Chapter 4123-7 Payments to Health Care Providers

Jurisdictional requirements applicable to payment for medical services rendered by a health care provider are as follows:

(A) Bills must be filed within the time as provided in rule 4123-3-23 of the Administrative Code or be forever barred.

(B) In claims where the date of injury is on or after December 11, 1967, and prior to October 11, 2006, there is no jurisdiction to consider payment for medical services, if six years or more have elapsed since the date of the last payment of a medical bill and no compensation has been paid, except as provided in the following cases:

(1) A bill filed within the six-year period for services rendered within the period can be paid after the six-year period in those cases in which, except for the time passage, it would have been paid.

(2) Where an application requesting the payment of medical bills and/or compensation is filed within the six-year period, there is justification to act on the application after the period.

(a) Bills for services rendered within the six-year period can be ordered paid and can be paid after the period. However, such bills must be filed no later than two years after the date that the services were rendered.

(b) Compensation can be ordered paid provided the proof supports an award. If compensation is paid, the claim is opened for an additional ten years for the payment of compensation and bills. Where there has been a payment of compensation under section 4123.56, 4123.57 or 4123.58 of the Revised Code, the claim is active for ten years from the date of the last payment of compensation or ten years from the last payment of a medical bill, whichever is later.

(3) Where wages in lieu of compensation for total disability were paid by the employer within six years of injury, with knowledge of a claimed compensable injury, as provided in section 4123.52 of the Revised Code, amended effective January 1, 1979.

(4) Where a request for authorization of treatment beyond the six-year period is made in an application filed within the six-year period, the authorization for treatment after that period cannot be granted, unless the claim has been opened by the payment of compensation.

(5) There is no jurisdiction to consider the merits of any application filed after the six-year period, even though supporting proof for the application was on file within the period.

(6) A bill filed within the six-year period but requiring an application to reactivate claim cannot be paid when such application is not filed within the period. The same applies to bills filed after the expiration of the six-year period for treatment rendered within that period.

(C) In claims where the date of injury is prior to December 11, 1967, there is no jurisdiction to consider payment for medical services if ten years or more have elapsed since the payment of compensation or benefits, or ten years have elapsed since the injury in cases in which no compensation has been awarded.

(D) In claims where the date of injury is on or after October 11, 2006, there is no jurisdiction to consider payment for medical services if five years or more have elapsed since the payment of compensation or benefits. The provisions of paragraph (B) of this rule shall apply to the payment of medical bills in claims where the date of injury is on or after October 11, 2006, except that where those provisions reference six year and ten year time limits, the time limits shall be five years.

Effective: 04/01/2007

R.C. 119.032 review dates: 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4123.52, 4123.65

Prior Effective Dates: 1/1/78, 12/21/79

Medical or other services to be approved for payment must be rendered as a direct result of an injury sustained or occupational disease contracted by a claimant in the course of and arising out of employment for which the claim was allowed by an order of the bureau of workers’ compensation or of the industrial commission, or for which the claim was recognized by a self-insuring employer. “Claimant,” as used in this chapter, is understood to mean:

(A) An employee or a worker who filed an industrial claim, alleging an injury or an occupational disease sustained in the course of and arising out of employment.

(B) An employee or a worker whose industrial claim was allowed for an injury sustained or an occupational disease contracted in the course and arising out of employment.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: RC 4121.121, 4121.30, 4121.44

Prior Effective Dates: 1/1/78

(A) Medical supplies and services will be considered for payment by a self-insuring employer when they are medically necessary for the diagnosis and treatment of conditions allowed in the claim, are causally related to the conditions allowed in the claim, and are rendered by a health care provider. Payment for services rendered to a claimant shall be paid to a health care provider only when the provider has either delivered, rendered or directly supervised the examination, treatment, evaluation or any other medically necessary and related services provided to the claimant. By submitting any fee bill to a self-insuring employer, in either hardcopy or electronic format, the health care provider affirms that medical supplies and services have been provided to the claimant as required by this rule.

(B) Services rendered by health care providers are subject to review for coding requirements outlined in paragraph (C) of this rule. Payments to health care providers may be adjusted based upon these guidelines.

(C) Coding systems.

(1) Billing codes.

(a) Practitioners are required to use the most current edition of the centers for medicare and medicaid services’ healthcare common procedure coding system (HCPCS) to indicate the procedure or service rendered to injured workers.

(b) Inpatient and outpatient hospital services must be billed using the national uniform billing committee’s revenue center codes.

(c) Outpatient medication services must be billed pursuant to the requirements described in the bureau’s provider billing and reimbursement manual.

(d) To insure accurate data collection, the bureau shall adopt a standardized coding structure which shall be adopted by any MCO, QHP or self-insuring employer.

(2) ICD-9 diagnosis codes.

Providers must use the most current edition of the “International Classification of Diseases, clinical modification” to indicate diagnoses.

(D) Prior to services being delivered, the provider must make reasonable effort to notify the claimant, bureau, MCO, QHP or self-insuring employer when the provider has knowledge that the services may not be related to the claimed or allowed condition(s) related to the industrial injury or illness, or that a service is non-covered. The provider may not knowingly bill or seek payment from the bureau, MCO, QHP or self-insuring employer for services that are not related to the claimed or allowed condition(s) related to the industrial injury or illness. The provider may not knowingly mislead or direct providers of ancillary services to bill or seek payment for services that are not related to the claimed or allowed condition.

The provider may not bill or seek payment from the claimant for services determined as medically unnecessary through the use of bona fide peer review based on accepted treatment guidelines.

Replaces: 4123-7-03

Effective: 04/01/2007

R.C. 119.032 review dates: 03/01/2012

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.30, 4121.44, 4123.66

Prior Effective Dates: 1/1/78

In cases where the claimant pays for medical services or supplies directly to a health care provider who does not accept assignment as defined in rule 4123-7-30 of the Administrative Code, or if any other person or payor, including a volunteer, makes the payment on behalf of the claimant, and the claim or condition is subsequently allowed, the bureau shall reimburse the payor upon submission of evidence of the service or supply and evidence of the payment for that service or supply. The payor will receive as payment the usual, customary, and reasonable amount that would have been paid by the bureau or self-insuring employer to the health care provider as provided by the rules of this chapter. Where the bureau, in good faith, has already made the payment to the health care provider, the payor shall be informed by the bureau to seek reimbursement from the payee.

Upon request, the bureau shall inform a claimant or payor whether a health care provider has agreed to submit fee bills to the bureau for direct payment and assignment as provided in rule 4123-7-30 of the Administrative Code.

