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