4123-9-10 Injury management services division of the bureau.

The duties of the injury management division services of the bureau shall include, but will not be limited to, the following:

(A) Implementing the health partnership program (HPP) and qualified health plan (QHP) in accordance with workers’ compensation statutes;

(B) Assessing the compliance of HPP and QHP with workers’ compensation statutes, rules and policies;

(C) Establishing criteria to determine the amount to be paid for medical services, equipment, and supplies;

(D) Authorizing, denying or adjusting provider payments;

(E) Developing programs to provide rehabilitation services to claimants in accordance with workers’ compensation statutes;

(F) Assuring that claimants’ rehabilitation services further return to work objectives;

(G) Developing, implementing and assessing claims, medical and vocational rehabilitation policies and procedures;

(H) Overseeing and consulting for contractual compliance issues regarding managed care organizations;

(I) Enrolling and certifying providers in HPP systems and maintaining disability evaluators panel;

(J) Resolving complaints regarding HPP;

(K) Assisting in provider training;

(L) Recovering medical payments made in excess or in error;

(M) Administering the employee health services for bureau and industrial commission central office employees, as well as the catastrophic nurse advocates program benefiting injured workers who have suffered catastrophic injuries from job-related accidents;

(N) Supporting systems initiatives for management of the bureau’s pharmacy benefits program;

(O) Developing requirements for enhancements and coordinating and testing systems for electronic data interchange transactions, related to claims, providers, network and medical billing processes, and for systems relating to claims;

(P) Providing analytical, statistical, and reporting services to internal and external customers, including but not limited to calculating the employer open enrollment report card, managed care organizations’ incentive payments, managed care organizations’ administrative payment set-offs, and most managed care organizations’ related statistics;

(Q) Coordinating medical, claims, and rehabilitation policies, procedures, and programs;

(R) Responding to local and statewide inquiries regarding claim handling practices and procedures.

HISTORY: Eff 9-20-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 4121.12, 4121.30, 4121.31

Rule amplifies: RC 4121.121, 4121.31

R.C. 119.032 review dates: 03/01/2008