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