Replaces: 4121-17-04, 4123-07-04

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: RC 4121.121, 4121.44, 4123.66

Prior Effective Dates: 1/1/78, 11/13/92

Medical fees shall not be approved for treatment by more than one physician for the same condition over the same period of time, except where a consultant, anesthetist or assistant is required, or where the necessity for treatment by a specialist is clearly shown and approved by the bureau, by the industrial commission or its medical section, or in self-insuring employers’ claims by the self-insuring employer, in advance of such treatment, except in cases of emergency. (For definition of “emergency” see rule 4123-7-16 of the Administrative Code.)

(A) The assistance of another physician is not ordinarily considered necessary in the application of a cast or for operation on fingers, thumbs, or toes. If there are any unusual conditions which require such assistance, a fee will be paid to the assistant (or ordered to be paid by the self-insuring employer in self-insuring employers’ claims) only on full explanation and upon approval of the industrial commission’s medical section.

(B) Reports of consultations and laboratory procedures must be submitted before fees for the same are approved.

(C) In cases where the consultant continues treatment, a fee for first treatment will be paid to the consultant rather than a consultant’s fee unless it is affirmatively shown that the referral by the attending physician for treatment by the consultant followed the receipt and evaluation of the consultant’s report.

(D) If a licensed practitioner receives a case in which the first treatment has been rendered by another physician, the physician is entitled to the usual, customary and reasonable fee (as determined under rule 4123-7-03 of the Administrative Code) for the first service.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: RC 4121.121, 4121.30, 4121.44

Prior Effective Dates: 1/1/78

In claims involving treatment of more than one condition or to more than one part of the body, care should be given by the attending physician to report all conditions and all parts of the body treated. Such information may be of major significance in later determination of the extent of disability as a result of the industrial injury or occupational disease. It shall be the duty of the claims examiners and/or claims reviewers to see to it that in claims under their jurisdiction proper steps are taken to obtain the necessary information on the question of extent of injuries or occupational diseases, either through correspondence or investigation, at the earliest possible time.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: RC 4121.121, 4121.30, 4121.44

Prior Effective Dates: 1/1/78

(A) Fee bills for treatment subsequent to the initial care should be filed on a regular, periodic basis, such as once every four to eight weeks. Fee bills should not include services which were a part of a former fee bill. Duplicate bills should not be filed as a substitute for an inquiry, except upon notification from the bureau that there is no record of the original.

(B) In cases where treatment was not authorized in advance, the hearing officer, at the hearing, may, in the hearing officer’s discretion, determine that fee bills for such treatment are to be paid retroactively.

(C) 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 bureau or self-insuring employer 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: RC 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: RC 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/1/78, 1/15/99

(A) As provided in rules 4123-6-02.8 and 4123-6-71 of the Administrative Code, a provider who undertakes treatment in an industrial case assumes the obligation to notify the bureau, MCO, QHP, or self-insuring employer of the injury within twenty-four hours of the initial treatment or initial visit.

(B) Interim medical reports and medical documentation.

Compensation for temporary total disability is payable upon submission of current supporting medical documentation. Interim reports must be filed, on forms provided by the bureau, at least every thirty days while the claimant remains on temporary total disability. Interim reports must include at least:

(1) The date of the report;

(2) The date of the last examination;

(3) The current “International Classification of Disease” diagnosis code(s), including a primary diagnosis code, with a narrative description identifying the condition and specific areas of the body being treated;

(4) Any reason(s) why recovery has been delayed;

(5) The date temporary total disability began;

(6) The current physical capabilities of the claimant;

(7) An estimated or actual return to work date;

(8) An indication of need for vocational rehabilitation;

(9) Objective findings; and

(10) Clinical findings supporting the above information.

(C) Treatment plan.

(1) Upon allowance of a claim by the bureau, industrial commission, or self-insuring employer, the physician of record and other providers treating the claimant shall provide and continue to update a treatment plan to the MCO, QHP, or self-insuring employer according to the format or information requirements designated by the bureau. A treatment plan should include at least the following:

(a) Details of the frequency, duration, and expected outcomes of medical interventions, treatments, and procedures;

(b) The projected or anticipated return to work date; and

(c) Factors that are unrelated to the work related condition, but are impacting recovery.

(2) Modifications should be made to the initial treatment plan as treatment is extended, changed, completed, added, deleted or canceled. The modification should describe the current prognosis for the injured worker, progress to date, and expected treatment outcomes.

(3) Treatment plans should be updated when significant changes occur in the claim which impact claims management. Changes include:

(a) Additional allowance;

(b) Re-activation;

(c) Authorization of expenditures from the surplus fund;

(d) Return to modified or alternative work;

(e) Maximum medical improvement;

(f) Rehabilitation;

(g) A new injury while receiving treatment in the claim.

(4) Supplemental reports from the attending physician and other providers may be requested by the bureau, industrial commission, employer, MCO, QHP, or by the claimant or representative. These reports shall be used to determine the appropriateness of a benefit or bill payment.

(D) In accepting a workers’ compensation case, a medical provider assumes the obligation to provide to the bureau, claimant, employer, or their representatives, MCO, QHP, or self-insuring employer, upon written request or facsimile thereof and within five business days, all medical, psychological, or psychiatric documentation relating causally or historically to physical or mental injuries relevant to the claim required by the bureau, MCO, QHP, or self-insuring employer, and necessary for the claimant to obtain medical services, benefits or compensation. Providers may charge fees for the provision of such records only to the extent permitted under rule 4123-6-20.1 of the Administrative Code.

HISTORY: Replaces rule 4121-17-08, 4123-7-08; Eff 1-1-78; 9-15-81; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4123.57, 4123.66

R.C. 119.032 review dates: 03/01/2009

A licensed practitioner, who is treating an industrial injury or occupational disease may, at any time, make a request in writing, fascimile, e-mail, or by telephone for information from the self-insuring employer as to conditions for which the claim was allowed and/or as to conditions which were being contested. Such requests shall be answered by the self-insuring employer within five working days from the date of the receipt of the request

HISTORY: Eff 1-1-78; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4123.05

Rule Amplifies: RC 4121.121, 4121.30, 4121.44

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

(A) This rule pertains to employees of self-insuring employers who do not have a QHP.

Choice of provider for employees of self-insuring employers with a QHP is governed by 4123-6-56 of the Administrative Code.

(B) In claims sustained on or after November 2, 1959, employees of self-insuring employers have free choice to select licensed physicians for treatment, as well as other medical services, including, but not limited to, hospital and nursing services.

