123-6-28 [Rescinded]Treatment of more than one condition or to more than one part of the body.

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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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, 2/14/05

4123-6-29 Request for information by the treating provider.

A provider treating an injured worker may, at any time, make a request in writing, facsimile, or e-mail, in accordance with the bureau's confidentiality and sensitive data requirements, 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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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, 2/14/05

4123-6-30 Payment for physical medicine.

(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, but not limited to, chiropractic treatments, physiotherapy, and physical therapy.

(B) Physical medicine must be prescribed by the physician of record or other approved treating provider licensed to practice medicine, osteopathy, chiropractic, mechanotherapy, dentistry, podiatry, or nursing as a certified registered nurse anesthetist, clinical nurse specialist, certified nurse midwife, or certified nurse practitioner. Physical medicine may be provided in the physician's office or referred to another licensed provider.

(C) To be eligible for reimbursement, physical medicine services must be provided by a physician, chiropractic physician, physical therapist, occupational therapist, massage therapist, athletic trainer or other qualified non-physician provider practicing within the scope of his or her license, certification, or registration.

(D) Fees for up to twelve physical therapy treatments within sixty days following the date of injury may be reimbursed without prior authorization, provided the treatments are for allowed soft tissue and musculoskeletal conditions in allowed claims and the criteria set forth in paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code are met. Otherwise, physical therapy treatment must be prior authorized.

(E) Payment for physical medicine used for treatment of the allowed conditions shall be made in accordance with rule 4123-6-10 of the Administrative Code.

(F) 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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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

4123-6-31 Payment for miscellaneous medical services and supplies.

(A) Acupuncture.

(1) 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. Such treatment must be prior authorized.

(2) 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.

(B) Braces, shoes, and other orthotic devices.

(1) 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.

(2) 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.

(3) 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.

(C) Dental care.

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

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

(b) 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.

(c) For industrial injuries or occupational diseases sustained on or after January 1, 1979, the requirements of paragraph (C)(1)(b) of this rule do not apply.

(2) 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.

(3) 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 (C)(1)(b) and (C)(1)(c) of this rule.

(4) 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.

(D) Eyeglasses and contact lenses.

(1) 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.

(a) 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.

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

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

(3) Refractions will be approved in situations described in paragraph (D)(2) of this rule.

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

(5) 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.

(E) Hearing aids.

(1) 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:

(a) 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.

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

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

(2) 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.

(F) X-rays.

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 prior authorization requirements in effect at the time when requesting authorization and payment for such studies.

Replaces: 4123-6-31, 4123-6-32, 4123-6-33, 4123-6-34,

4123-6-35, 4123-6-36 Effective: 02/01/2010
R.C. 119.032 review dates: 11/01/2014
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: 2/12/97, 10/14/02, 10/10/03, 2/14/05, 9/22/08

4123-6-32 [Rescinded]Payment for x-rays.

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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-33 [Rescinded]Payment for dental care.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-34 [Rescinded]Payment for eyeglasses and contact lenses.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-35 [Rescinded]Payment for hearing aids.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-36 [Rescinded]Payment for shoes, braces, and other orthotic devices.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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, 2/14/05

4123-6-37 Payment of hospital bills.

(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 , prior authorization must be obtained in advance of all hospitalizations. The hospital must notify the bureau, the injured worker's MCO, QHP, or self-insuring employer 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, MCO, QHP, or self-insuring employer 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 in accordance with rule 4123-6-10 of the Administrative Code.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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: 2/12/97, 3/1/04

4123-6-37.1 Payment of hospital inpatient services.

(A) HPP.

Unless an MCO has negotiated a different payment rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code, reimbursement for hospital inpatient services with a discharge date of February 1, 2014, or after shall be as follows:

(1)

(a) Reimbursement for hospital inpatient services, other than outliers as defined in paragraph (A)(3) of this rule or services provided by hospitals subject to reimbursement under paragraph (A)(4) of this rule, shall be calculated using the applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system, multiplied by a 2014 bureau adjustment of 1.008, and further multiplied by a payment adjustment factor of 1.20, according to the following formula:

(MS-DRG reimbursement rate x 1.008 ) x 1.20 = bureau reimbursement for hospital inpatient service.

