4123-7-26 Payment to nursing homes and residential care/assisted living services.

(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