In claims sustained prior to November 2, 1959, medical services furnished by the self-insuring employer must be utilized.

(C) Emergency treatment shall not constitute an exercise of free choice of physician.

(D) Once an employee of a self-insuring employer goes to a physician for treatment other than on an emergency basis, the employee is deemed to have made a choice of physician and the employee shall notify the employer of a change of physician.

(1) Change of physician requests shall be made to the self-insuring employer in writing, and shall include the name and address of the new physician and the proposed treatment.

(2) Self-insuring employers shall approve written requests for a change of physician within seven days of receipt.

HISTORY: Eff 1-1-78; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.30, 4121.44, 4123.651, 4123.66

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

Rescinded eff 2-14-05

(A) “Physical therapy” means the evaluation and treatment of a person by physical measures and the use of therapeutic exercises and rehabilitative procedures, with or without assistive devices, for the purpose of preventing, correcting, or alleviating any disability. Physical therapy includes the establishment and modification of physical therapy programs, treatment planning, instruction and consultative services. Physical measures include massage, heat, cold, air, light, water, electricity, sound, and the performance of tests of neuromuscular function as an aid to such treatment. Physical therapy does not include the diagnosis of a patient’s disability, the use of Roentgen rays or radium for diagnostic or therapeutic purposes, or the use of electricity for cauterization or other surgical purposes. Physical therapy includes physiotherapy.

(B) Physical therapy (or physiotherapy) treatment may be rendered only upon the prescription of, or the referral by, the doctor of record who is licensed to practice medicine and surgery, dentistry or podiatry, or by a consultant in an industrial claim, who has the same qualifications.

(C) Fees for physical therapy (or physiotherapy) used for treatment of the allowed conditions shall be approved only to such licensed practitioners who hold a valid license to practice physical therapy (or physiotherapy) as physical therapists (or physiotherapists) or as physical therapist assistants.

(D) Fees, as described in paragraph (C) of this rule shall not be approved for more than ten treatments, unless authorized in advance by the bureau, by the industrial commission, or by a self-insuring employer in self-insuring employers’ claims. In justifiable cases where the treatments have exceeded ten without prior approval, the case shall be referred to the medical section for a review and possible approval.

(E) Authorization for additional physiotherapy treatment must be requested, in advance, by a doctor of record or a consultant. Such request shall contain, but will not be limited to, the following information:

(1) An outline as to what has been accomplished by the physiotherapy treatment rendered.

(2) The reason for the necessity of further physiotherapy treatment, considered in light of the allowed industrial condition.

(3) The number of additional treatments which are anticipated.

(F) Additional fees for physiotherapy in cases covered by a flat fee are not approved without specific authorization.

HISTORY: Eff 1-1-78

Rule promulgated under: RC Chapter 119.

Rule amplifies: RC 4121.121, 4121.30, 4121.31 in conjunction with 4123.66 and 4755.40 to 4755.50

“Practice of chiropractic” or “practice as a chiropractor” means utilization of the relationship between the muscular skeletal structures of the body, the spinal column and the nervous system, in the restoration and maintenance of health, in connection with which patient care is conducted with due regard for first aid, hygienic, nutritional, and rehabilitative procedures and the specific vertebral adjustment and manipulation of the articulations and adjacent tissues of the body. The chiropractor is authorized to examine, diagnose, and assume responsibility for the care of patients. The practice of chiropractic does not permit the chiropractor to treat infectious or contagious diseases, to perform surgery or acupuncture, or to prescribe or administer drugs for treatment. Roentgen rays shall be used only for diagnostic purposes. An individual holding a valid, current certificate of registration to practice chiropractic is entitled to use the title “doctor” or “doctor of chiropractic” and is a “physician” for the purposes of Chapter 4123. of the Revised Code (section 4734.09 of the Revised Code).

(A) Treatment procedures include and permit:

(1) The use of all varieties of specific vertebral adjustments and manipulations of the articulations and adjacent tissues of the body.

(2) Furnishing and fitting of proper orthopaedic appliances and supports.

(B) In cases of prolonged chiropractic treatment or if the charges made for such treatment appear to be excessive, claims shall be referred to the industrial commission’s medical section for a review and opinion before a determination is made on the issue or issues raised.

(C) The appropriateness of charges made by chiropractors for treatment rendered in industrial claims shall be determined by the industrial commission’s medical section, or self-insuring employer in self-insuring employers’ claims, in the manner as provided in rule 4123-7-03 of the Administrative Code.

HISTORY: Eff 1-1-78

Rule promulgated under: RC Chapter 119.

Rule amplifies: RC 4121.121, 4121.30, 4121.31 in conjunction with 4123.66 and 4734.09

(A) Acupuncture is a recognized method of treatment in Ohio. Such treatment must be pre-authorized by a self-insuring employer in self-insuring employers’ claims. It must be administered by a licensed doctor of medicine, doctor of osteopathic medicine and surgery, doctor of podiatric medicine who has completed a course of study in acupuncture under the administration of an approved college of medicine, college of osteopathic medicine and surgery, or a college of podiatric medicine, doctor of chiropractic who holds a certificate to practice acupuncture from the Ohio state chiropractic board, or a registered non-physician acupuncturist.

(B) Services provided by a non-physician acupuncturist must be prescribed by persons licensed under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery or podiatry or Chapter 4734. of the Revised Code to practice chiropractic. A registered non-physician acupuncturist shall perform acupuncture under the general supervision of the injured worker’s prescribing physician or chiropractic physician. General supervision does not require that the acupuncturist and the prescribing physician or chiropractic physician practice in the same office.

Effective: 09/22/2008

R.C. 119.032 review dates: 07/03/2008 and 09/01/2013

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/1/78, 10/10/03

A self-insuring employer shall pay for x-ray examinations (including CT, MRI, and discogram) when medical evidence shows that the examination is medically necessary either for the treatment of an allowed injury or occupational disease, or for diagnostic purposes to pursue more specific diagnoses in an allowed claim. Providers shall follow all bureau prior authorization policies in effect at the time when requesting authorization and payment for such studies.

HISTORY: Eff 1-1-78; Replaces: 4123-7-15 Eff 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.30, 4121.31, 4123.66

R.C. 119.032 review dates: 03/01/2009

Rescinded eff 2-14-05

Providers billing for services rendered in self-insured claims shall follow the procedures set forth in the bureau’s provider billing and reimbursement manual.