(b) In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare inpatient prospective payment system as implemented by the materials specified in paragraph (A)(7) of this rule other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 as amended as of the effective date of this rule, the "applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system" as specified in this paragraph shall be determined by the bureau without regard to such subsequent adjustments.

(2) In addition to the payment specified by paragraph (A)(1) 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 February first of each year, using the most current cost report data available from the centers for medicare and medicaid services, 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 (A)(3) of this rule or services provided by hospitals subject to reimbursement under paragraph (A)(4) of this rule.

(3)

(a) Reimbursement for outliers as determined by medicare's inpatient prospective payment system outlier methodology shall be calculated using the applicable medicare severity diagnosis related group (MS-DRG) outlier reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system multiplied by a 2014 bureau adjustment of 1.008 and further multiplied by a payment adjustment factor of 1.80, according to the following formula:

(MS-DRG outlier reimbursement rate x 1.008 ) x 1.80 = bureau reimbursement for hospital inpatient service outlier.

(b) In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare inpatient prospective payment system as implemented by the materials specified in paragraph (A)(7) of this rule other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 as amended as of the effective date of this rule, the "applicable medicare severity diagnosis related group (MS-DRG) outlier reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system" as specified in this paragraph shall be determined by the bureau without regard to such subsequent adjustments.

(4) 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:

(a) For hospitals the department of health and human services, centers for medicare and medicaid services maintained hospital-specific cost-to-charge ratio information on as of October 1, 2013, based on the hospitals' submitted cost report (CMS-2552-96), reimbursement shall be equal to the hospital's allowable billed charges multiplied by the hospital's reported operating cost-to-charge ratio (from the inpatient provider specific file in use by medicare on October 1, 2013) multiplied by a payment adjustment factor of 1.14 , not to exceed seventy per cent of the hospital's allowed billed charges.

(b) For hospitals the department of health and human services, centers for medicare and medicaid services did not maintain hospital-specific cost-to-charge ratio information on as of October 1, 2013, reimbursement shall be equal to the hospital's allowable billed charges multiplied by the applicable fiscal year 2014 urban or rural statewide average operating cost-to-charge ratio set forth in table 8A of the federal rule referenced in paragraph (A)(5)(b) of this rule (the Ohio average operating cost-to-charge ratio shall be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.14 , not to exceed seventy per cent of the hospital's allowed billed charges.

(5) Reimbursement for inpatient services provided by hospitals and distinct-part units of hospitals that do not participate in the medicare program shall be calculated using the national standardized amount for fiscal year 2014, full update, as found at 78 Fed. Reg. 50984 - 50985 (2013).

(6) Reimbursement for inpatient services provided by "new hospitals" as defined in 42 C.F.R. 412.300(b) as published in the October 1, 2013 Code of Federal Regulations shall be calculated in the same manner as provided under paragraph (A)(4)(b) of this rule.

(7) 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 et seq. as amended, excluding 42 U.S.C. 1395ww(d)(4)(D) , 42 U.S.C. 1395ww(m) , and 42 U.S.C. 1395ww(q) , as implemented by the following materials, which are incorporated by reference:

(a) 42 C.F.R. Part 412 as published in the October 1, 2013 Code of Federal Regulations;

(b) Department of health and human services, centers for medicare and medicaid services' " 42 CFR Parts 412, 413, 414, et al. medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2014 rates; quality reporting requirements for specific providers ; hospital conditions of participation; payment policies related to patient status" final rule, 78 Fed. Reg. 50495 - 51040 (2013).

