(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.
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