HISTORY: Replaces rule 4121-17-17, 4123-7-17; Eff 1-1-78; 5-18-92; Replaces: 4123-17-17 Eff 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4123.05, 4123.66

Rule Amplifies: RC 4121.44, 4123.651, 4123.66

R.C. 119.032 review dates: 03/01/2009

(A) A self-insuring employer shall pay for dental care in the following cases:

(1) Where an industrial injury or occupational disease either has caused damage or has adversely affected the claimant’s natural teeth.

(2) For industrial injuries or occupational diseases sustained prior to January 1, 1979, artificial teeth or other denture must be in place in the worker’s mouth at the time of damage or loss.

(3) For industrial injuries or occupational diseases sustained on or after January 1, 1979, the requirements of division (A)(2) of this rule do not apply.

(B) Responsibility for injuries or occupational diseases affecting the claimant’s natural teeth is limited to the repair or replacement of those teeth actually injured at the time of the accident, or directly affected by the injury or disease. This responsibility does not include the replacement of teeth which are extracted or repaired for purposes unrelated to the industrial injury or occupational disease.

(C) Replacement of artificial teeth when the injury or occupational disease has resulted in a deformity of the jaw to the extent that artificial teeth cannot be used, is subject to the limitations of paragraphs (A)(2) and (A)(3) of this rule.

(D) Responsibility for the repair of both natural and artificial teeth is limited to the damage done at the time of the accident, or to the damage directly caused by an allowed injury or occupational disease.

HISTORY: Eff (Amended) 1-1-78; 12-21-79; Replaces: 4123-7-18 Eff 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4123.05, 4123.66

Rule Amplifies: RC 4123.66

R.C. 119.032 review dates: 03/01/2009

(A) A self-insuring employer shall approve payment to replace eyeglasses or contact lenses when an industrial injury or an industrial accident which not only causes an injury, but also results in the damage or loss of the claimant’s eyeglasses or contact lenses.

(1) In the event of injury prior to January 1, 1979, the eyeglasses must be in place on the claimant’s face and the contact lenses shall be in place in the claimant’s eye(s) at the time of injury.

(2) In the event of injury on or after January 1, 1979, the requirements of paragraph (A)(1) of this rule do not apply.

(B) Contact lenses or glasses are reimbursed when loss of vision is the direct result of an allowed injury or occupational disease.

(C) Refractions will be approved in situations described in paragraph (B) of this rule.

(D) Replacement of glasses with contact lenses is approved when medical evidence indicates a direct need due to an allowed injury or occupational disease.

(E) Glasses or contact lenses will be approved for treatment purposes, when necessary, as a direct result of the allowed injury or occupational disease. Any subsequent adjustment, maintenance supplies, or change in a claimant’s glasses or contact lenses, if required for treatment of the allowed injury or occupational disease, will also be approved when supported by evidence of a direct causal relationship.

When eyeglasses and/or contact lenses were damaged or broken in an industrial accident in which an injury was sustained by the claimant and have been replaced, no further replacement will be approved due to subsequent breakage or for any other reason except as provided in this paragraph of this rule.

HISTORY: Eff 1-1-78; 12-21-79; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4123.05, 4123.66

Rule Amplifies: RC 4123.66

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

(A) Where an industrial injury or an industrial accident which causes an injury also damages the claimant’s hearing aid(s), a self-insuring employer shall approve payment to replace such hearing aid(s) as follows:

(1) For injuries or accidents sustained prior to January 1, 1979, the hearing aid(s) must be in place in the claimant’s ear(s) at the time of the injury or accident.

(2) For injuries or accidents sustained on or after January 1, 1979, the requirements of paragraph (A)(1) of this rule do not apply.

(3) Once hearing aid(s) have been replaced, no further replacement will be approved.

(B) When a partial loss of hearing is the direct result of an allowed industrial injury or occupational disease, payment for hearing aid(s) is justified in order to improve the claimant’s ability to hear.

HISTORY: Eff 1-1-78; 12-21-79; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4123.05, 4123.66

Rule Amplifies: RC 4123.66

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

A self-insuring employer shall approve payment only for those orthotic devices prescribed in writing by the physician of record for treatment of an allowed injury or occupational disease. The use of the orthotic device must be directly related to the allowed industrial injury or occupational disease.

(A) Orthotic devices shall be custom fitted or custom fabricated and delivered to the satisfaction of the prescribing physician and the administrative agencies. Repairs, modifications, and adjustments to secure satisfactory application of the orthotic appliance shall be made within sixty days of fitting and application without additional charge by the supplier of the orthotic device.

(B) No charge shall be made for measurement, transportation, or other expenses incurred by the supplier-orthotist, except when the supplier-orthotist is required to travel beyond the limits of the metropolitan community in which he maintains his place of business by reason of the physical incapacity of the claimant or by reason of direct prescription by the attending physician. The supplier-orthotist shall be paid for traveling expenses on a round-trip basis. Additional charges must be separately specified on the supplier-orthotist’s billing, including the points of travel and the name of the physician prescribing the travel. Payment will be made for a maximum of three round-trip calls.

HISTORY: Eff 1-1-78; Replaces: 4123-7-21 Eff 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.30, 4123.66

R.C. 119.032 review dates: 03/01/2009

Rescinded eff 2-14-05

(A) Medication must be for treatment of an occupational injury or disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer.

(B) Medication must be prescribed by the physician of record in the industrial claim or by the treating physician, or by such other treating provider as may be authorized by law to prescribe such medication.

(C) Drugs covered are limited to those that are approved for use in the United States by the Food and Drug Administration and that are dispensed by a registered pharmacist from an enrolled pharmacy provider.

(D) A self-insuring employer may approve and reimburse for various drugs as a part of a comprehensive treatment plan submitted by the physician of record or a treating physician when reasonably related to and medically necessary for treatment of the allowed conditions in the claim, provided that such approval and reimbursement shall not constitute the recognition of any additional conditions in the claim even if such drugs are used to treat conditions that have not been allowed in the claim.

(E) Payment for medications to pharmacy providers shall include a product cost component and a dispensing fee component.

(1) The product cost component shall be the lesser of the following: maximum allowable cost established under paragraph (O) of this rule, if applicable, or the average wholesale price of the commonly stocked package size plus or minus a percentage. The percentage amount added or subtracted from the average wholesale price shall be determined by the bureau, and shall be subject to annual review.

(2) The dispensing fee component shall be a flat rate fee determined by the bureau and subject to annual review, unless the self-insuring employer has negotiated a payment rate with the pharmacy provider pursuant to rule 4123-7-39 of the Administrative Code.

(a) Only pharmacy providers are eligible to receive a dispensing fee.

(b) The dispensing fee may include an additional incentive component for pharmacy providers that accept assignment.

