4123-6-16.3 Reimbursement of retroactive medical treatment reimbursement requests.

(A) Except as otherwise provided in paragraph (D) of this rule, medical treatment reimbursement requests submitted retroactively to the MCO responsible for medical management of claim by an injured worker's physician of record or eligible treating provider, without just cause, for non-emergency treatment delivered, rendered, or directly supervised by the physician of record or eligible treating provider shall, if approved, be reimbursed at seventy-five per cent of the applicable fee schedule amount, and the physician of record or treating provider may not balance bill the injured worker for the difference.

(B) For purposes of this rule, "just cause" includes, but is not limited to:

(1) The treatment requested was emergency treatment;

(2) The provider was not aware that services were for a workers' compensation claim;

(3) The provider was non-bureau certified and had no established relationship with the injured worker;

(4) The provider was initially bureau certified within six months prior to the treatment request;

(5) The treatment requested was for a pending claim allowance or additional allowance with the bureau or industrial commission;

(6) The treatment provided was within the bureau's presumptive authorization guidelines, or does not require prior authorization per the bureau's provider billing and reimbursement manual;

(7) The treatment request was submitted retroactively due to bureau or MCO error;

(8) Other documented justification as deemed sufficient by the bureau.

(C) Determinations that an approved medical treatment reimbursement request shall be reimbursed at seventy-five per cent of the applicable fee schedule amount pursuant to paragraph (A) of this rule shall be subject to the grievance hearing procedure for disputed bill payments provided by rule 4123-6-04.4 of the Administrative Code.

(D) Retroactive medical treatment reimbursement requests submitted within seven calendar days of the initiation of treatment or prior to the date of the physician of record or eligible treating provider's next encounter with the injured worker, whichever is earlier, shall not be subject to payment reduction under paragraph (A) of this rule.

Effective: 01/01/2013
R.C. 119.032 review dates: 11/01/2014
Promulgated Under: 119.03
Statutory Authority: 4123.66 , 4121.441
Rule Amplifies: 4121.12 , 4121.121