(B) QHP or self insuring employer (non-QHP):

A QHP or self-insuring employer may reimburse hospital inpatient services at:

(1) The applicable rate under the methodology set forth in paragraph (A) of this rule; or

(2)

(a) For hospitals the department of health and human services, centers for medicare and medicaid services maintained hospital-specific cost-to-charge ratio information on as of October 1, 2013, based on the hospitals' cost report (CMS-2552-96), the hospital's allowable billed charges multiplied by the hospital's reported operating cost-to-charge ratio (from the inpatient provider specific file in use by medicare on October 1, 2013) multiplied by a payment adjustment factor of 1.14 , not to exceed seventy per cent of the hospital's allowed billed charges;

(b) For hospitals the department of health and human services, centers for medicare and medicaid services did not maintain hospital-specific cost-to-charge ratio information on as of October 1, 2013, the hospital's allowable billed charges multiplied by the applicable fiscal year 2014 urban or rural statewide average operating cost-to-charge ratio set forth in table 8A of the federal rule referenced in paragraph (A)(5)(b) of this rule (the Ohio average operating cost-to-charge ratio shall be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.14 , not to exceed seventy per cent of the hospital's allowed billed charges; or

(3) The rate negotiated between the hospital and the QHP or self-insuring employer in accordance with rule 4123-6-46 of the Administrative Code.

Effective: 02/01/2014
R.C. 119.032 review dates: 11/01/2014
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: 1/1/07, 4/1/07, 1/1/08, 2/1/09, 2/1/10, 2/1/11, 2/1/12, 2/3/13

4123-6-37.2 Payment of hospital outpatient services.

(A) HPP:

Unless an MCO has negotiated a different payment rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code, reimbursement for hospital outpatient services with a date of service of May 5, 2014 or after shall be the applicable rate set forth in paragraphs (A)(1) to (A)(6) of this rule as follows multiplied by a payment adjustment factor of 1.0212:

(1) Except as otherwise provided in this rule, reimbursement for hospital outpatient services shall be equal to the applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system as implemented by the materials specified in paragraph (A)(7) of this rule, multiplied by a bureau-specific payment adjustment factor, which shall be 2.53 for children's hospitals and 1.62 for all hospitals other than children's hospitals, with the following additional adjustments for specific services:

(a) For services reimbursed under the medicare clinical lab fee schedule, the applicable medicare rate specified in this paragraph shall be further multiplied by a 2014 bureau adjustment factor of 1.0175;

(b) For services reimbursed under the medicare physician fee schedule, the applicable medicare rate specified in this paragraph shall be further multiplied by a 2014 bureau adjustment factor of 1.201.

The medicare integrated outpatient code editor and medicare medically unlikely edits in effect as implemented by the materials specified in paragraph (A)(7) of this rule shall be utilized to process bills for hospital outpatient services under this rule; however, the outpatient code edits identified in table 1 of appendix A to this rule shall not be applied.

The annual medicare outpatient prospective payment system outlier, hold harmless, and exempt cancer hospital reconciliation processes shall not be applied to payments for hospital outpatient services under this rule.

For purposes of this rule, hospitals shall be identified as critical access hospitals, rural sole community hospitals, essential access community hospitals and exempt cancer hospitals based on the hospitals' designation in the medicare outpatient provider specific file in effect as implemented by the materials specified in paragraph (A)(7) of this rule.

For purposes of this rule, the following hospitals shall be recognized as "children's hospitals": nationwide children's hospital (Columbus), Cincinnati children's hospital medical center, shriners hospital for children (Cincinnati), university hospitals rainbow babies and children's hospital (Cleveland), Toledo children's hospital, children's hospital medical center of Akron, and children's medical center of Dayton.

In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare outpatient prospective payment system as implemented by the materials specified in paragraph (A)(7) of this rule, other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 to 907 as amended as of the effective date of this rule, the "applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system" as specified in this paragraph shall be determined by the bureau without regard to such subsequent adjustments.

(2) Services reimbursed via fee schedule. These services shall not be wage index adjusted.

(a) Services reimbursed via fee schedule to which the bureau-specific payment adjustment factor shall be applied.