(c) Except as provided below, dispensing fees shall be limited to one dispensing fee per patient per generic code number (GCN), or other proprietary code that serves to group together pharmaceutically equivalent products (defined as products that contain the same active ingredients in the same strengths, dosage forms, and routes of administration), per rolling twenty-five days. Exceptions to the single dispensing fee are:

(i) Cases where the physician has prescribed a second round of medication within the twenty-five day period;

(ii) Cases where the physician has changed the dosage;

(iii) Cases where the medication did not last for the intended days supply;

(iv) Cases where the medication has been lost, stolen or destroyed;

(v) Controlled substances (which are limited to two dispensing fees per twenty-five days).

(vi) Cases where the self-insuring employer determines the limitations of this paragraph to be unnecessary under the specific circumstances.

(F) The pharmacy provider is required to bill medication at their usual and customary charge. The amount paid to the provider will be the lesser of the provider’s usual and customary charge or the reimbursement allowed as determined in paragraph (E) of this rule, unless the self-insuring employer has negotiated a payment rate with the provider pursuant to rule 4123-7-39 of the Administrative Code. Pharmacy providers are required to submit for billing the national drug code of the stock bottle from which the dispensed medication is obtained. Drugs may be dispensed in unit dose packaging, but the NDC number of the closest comparable bulk package listed in the bureau or vendor payment system must be used for billing purposes.

(G) The pharmacy provider is required to follow all applicable line by line billing instructions as published in the bureau’s health care provider billing and reimbursement manual. At least thirty days written notice will be given prior to required changes in billing procedures.

(H) Claimant reimbursement for medications shall at least be equal to the bureau’s established rate for the medication, unless the self-insuring employer has negotiated a payment rate with the pharmacy provider utilized by the claimant pursuant to rule 4123-7-39 of the Administrative Code, in which case the claimant reimbursement shall be at least the rate negotiated with the provider. Requests for reimbursement must be paid within 30 days of receipt of the request.

(I) Self-insuring employers must obtain a drug utilization review from a physician before terminating payment for current medications, as follows:

(1) Before terminating payment for current medications, the self-insuring employer shall notify all parties to the claim (including authorized representatives) and the prescribing physician, in writing, that a physician drug review is being performed, or has been performed, regarding the necessity and appropriateness of the continued use of current medications (by therapeutic drug class).

(2) The written notice shall inform all parties to the claim (including authorized representatives) and the prescribing physician that they have 21 days from receipt of the notice to provide additional information and/or medical documentation to justify the need for continued use of the medications (by therapeutic drug class).

(3) The self-insuring employer shall provide all medically related information regarding the medications to an independent physician reviewer for review and opinion as to the necessity or appropriateness of the medications. If the self-insuring employer has obtained an independent physician reviewer’s report prior to sending the notice required by paragraph (I)(1) of this rule and subsequently receives additional information and/or medical documentation pursuant to paragraph (I)(2) of this rule, the self-insuring employer shall provide the additional information and/or medical documentation to the independent physician reviewer and obtain an addendum. The independent physician reviewer’s report (and addendum, if applicable) shall address the medical rationale, necessity and appropriateness of the drug treatment in the control of symptoms associated with the allowed conditions in the claim.

(4) When the independent physician reviewer’s report (and addendum, if applicable) indicates the drug treatment is not medically necessary or appropriate for treatment or in the control of symptoms associated with the allowed conditions in the claim, the self-insuring employer may terminate reimbursement for the medications (by therapeutic drug class) effective as of the date of receipt of the independent physician reviewer’s report, or addendum if one is obtained, or in the case that a drug is in a therapeutic class that requires a “weaning-off” period, such other date as agreed to by the prescribing physician and self-insuring employer.

(5) In the event the self-insuring employer terminates reimbursement for the medications as set forth in paragraph (I)(4) of this rule, the self-insuring employer or its authorized representative shall provide all parties to the claim (including authorized representatives) and the prescribing physician with a copy of the independent physician reviewer’s report (and addendum, if applicable) and the self-insuring employer shall notify the employee and the employee’s representative in writing of its decision to terminate. The employer’s notification to the employee and employee’s representative shall indicate that the employee has the right to request a hearing before the Industrial Commission.

(6) In the event there is a dispute as to whether the drug treatment is medically necessary or appropriate for treatment of the symptoms associated with the allowed conditions in the claim, the disputed matter shall be adjudicated in accordance with Rule 4123-19-03(K)(5) of the Administrative Code.

(J) Self-insuring employers may deny initial requests for a therapeutic class of drugs as not being reasonably related to or medically necessary for the treatment of the allowed conditions in a claim.

(K) Self-insuring employers may utilize medication utilization protocols formulated by the bureau for select conditions or diseases consistent with one or more of the following:

(1) Compendia consistent of the following:

(a) “United States Pharmacopoeia – Drug Information”;

(b) “American Medical Association Drug Evaluations”;

(c) “Drug Facts and Comparisons”; or,

(2) Peer reviewed medical literature.

Refusal to comply with the established protocols shall result in refusal of reimbursement for the medications which are not within the established protocols. This rule does not require the discontinuation of treatment with medications that are not within the established protocols, but simply states the bureau’s or self-insured employer’s refusal to reimburse for such medications.

(L) Through internal development or through vendor contracts, self-insuring employers may implement a point-of-service adjudication system. Upon implementation, a self-insuring employer may require pharmacy providers to submit bills for medication by an on-line point-of-service authorization terminal or a host-to-host link with the established bill processing system as a condition of reimbursement, and may refuse submission by paper or by tape-to-tape.

(M) Self-insuring employers utilizing a point of service adjudication system may require prior authorization of drugs or therapeutic classes of drugs which appear on BWC’s published list of drugs or therapeutic classes of drugs for which prior authorization is required.

(N) Self-insuring employers utilizing a point of service adjudication system may apply the following dispensing limitations, adopted by the bureau, to medications approved and reimbursed by the self-insuring employer:

(1) The bureau may publish a list of drugs identifying those drugs that are considered “chronic” medications. Drugs not identified as chronic medications shall be considered “acute” medications.

(a) Acute medications may be limited by the self-insuring employer to a thirty-four day supply.

(b) Chronic maintenance medications may be limited by the self-insuring employer to a one-hundred-two day supply.

(2) The bureau may publish maximum prescription quantities which represent the largest number of units per drug that may be dispensed at any one time for a single prescription.

