LAW
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Ohio Laws and Rules
(A) The bureau shall pay a non-bureau certified provider only for initial or emergency treatment of an employee for a workers’ compensation injury under the HPP. If the non-bureau certified provider does not obtain further authorization of treatment from the employer’s MCO as provided in paragraph (B) of this rule, the employee may continue to obtain treatment from the non-bureau certified provider, but the payment for the treatment shall be the employee’s sole responsibility. The non-bureau certified provider shall inform the employee upon the initial or emergency treatment that the provider is not a participant in the HPP and that the employee will not be reimbursed by the bureau, MCO, or employer for the cost of further treatment after the initial or emergency treatment.
(B) The bureau shall pay a non-bureau certified provider for subsequent treatment after the initial or emergency treatment in the following circumstances:
(1) Where the services provided by the non-bureau certified provider are unavailable through a like provider in the MCO provider panel, the MCO may allow special authorization for the provider to continue treatment where medically necessary for the employee’s care. The MCO shall notify the bureau accordingly.
(2) Where the services provided by the non-bureau certified provider are available through a like provider in the MCO provider panel, the MCO may authorize the treatment by a non-bureau certified provider only if the provider becomes a bureau-certified provider. In such case, the MCO shall assist the provider in completing the bureau provider application and bureau provider agreement prior to authorization of or payment for additional treatment. Upon application by the non-bureau certified provider and certification by the bureau, the provider shall be paid for service rendered pursuant to rule 4123-6-11 of the Administrative Code.
(3) All payments by the bureau for the allowed services of a non-bureau certified provider shall be through the employer’s MCO.
(C) The MCO shall accumulate the various bills and medical records for services rendered to employees for allowed conditions from non-bureau certified providers who are not MCO panel providers for that MCO, but whose care is managed by the MCO, and shall submit the bills electronically to the bureau for payment in a bureau approved format utilizing billing policies defined by the bureau. The MCO shall submit a bill to the bureau within seven business days of its receipt of the bill from the provider.
(D) For a non-bureau certified provider whose care is managed by the MCO for an initial or emergency visit, the bureau shall pay the MCO the lesser of the bureau fee schedule or the billed charges by the provider for the services rendered.
(E) The bureau does not pay for failed or missed appointments or procedures. Bills must only contain descriptions of services that have been actually rendered for the actual conditions treated. A provider shall not transmit to the MCO or bureau any bill containing false or misleading information that would cause a provider to receive payment for services that the provider is not entitled to receive.
R.C. 119.032 review dates: 10/27/2004 and 03/01/2009
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05
Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 2/16/96, 1/15/99