4121.442 Health care quality advisory council.

(A) The administrator of workers' compensation shall develop standards for qualification of health care plans of the Ohio workers' compensation qualified health plan system to provide medical, surgical, nursing, drug, hospital, and rehabilitation services and supplies to an employee for an injury or occupational disease that is compensable under this chapter or Chapter 4123., 4127., or 4131. of the Revised Code. In adopting the standards, the administrator shall use nationally recognized accreditation standards. The standards the administrator adopts must provide that a qualified plan provides for all of the following:

(1) Criteria for selective contracting of health care providers;

(2) Adequate plan structure and financial stability;

(3) Procedures for the resolution of medical disputes between an employee and an employer, an employee and a provider, or an employer and a provider, prior to an appeal under section 4123.511 of the Revised Code;

(4) Authorize employees who are dissatisfied with the health care services of the employer's qualified plan and do not wish to obtain treatment under the provisions of this section, to request the administrator for referral to a health care provider in the bureau's health care partnership program. The administrator must refer all requesting employees into the health care partnership program.

(5) Does not discriminate against any category of health care provider;

(6) Provide a procedure for reporting injuries to the bureau of workers' compensation and to employers by providers within the qualified plan;

(7) Provide appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service;

(8) Provide adequate methods of peer review, utilization review, quality assurance, and dispute resolution to prevent and provide sanctions for inappropriate, excessive, or not medically necessary treatment;

(9) Provide a timely and accurate method of reporting to the administrator necessary information regarding medical and health care service and supply costs, quality, and utilization to enable the administrator to determine the effectiveness of the plan;

(10) Authorize necessary emergency medical treatment for an injury or occupational disease provided by a health care provider who is not a part of the qualified health care plan;

(11) Provide an employee the right to change health care providers within the qualified health care plan;

(12) Provide for standardized data and reporting requirements;

(13) Authorize necessary medical treatment for employees who work in Ohio but reside in another state.

(B) Health care plans that meet the approved qualified health plan standards shall be considered qualified plans and are eligible to become part of the Ohio workers' compensation qualified health plan system. Any employer or group of employers may provide medical, surgical, nursing, drug, hospital, and rehabilitation services and supplies to an employee for an injury or occupational disease that is compensable under this chapter or Chapter 4123., 4127., or 4131. of the Revised Code through a qualified health plan.

Effective Date: 09-17-1996; 12-30-2004; 06-27-2005