(3) Requests submitted that exceed either the days supply limit or maximum quantity limit shall be denied; provided, however, that the pharmacy provider may still fill the prescription up to the days supply limit or maximum quantity limit, as applicable. Denials may be overridden by the self-insured employer in cases where medical necessity and appropriateness have been determined.

(4) Refills requested before seventy-five per cent of the days supply has been utilized will be denied, except in cases where the dosage of a noncontrolled drug has been increased and has a new prescription number. Denials may be overridden by the self-insured employer for the following documented reasons:

(a) Previous supply was lost, stolen or destroyed;

(b) Pharmacist entered previous wrong day supply;

(c) Out of country vacation or travel;

(d) Hospital or police kept the medication.

(O) Self-insuring employers utilizing a point of service adjudication system may apply the maximum allowable cost list of the point of service adjudication system vendor to medications which are pharmaceutically and therapeutically equivalent, that is, contain identical doses of the active ingredient and have the same biological effects as determined by the food and drug administration (FDA) and designated by an “A” code value in the FDA publication, “Approved Drug Products With Therapeutic Equivalence Evaluations.” Claimants who request a brand name drug or whose physician specifies a brand name drug designated by “dispense as written” on the prescription for a medication which has an applicable maximum allowable cost price shall be liable for the product cost difference between the established maximum allowable cost price of the drug product and the average wholesale price plus or minus the bureau established percentage of the dispensed brand name drug.

(P) A self-insuring employer has sufficient grounds to refuse to pay for the dispensing of drugs and other medications when a pharmacy provider fails to observe any state or federal law relating to his or her professional licensure or to the dispensing of drugs and other medication.

Replaces: 4123-7-23

Effective: 06/01/2006

R.C. 119.032 review dates: 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.121, 4121.30

Rule Amplifies: 4121.44, 4123.66

Prior Effective Dates: 1/1/78, 5/18/92, 1/1/03

(A) Direct reimbursement will not be made to members of a hospital resident staff.

(B) Payment for personal comfort items, which include, but are not limited to, telephones, television, and private rooms provided at the patient’s request, are not compensable.

(C) Bureau fees for hospital inpatient services.

(1) Bureau fees for hospital inpatient services will be based on usual and customary methods of payment, such as prospective payment systems, including diagnosis related groups (DRG), per diem rates, rates based on hospital costs to charge ratios or percent of allowed charges.

(2) Except in cases of emergency as defined in rule 4123-6-01 of the Administrative Code, prior authorization must be obtained in advance of all hospitalization. The hospital must notify the self-insured employer of emergency inpatient admissions within one business day of the admission.

Failure to comply with this rule shall be sufficient ground for denial of room and board charges by the self-insured employer from the date of admission up to the actual date of notification. Room and board charges denied pursuant to this rule may not be billed to the injured worker.

(D) Bureau fees for hospital outpatient services.

(1) Bureau fees for hospital outpatient services, including emergency services, will be reimbursed in accordance with usual and customary methods of payment which may include prospectively determined rates, allowable fee maximums, ambulatory payment categories (APC), and hospital cost to charge ratios, or a percent of allowed charges, as determined by the bureau.

(2) Treatment in the emergency room of a hospital must be of an immediate nature to constitute an emergency as defined in this chapter. Prior authorization of such treatment is not required. However, in situations where the emergency room is being utilized to deliver non-emergency care, notification will be provided to the injured worker, the hospital, and the provider of record that continued use of the emergency room for non-emergent services will not be reimbursed.

(E) The bureau may establish the same or different fees for in-state and out-of-state hospitals based on the above reimbursement methodologies.

(F) Payment will be made for hospital services based on rules 4123-7-01 and 4123-7-02 of the Administrative Code.

HISTORY: Replaces rule 4121-17-24; Eff 1-1-78; 9-1-93; Replaces: 4123-7-24 Eff 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.31, 4121.44, 4123.66

R.C. 119.032 review dates: 03/01/2009

(A) Employment of nursing service.

(1) The need for nursing services must be the direct result of an allowed injury or occupational disease.

(2) Except as described in rule 4123-7-25.1 of the Administrative Code, home health nursing services shall be provided by registered nurses and licensed practical nurses employed by a medicare certified, joint commission on accreditation of healthcare organizations (JCAHO) accredited, or community health accreditation (CHAP) accredited home health agency.

(B) Fees for home health agency nursing services. Fees for home health agency nursing services will be determined by the bureau.

(C) Authorization for home health nursing services.

(1) Authorization for home health nursing services shall be considered by a self-insuring employer only in cases where the claimant, as the direct result of an allowed injury or occupational disease, is bedfast or otherwise confined to the home, is mentally incapable of self-care or requires home care services ordered for hospital discharge follow-up.

(2) The request for authorization from the physician of record or treating physician must identify the reason for home health nursing services, the period of time the services will be required, the specific services and the number of hours per day that are required.

(3) In addition to skilled nursing services provided by a registered nurse or licensed practical nurse, the claimant may be approved for home health aide or attendant services if he/she is unable to independently perform activities of daily living, including, but not limited to, feeding, bathing, dressing, providing personal hygiene, and transferring from bed to chair. Household, personal or other duties such as maintaining a household, washing clothes, preparing meals or running errands are not considered nursing services and will not be reimbursed.

(4) Authorization must be obtained from the self-insuring employer prior to rendering home health nursing services, except in cases of emergency or where the claimant’s allowed condition could be endangered by the delay of services.

(D) All covered home health services must be rendered on a part-time or intermittent care basis, in accordance with the written treatment plan and the bureau standard of care. Part-time or intermittent care means that services are generally rendered for no more than eight hours per day. Home health services rendered on a full time or continuous care basis are not covered. More appropriate alternative settings will be considered for claimants requiring more than eight hours per day of care, where medical necessity is documented. Exceptional cases may be reviewed by the self-insuring employer.

(E) A review of the claim or assessment of the injured worker will be conducted by the self-insuring employer at least annually to ensure that nursing services are necessary as a direct result of the allowed injury or occupational disease.

(F) Home health agency providers must maintain records which fully document the extent of services provided to each claimant. All records must be maintained in accordance with the conditions of participation required for medicare certification, joint commission on accreditation of healthcare organizations (JCAHO) accreditation, or community health accreditation (CHAP) accreditation. The provider may be required to furnish detailed hourly descriptions of care delivered to a claimant to review care needs and medical necessity.

Replaces: 4123-7-25

Effective: 06/01/2005

R.C. 119.032 review dates: 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/1/78, 12/14/92, 1/9/95

(A) Nursing services provided prior to December 14, 1992.