Except as otherwise provided in paragraphs (A)(2)(b)(ii) and (A)(2)(b)(iii) of this rule, hospital outpatient services reimbursed via fee schedule under the medicare outpatient prospective payment system shall be reimbursed under the applicable medicare fee schedule in effect as implemented by the materials specified in paragraph (A)(7) of this rule.

(b) Services reimbursed via fee schedule to which the bureau-specific payment adjustment factor shall not be applied.

(i) Hospital outpatient vocational rehabilitation services for which the bureau has established a fee, which shall be reimbursed in accordance with table 2 of appendix A to this rule.

(ii) Hospital outpatient services reimbursed via fee schedule under the medicare outpatient prospective payment system that the bureau has determined shall be reimbursed at a rate other than the applicable medicare fee schedule in effect as implemented by the materials specified in paragraph (A)(7) of this rule, which shall be reimbursed in accordance with table 3 of appendix A to this rule.

(iii) Hospital outpatient services not reimbursed under the medicare outpatient prospective payment system that the bureau has determined are necessary for treatment of injured workers, which shall be reimbursed in accordance with tables 4 and 5 of appendix A to this rule.

(3) Services reimbursed at reasonable cost. To calculate reasonable cost, the line item charge shall be multiplied by the hospital's outpatient cost to charge ratio from the medicare outpatient provider specific file in effect as implemented by the materials specified in paragraph (A)(7) of this rule. These services shall not be wage index adjusted.

(a) Services reimbursed at reasonable cost to which the bureau-specific payment adjustment factor shall be applied.

Critical access hospitals shall be reimbursed at one hundred one per cent of reasonable cost for all payable line items.

(b) Services reimbursed at reasonable cost to which the bureau-specific payment adjustment factor shall not be applied.

(i) Services designated as inpatient only under the medicare outpatient prospective payment system.

(ii) Hospital outpatient services reimbursed at reasonable cost as identified in tables 3 and 4 of appendix A to this rule.

(4) Add-on payments calculated using the applicable medicare outpatient prospective payment system methodology and formula in effect as implemented by the materials specified in paragraph (A)(7) of this rule. These add-on payments shall be calculated prior to application of the bureau-specific payment adjustment factor.

(a) Outlier add-on payment. An outlier add-on payment shall be provided on a line item basis for partial hospitalization services and for ambulatory payment classification reimbursed services for all hospitals other than critical access hospitals.

(b) Rural hospital add-on payment. A rural hospital add-on payment shall be provided on a line item basis for rural sole community hospitals, including essential access community hospitals; however, drugs, biological, devices reimbursed via pass-through and reasonable cost items shall be excluded. The rural add-on payment shall be calculated prior to the outlier add-on payment calculation.

(c) Hold harmless add-on payment. A hold harmless add-on payment shall be provided on a line item basis to exempt cancer centers and children's hospitals. The hold harmless add-on payment shall be calculated after the outlier add-on payment calculation.

(5) Providers not participating in the medicare program.

Reimbursement for outpatient services provided by hospitals and distinct-part units of hospitals that do not participate in the medicare program shall be calculated in accordance with the methodologies set forth in this rule, using a default hospital outpatient cost-to-charge ratio of forty-seven per cent where applicable.

(6) Reimbursement for outpatient services provided by "new hospitals" as defined in 42 C.F.R. 412.300(b) as published in the October 1, 2013 Code of Federal Regulations shall be calculated in the same manner as provided under paragraph (A)(5) of this rule.

(7) For purposes of this rule, the "applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system " and the medicare outpatient prospective payment system " 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 et seq. as amended, as implemented by the following materials, which are incorporated by reference:

(a) 42 C.F.R. Part 419 as published in the October 1, 2013 Code of Federal Regulations;

(b) Department of health and human services, centers for medicare and medicaid services' "42 CFR Parts 405, 410, 412, and elsewhere. Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program; Organ Procurement Organizations; Quality Improvement Organizations; Electronic Health Records (EHR) Incentive Program; Provider Reimbursement Determinations and Appeals; final rule", 78 Fed. Reg.__74825 -75200 (2013).

