LAW
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Ohio Laws and Rules
(A) All payments by the bureau for the allowed services of a bureau certified provider shall be through the MCO managing the care of the claim, whether for an MCO panel provider or a bureau certified provider who is not a panel provider of that MCO.
(B) The MCO shall accumulate the various medical records and bills for services rendered to employees for allowed conditions by its MCO panel providers and submit the bills electronically to the bureau for payment in a bureau approved format utilizing billing policies defined by the bureau. The MCO shall submit a bill to the bureau within seven business days of its receipt of the bill from the provider.
(C) The MCO shall accumulate the various bills for services rendered to employees for allowed conditions by bureau-certified providers who are not MCO panel providers for that MCO, but whose care is managed by the MCO, and submit the bills electronically to the bureau for payment in a bureau approved format utilizing billing policies defined by the bureau. The MCO shall submit a bill to the bureau within seven business days of its receipt of the bill from the provider.
(D) For an MCO panel provider, the bureau shall reimburse the MCO the least of the bureau fee schedule, the MCO panel provider fee schedule, or the billed charges by the provider for the services rendered.
(E) For a bureau certified provider who is not an MCO panel provider for that MCO but whose care is managed by that MCO, the bureau will reimburse the MCO the lesser of the bureau fee schedule or the billed charges by the provider for the services rendered.
(F) The bureau does not pay for failed or missed appointments or procedures. Bills must only contain descriptions of services that have been actually rendered for the actual conditions treated. A provider shall not transmit to the MCO or bureau any bill containing false or misleading information that would cause a provider to receive payment for services that the provider is not entitled to receive.
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