(1) Registered nurses and licensed practical nurses who are not employed by a medicare certified, joint committee on accreditation of healthcare organizations (JCAHO) accredited, or community health accreditation program (CHAP) accredited home health agency may continue to provide authorized services to a claimant if the services began prior to December 14, 1992.

(2) The need for nursing services must be the direct result of an allowed injury or occupational disease.

(3) In the event the registered nurse or licensed practical nurse is no longer able to provide approved services or if services are stopped and later restarted, nursing services shall be provided only by an employee of a medicare certified, joint committee on accreditation of healthcare organizations (JCAHO) accredited, or community health accreditation program (CHAP) accredited home health agency.

(B) Non-licensed caregiver services.

(1) Requests for extension of caregiver services initially provided prior to December 14, 1992.

(a) Prior to December 14, 1992, caregiver services provided by a non-licensed person including claimant’s spouse, friend or family member were considered for reimbursement by a self-insuring employer in cases where the claimant, as a direct result of an allowed injury or occupational disease, was bedfast, confined to a wheelchair, had a disability of two or more extremities which prevented the claimant from caring for his/her own body needs or was otherwise unable to take care of his/her own bodily functions. Services include, but are not limited to, feeding, bathing, dressing, providing personal hygiene, and transferring from bed to chair. Household, personal or other duties such as maintaining a household, washing clothes, preparing meals, or running errands, are not considered nursing services, and will not be reimbursed.

(b) Requests for an extension of caregiver services approved by a self-insuring employer prior to December 14, 1992, delivered by a non-licensed person, other than an attendant, aide, or claimant’s spouse, but including other family members or friends, will be approved only if:

(i) The claimant does not have a spouse because the claimant is not married, or the claimant’s spouse is deceased, or the claimant’s spouse is physically or mentally incapable of caring for the claimant; and,

(ii) The approved home health agency is greater than thirty-five miles from the claimant’s location and the home health agency refuses to provide services to the claimant.

(c) In the event the caregiver is no longer able to provide approved services or if services are stopped and later restarted, services shall be provided only by an employee of a medicare certified, joint committee on accreditation of healthcare organizations (JCAHO) accredited, or community health accreditation program (CHAP) accredited home health agency.

(2) Requests for extension of caregiver services initially provided on or after December 14, 1992 and prior to January 9, 1995.

(a) Requests for approval by a self-insuring employer of caregiver services delivered by a non-licensed person, other than an attendant, aide, or claimant’s spouse were considered for reimbursement only if the claimant did not have a spouse or the spouse was physically or mentally incapable of caring for the claimant, or an approved home health agency was greater than thirty-five miles from the claimant’s location and the home health agency refused to provide services to the claimant.

(b) Criteria for approval of caregiver services were as indicated in paragraph (B)(1)(a) of this rule.

(c) After January 9, 1995, persons who are not home health agency nurse aides or attendants, but who are currently approved to provide caregiver services to a claimant, may continue to do so until services are no longer medically necessary or unless services are not authorized. After January 9, 1995, approval of caregiver services by a self-insuring employer shall only be considered when services are rendered by a home health agency nurse’s aide or attendant.

(d) In the event the caregiver is no longer able to provide approved services or if services are stopped and later restarted, services shall be provided only by an employee of a medicare certified, joint committee on accreditation of healthcare organizations (JCAHO) accredited, or community health accreditation program (CHAP) accredited home health agency.

(C) All covered home health services must be rendered on a part-time or intermittent care basis, in accordance with the written treatment plan and the bureau standard of care. Part-time or intermittent care means that services are generally rendered for no more than eight hours per day. Home health services rendered on a full time or continuous care basis are not covered. More appropriate alternative settings will be considered for claimants requiring more than eight hours per day of care, where medical necessity is documented. Exceptional cases may be reviewed by the self-insuring employer.

(D) A review of the claim or assessment of the injured worker will be conducted by the self-insuring employer at least annually to ensure that nursing services are necessary as a direct result of the allowed injury or occupational disease.

Replaces: Part of 4123-7-25

Effective: 06/01/2005

R.C. 119.032 review dates: 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/1/78, 12/14/92, 1/9/95

(A) Payment by a self-insuring employer to a nursing home or residential care/assisted living facility for the care of a claimant who sustained an injury or contracted an occupational disease in the course of and arising out of employment shall be made only in cases where the need for such care is the direct result of the allowed industrial condition, as indicated in rule 4123-7-02 of the Administrative Code.

(B) Payment will be made only for care provided in state licensed, medicaid certified nursing homes and residential care/assisted living facilities.

(C) In claims managed by a self-insuring employer, care must be pre-authorized, except when a nursing home or residential care/assisted living facility is used immediately following an approved or emergency hospitalization.

(1) The allowed per diem rate for a claimant shall be no greater than the bureau’s fee schedule or the rate negotiated between the nursing home or residential care/assisted living facility and the self-insuring employer.

(2) Nursing home care shall be provided on a semiprivate or ward bed basis, unless a situation exists when the use of a private room is necessary due to the allowed industrial condition. In these cases, the use of such a private room must be preauthorized, except in cases of emergency, as defined in rule 4123-6-01 of the Administrative Code, or where claimant’s condition would be endangered by delay.

(3) Fee bills for prescription medication provided to claimants in nursing homes and residential care/assisted living facilities for the treatment of the allowed industrial injury or occupational disease shall be submitted by the providing pharmacy to the self-insuring employer in compliance with rule 4123-7-23 of the Administrative Code.

Replaces: 4123-7-26

Effective: 06/01/2005

R.C. 119.032 review dates: 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 1/1/78, 12/14/92

Rescinded eff 2-14-05

(A) In all cases arising under division (B) of section 4123.57 of the Revised Code, if a claimant requires the purchase or repair of an artificial appliance, the bureau shall pay the cost of purchasing or repairing the artificial appliance out of the surplus fund. The purchase or repair is made regardless of whether the appliance is part of the claimant’s vocational rehabilitation, or if the claimant has, or will ever be able, to return to work.

(B) The bureau is responsible for processing requests for prosthetics and travel expenses associated with the prosthetic in all self-insured claims. When a prosthetic device is needed in a self-insured claim, the provider will send a request for the prosthetic and/or request for repair, as well as the subsequent bills, to the bureau.

HISTORY: Replaces rule 4121-17-28; Eff 1-1-78; 4-7-80; 7-10-80; 5-23-94; Replaces: 4123-7-28 Eff 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4123.05, 4123.66

Rule Amplifies: RC 4121.61, 4123.57, 4123.66

R.C. 119.032 review dates: 03/01/2009

(A) Direct payment to a health care provider or other person authorized by the industrial commission or self-insuring employer for medical care rendered to a claimant under the act does not imply or create a legal relationship between the industrial commission or bureau self-insuring employer and such person where no other legal relationship by contract or otherwise exists.