(B) QHP or self-insuring employer (non-QHP):

A QHP or self-insuring employer may reimburse hospital outpatient services at:

(1) The applicable rate under the methodology set forth in paragraph (A) of this rule; or

(a) For hospitals the department of health and human services, centers for medicare and medicaid services maintained hospital-specific cost-to-charge ratio information on as of January 1, 2014, based on the hospitals' submitted cost report (CMS-2552-96), the hospital's allowable billed charges multiplied by the hospital's reported cost-to-charge ratio (from the outpatient provider specific file in use by medicare on January 1, 2014) multiplied by a payment adjustment factor of 1.16 , not to exceed sixty per cent of the hospital's allowed billed charges.

(b) For hospitals the department of health and human services, centers for medicare and medicaid services did not maintain hospital-specific cost-to-charge ratio information on as of January 1, 2014, the hospital's allowable billed charges multiplied by the applicable FY14 urban or rural statewide average outpatient cost-to-charge ratio set forth in table 11 of the federal rule referenced in paragraph (A)(7)(b) of this rule (the Ohio average cost-to-charge ratio shall be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.16 , not to exceed sixty per cent of the hospital's allowed billed charges; or

(2) The rate negotiated between the hospital and the QHP or self-insuring employer in accordance with rule 4123-6-46 of the Administrative Code.

Click to view Appendix

Click to view Appendix

Effective: 05/05/2014
R.C. 119.032 review dates: 01/01/2015
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: 9/1/07, 1/1/11, 4/1/11, 4/1/12, 4/1/13

4123-6-37.3 Payment of ambulatory surgical center services.

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 May 5, 2014 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 May 5, 2014.

Click to view Appendix

Click to view Appendix

Effective: 05/05/2014
R.C. 119.032 review dates: 02/01/2015
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.121 , 4121.31 , 4123.05
Rule Amplifies: 4121.121 , 4121.44 , 4121.441 , 4123.66
Prior Effective Dates: 4/1/09, 4/1/10, 4/1/11, 4/1/12, 4/1/13

4123-6-38 Payment for home health nursing services.

(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 home health agency meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the Administrative Code.

(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 in accordance with rule 4123-6-10 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 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 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 least 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 commission accreditation, or community health accreditation program (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.

Effective: 07/01/2013
R.C. 119.032 review dates: 11/01/2014
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, 2/14/05, 2/1/10

4123-6-38.1 Payment for nursing and caregiver services provided by persons other than home health agency employees.

(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 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 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 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 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 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

least annually to ensure that nursing services are necessary as a direct result of the allowed injury or occupational disease.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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, 2/14/05

4123-6-38.2 Payment of nursing home and residential care/assisted living services.

(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 nursing homes and residential care/assisted living facilities meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the Administrative Code.

(C) Nursing home or residential care/assisted living facility 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 bureau, MCO, QHP, or self-insuring employer.

(2) Nursing home care shall be provided on a semiprivate bed basis, unless a situation exists when the use of a private room is medically 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 the 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 the rules of this chapter of the Administrative Code.

Effective: 07/01/2013
R.C. 119.032 review dates: 11/01/2014
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: 2/14/05, 2/1/10

4123-6-39 Payment for prosthetic device or other artificial appliances.

(A) 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, as determined by any one of the following:

(1) the amputee clinic at the Ohio state university medical center;

(2) the rehabilitation services commission;

(3) a multidisciplinary amputee clinic or prescribing physician approved by the administrator or the administrator's designee, 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.

(B) The bureau is responsible for processing requests for prosthetics and travel expenses associated with the prosthetic in all self-insured claims. When a prosthetic device is needed in a self-insured claim, the provider will send a request for the prosthetic and/or request for repair, as well as the subsequent bills, to the bureau.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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 , 4121.61 , 4123.57 ,
4123.66 Prior Effective Dates: 2/12/97, 2/14/05

4123-6-40 Payment of claimant travel expenses.

