4123-6-69 QHP dispute resolution process.

(A) This rule shall provide time frames and procedures for review of requests for the delivery of medical services and for the resolution of disputes that may arise between an employee and an employer, an employee and a provider, or an employer and a provider. This rule applies to, but is not limited to, reviews of records, medical disputes arising over issues such as, but not limited to, quality assurance, utilization review, a determination that a service provided to an employee is not covered, is covered or is medically unnecessary; or disputes involving individual health care providers.

(B) Initial review and decision upon requests for the delivery of medical services that include, but are not limited to, medical treatment, major diagnostic testing, hospitalization, surgery and physical therapy, shall be completed by the QHP. The employee, employer and provider shall be notified verbally of the outcome of the initial review within forty-eight hours of the request. Within seven working days of the verbal notification, the verbal notification shall be committed to writing and mailed to the employee, employer and provider.

(C) A QHP shall have a dispute resolution process beyond initial review that includes a minimum of two levels of peer review of a medical diagnosis or treatment issue if an individual health care provider is involved in the dispute, or a minimum of two levels of dispute resolution if an individual health care provider is not involved in the dispute.

(D) A QHP dispute resolution process shall be completed and the QHP shall notify the parties to the dispute and their initial written notice of a dispute, unless an extension of time is otherwise agreed to by the parties. Any party appealing a decision to a higher level within a QHP's dispute resolution process shall provide notice of such appeal to all the parties to the dispute within seven working days of notice of decision.

(E) The dispute resolution process shall begin upon written notice of the dispute by the party maintaining the dispute to the parties of the dispute. If an individual health care provider is involved in the dispute, there shall be available at least two levels of peer review if appealed, with at least one level conducted by an individual or individuals licensed pursuant to the same section of the revised code as the health care provider who is a party to the dispute. The other level of peer review shall include, at the discretion of the QHP medical director, one or more of the following: a review conducted by a multi-disciplinary medical panel or board; an independent or agreed upon medical examination; or the use of other resources beneficial to the resolution of the dispute.

(F) A dispute unresolved by a QHP dispute resolution process may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code.

(G) Notwithstanding the requirements set forth in paragraph (F) of this rule, a dispute unresolved by a QHP providing medical management and cost containment services for a state fund employer shall be referred by the QHP to the bureau within seven working days of the final decision rendered within the QHP dispute resolution process. Within fourteen days of receipt of an unresolved medical dispute, the bureau shall conduct an independent review of the unresolved medical dispute received from the QHP and enter a final bureau order pursuant to section 4123.511 of the Revised Code. This order shall be mailed to all parties and may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code.

R.C. 119.032 review dates: 11/17/2009 and 11/01/2014

Promulgated Under: 119.03

Statutory Authority: 4121.12 , 4121.30 , 4121.31 , 4123.05

Rule Amplifies: 4121.121 , 4121.44 , 4121.441 , 4121.442 , 4123.66

Prior Effective Dates: 9/5/96