(B) The services rendered to the claimant are the legal obligation of the patient-claimant.

The direct payment by the self-insuring employer to the health care provider is simply a discretionary method by which the award made to the claimant for medical expenses may be discharged.

(C) Except as prohibited by division (K) of section 4121.44 of the Revised Code and rule 4123-6-62 of the Administrative Code, whether the bureau self-insuring employer chooses to pay money to the claimant, or chooses to discharge claimant’s obligation by a direct payment to the creditor-health care provider, the sole legal recourse of such health care provider is against the claimant.

HISTORY: Eff 1-1-78; 11-13-92; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4123.05, 4123.66

Rule Amplifies: 4121.44, 4123.66

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

Rescinded eff 2-14-05

The rules of this chapter shall govern payments to health care providers in claims before both self-insuring employers and the industrial commission, and shall apply to claims adjudication by both the industrial commission and by self-insuring employers. However, nothing in these rules shall inhibit or diminish the commission’s right to establish adjudicatory policy under Chapters 4121., 4123., 4127., and 4131. of the Revised Code, or otherwise prevent the full adjudication of claims properly before the commission or its hearing officers.

HISTORY: Eff 7-16-90; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4123.05, 4123.66

Rule Amplifies: 4121.121, 4121.30, 4121.44, 4123.66

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

(A) A self-insuring employer may approve payment for a transcutaneous electric nerve stimulator (TENS) unit for treatment of allowed conditions in a claim directly resulting from an allowed industrial injury or occupational disease as provided in this rule and in the bureau’s provider billing and reimbursement manual.

(1) The injured worker’s physician of record must request prior authorization from the self-insuring employer in order to have a prescribed transcutaneous electrical nerve stimulator (TENS) unit and supplies furnished. Each injured worker who requires a TENS unit will be provided only one unit at a time. For each TENS unit request approved, the unit will be rented for a trial period lasting a minimum of one month but not to exceed four months preceding purchase of the TENS unit, in order to evaluate the medical necessity and effectiveness of the TENS treatment.

(2) The medical necessity and effectiveness of the TENS treatment shall be evaluated each month during the trial period. TENS treatment will be discontinued at the end of any trial period month where the treatment is not proven medically necessary or effective. The bureau will only pay rental costs through the month during the trial period that the TENS unit was actually used before treatment was discontinued.

(3) The self-insuring employer will authorize the purchase of the TENS unit only if the analysis at the end of the trial period establishes that the TENS treatment was medically necessary and effective during the entire trial period. All rental payments previously made by the self-insuring employer will be applied to the purchase price of the TENS unit. A TENS unit purchased by the self-insuring employer and furnished to the injured worker is not the personal property of the worker, however, but remains the property of the self-insuring employer. At its discretion, the self-insuring employer reserves the right to reclaim and recover the TENS unit from the injured worker at the completion of the course of TENS treatment. Once a TENS unit is purchased, the self-insuring employer will reimburse for repair or replacement, at its discretion, upon submission of a request for such from the physician of record, along with medical documentation substantiating the continued medical necessity and effectiveness of the unit. Additionally, while the injured worker continues to use the TENS unit and to order supplies, the physician of record must provide medical documentation annually substantiating the need for continued use of the unit.

(B) Injured workers who have TENS units must complete and submit to the TENS provider a monthly written request for specific supplies needed in the following month. The TENS provider will deliver the supplies and bill the self-insuring employer for them only after the injured worker’s written request is received by the TENS provider. The self-insuring employer will not pay TENS providers unless the written request was submitted by the injured worker to the TENS provider prior to delivery of supplies. The provider shall retain the original written request for supplies for a minimum of two years after the date of service for the shipment to which it applies. The TENS provider must bill monthly for each shipment of supplies sent to the injured worker. The bill must indicate the actual date of service reflecting the date that services or supplies were provided. The self-insuring employer may adjust bills upon audit if the audit discloses the provider’s failure to comply with this rule.

(C) The TENS provider shall maintain the following records and make them available upon request:

(1) The injured worker’s monthly written requests;

(2) Records of the provider’s wholesale purchase of TENS supplies or equipment; and,

(3) Records of delivery of supplies to injured workers and of the delivery or return of TENS units.

If records are requested, the provider shall supply copies of the information at no extra cost. Failure to provide the bureau with requested records will result in denial or adjustment of bills related to the records in question.

(D) Self-insuring employers may approve payment for a neuromuscular electrical stimulator (NMNS) unit for treatment of allowed conditions in a claim directly resulting from an allowed industrial injury or occupational disease, as provided in the bureau’s provider billing and reimbursement manual.

HISTORY: Eff 9-1-93; 3-1-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 4121.121, 4121.30, 4123.05

Rule amplifies: RC 4123.66

RC 119.032 review dates: 11/28/03, 3/01/09

Payment for in-state and out-of-state practitioner services by self-insuring employers shall be equal to or greater than the fee schedule established by the bureau in state fund claims, unless otherwise negotiated in accordance with rules 4123-6-63 and 4123-7-39 of the Administrative Code.

HISTORY: Eff 5-23-94;Replaces: 4123-7-35 Eff 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4123.05, 4123.66

Rule Amplifies: RC 4121.121, 4121.44, 4123.66

R.C. 119.032 review dates: 03/01/2009

Rescinded eff 2-14-05

Rescinded eff 2-14-05

(A) A self-insuring employer may negotiate payment rates with health care providers for services and supplies provided in the treatment of workers’ compensation claims.

(B) A self-insuring employer may enter into volume-based contracts with medical providers for services including, but not limited to, the purchase or rental of durable medical equipment and supplies.

(C) A self-insuring employer may inform injured workers of the availability of services, supplies, or equipment from particular health care providers where the self-insuring employer has a contract for services or supplies, a discount for services or supplies, or where cost-effective payment levels or rates are obtained by the self-insuring employer by contract, so long as access to quality and convenient medical services or supplies is maintained for injured workers.

HISTORY: Eff 5-18-92; 2-14-05

Promulgated Under: 119.03

Statutory Authority: RC 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4123.05, 4123.66

Rule Amplifies: 4121.44, 4121.651, 4123.66

R.C. 119.032 review dates: 10/26/2004 and 03/01/2009

Rescinded eff 2-14-05

Rescinded eff 2-14-05