(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: 11/17/2009 and 11/01/2014
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

4123-6-41 No legal relationship between the industrial commission or bureau and a health care provider.

(A) Direct payment to a health care provider or other person by the industrial commission, self-insuring employer, 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, self-insuring employer, 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 , when payment is made to the claimant, the sole legal recourse of the health care provider is against the claimant.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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, 1/1/99, 2/14/05

4123-6-42 Interest on late payments for equipment, materials, goods, supplies or services in state insurance fund, public work relief employees' compensation fund, coal workers pneumoconiosis fund, and marine industry fund claims.

(A) Payment is made for equipment, materials, goods, supplies, or services incurred by the claimant in connection with claims against the state insurance fund, public work relief employees' compensation fund, coal workers pneumoconiosis fund, or marine industry fund in accordance with 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 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, industrial 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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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: 2/12/97

4123-6-43 Payment for transcutaneous electrical nerve stimulators and neuromuscular electrical stimulators.

(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.

(1) Prior authorization is required for TENS units and supplies. A claimant shall be provided only one TENS unit at a time. For each TENS unit request approved, the unit shall be rented for a thirty day trial period before purchase of the TENS unit. This trial period is to evaluate the medical necessity and effectiveness of the TENS treatment. TENS treatment will be discontinued at the end of the thirty day trial period month where the treatment has not proven to be medically necessary or effective. Reimbursement of rental costs will be considered only for the trial period that the TENS unit was actually used before treatment was discontinued. For each TENS unit provided, payment shall be limited to necessary disposable or rechargeable batteries, but not both.

(2) The bureau shall apply all rental payments previously made 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 or self-insuring employer. The bureau or self-insuring employer 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, the bureau or self-insuring employer will reimburse for repair or replacement of the unit upon submission of a request from the physician of record or treating provider that includes medical documentation substantiating the continued medical necessity and effectiveness of the unit.

(B) The claimant's MCO shall regularly determine the specific TENS supplies needed by the claimant throughout the period of time authorized for TENS use. The TENS provider must receive authorization from the claimant's MCO prior to the delivery of supplies and/or equipment. The TENS provider shall then deliver the supplies and bill the claimant's MCO after authorization is received. A self-insuring employer may, but is not required to, follow the same procedure as an MCO under this rule; provided, however, that in no event shall a self-insuring employer require a claimant to submit a written request for TENS supplies and/or equipment. The claimant's MCO shall retain documentation of the contact with the claimant substantiating the claimant's need for supplies in accordance with the time frames set forth in rule 4123-6- 14.1 of the Administrative Code. The TENS provider's bill must indicate the actual date of service, reflecting the date that services or supplies were provided. The bureau, MCO, QHP, or self-insuring employer may adjust bills upon audit if the audit discloses the provider's failure to comply with this rule.

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

(1) Authorizations of TENS supplies or equipment received from the injured worker's MCO, and all other documentation relating to the injured worker's need for TENS supplies or equipment received by the provider prior to the delivery of the supplies or equipment, including any requests received from the injured worker, if applicable;

(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 may result in denial or adjustment of bills related to these records.

(D) Payment will be approved for a neuromuscular electrical stimulator (NMES) 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.

Effective: 12/06/2010
R.C. 119.032 review dates: 11/01/2014
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: 2/12/97, 3/1/04, 2/1/10

4123-6-44 Bureau fees for provider services rendered by in-state and out-of-state providers.

Bureau fees for in-state or out-of-state providers 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 providers. 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 provider services will be made in accordance with rule 4123-6-10 of the Administrative Code.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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: 2/16/97

4123-6-45 Audit of providers' patient and billing related records.

(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: 11/17/2009 and 11/01/2014

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

4123-6-45.1 Records to be retained by provider.

(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: 11/17/2009 and 11/01/2014

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

4123-6-46 Standardized or negotiated payment rates for services or supplies.

(A) The bureau or self-insuring employer may negotiate payment rates with health care providers for services and supplies provided in the treatment of workers' compensation claims.

(B) The bureau or self-insuring employer may enter into volume-based contracts with medical providers for services including, but not limited to, the purchase or rental of durable medical equipment and supplies.

(C) The bureau or self-insuring employer may inform injured workers of the availability of services, supplies, or equipment from particular health care providers with whom a contract for services or supplies, a negotiated payment rate for services or supplies, or a contract for cost-effective payment levels or rates has been entered into, so long as access to quality and convenient medical services or supplies for injured workers is maintained .

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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 , 4123.651 , 4123.66
Prior Effective Dates: 2/12/97, 2/14/05

4123-6-50 [Rescinded]Self-insured employer participation in the QHP system; reporting requirements for non-participating employers.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-51 Employer participation in the QHP system - bureau certification of QHPs.

(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 (A)(1 to (A)(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.

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

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

(E) The bureau shall continue to certify health plans and shall periodically, at least annually, update its list of certified QHPs.

Replaces: 4123-6-52, 4123-6-73

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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

4123-6-52 [Rescinded]Employer participation in the QHP system - initial QHP certification enrollment period established; length of certification period.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-53 Employer participation in the QHP system - QHP quality assurance program required.

(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: 11/17/2009 and 11/01/2014

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

4123-6-54 Employer participation in the QHP system - QHP certification application.

(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: 11/17/2009 and 11/01/2014

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

4123-6-55 Employer participation in the QHP system - bureau's authority to decertify, to refuse to certify or recertify a QHP.

(A) The bureau is authorized to decertify, 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. Such notice shall set forth 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 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 decertify, refuse to recertify, or revoke or suspend the certification of a QHP, employees and employers shall not receive services from such QHP pursuant to the QHP system.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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

4123-6-56 [Rescinded]Employee access to the QHP system - choice and change of provider.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-57 [Rescinded]Provider access to the QHP system - generally.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-58 Provider access to the QHP system - provider participation in QHP system and other related health care program not linked.

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. If the QHP utilizes a leased provider network, the QHP shall not apply the discounted payment rates of the leased network to services rendered by the provider in the QHP unless the signed, written consent of the provider has been obtained.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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

4123-6-59 Provider access to the QHP system - QHP provider selection.

(A) 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.

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

(C) 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.

(D) 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.

(E) 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.

(F) 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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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

4123-6-60 [Rescinded]Provider access to the QHP system - medical record keeping.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-61 [Rescinded]Payment in the QHP system - employer responsibility - generally.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-62 [Rescinded]Payment in the QHP system - balance billing prohibited.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-63 [Rescinded]Payment in the QHP system - application of bureau fee schedule in the QHP system.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-64 [Rescinded]Payment in the QHP system - vendor payment to providers.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-65 Payment in the QHP system - employer payment to vendor that provides medical management and cost containment services and/or QHPs.

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: 11/17/2009 and 11/01/2014

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

4123-6-66 [Rescinded]Payment in the QHP system - authorization and payment for initial emergency medical treatment.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-67 [Rescinded]Payment in the QHP system - payment to providers in states that border Ohio.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-68 [Rescinded]Providers in states that do not border Ohio - QHP freedom to negotiate; restriction on provider charges to employee.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-69 QHP dispute resolution process.

(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: 11/17/2009 and 11/01/2014

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

4123-6-70 Evaluation of the QHP system by the bureau; reporting requirements by employers and QHPs.

(A) To enhance the quality of the QHP system, and pursuant to division (A)(9) of section 4121.442 of the Revised Code, the administrator shall require employers and QHPs that participate in the workers' compensation QHP system to report data to be used by the administrator to 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.

(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 (A)(1) to (A)(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.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
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

4123-6-71 [Rescinded]Initial report of an injury and reporting requirements by providers and employees in the QHP system.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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

4123-6-72 Confidentiality.

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

4123-6-73 [Rescinded]Bureau requirement to develop information describing rights under the QHP system.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009
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