Rule 4123-6-16 | Alternative dispute resolution for HPP medical issues.
(A) Pursuant to division (A)(1) of section 4121.441 of the Revised Code, this rule provides procedures for an alternative dispute resolution (ADR) process for medical disputes between an employer, an injured worker, or a provider and an MCO arising from the MCO's decision regarding a medical treatment reimbursement request (on form C-9 or equivalent). An injured worker or employer must exhaust the ADR procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code on an MCO's decision regarding a medical treatment reimbursement request.
(B) Within fourteen days of receipt of an MCO decision, an injured worker, employer, or provider may dispute the decision in writing (on form C-11 or equivalent) to the MCO. The written medical dispute must contain, at a minimum, the following elements:
(1) Injured worker name.
(2) Injured worker claim number.
(3) Date of initial medical treatment reimbursement request in dispute.
(4) Specific issue(s) in dispute, including description, frequency/duration, beginning/ending dates, and type of treatment/service/body part.
(5) Name of party making written appeal request.
(6) Signature of party making written appeal request or the party's authorized representative.
Written medical disputes that do not contain the minimum elements set forth in this paragraph may be dismissed by the MCO or bureau.
(C) Upon receipt of a written medical dispute, the MCO will initiate the ADR process, which consists of one independent level of professional review ("peer review") as follows:
(1) If an individual health care provider eligible to be physician of record would be providing the services requested in the dispute, the peer review is to be conducted by an individual or individuals licensed pursuant to the same section of the Revised Code as the health care provider who would be providing the services requested.
(2) Notwithstanding paragraph (C)(1) of this rule, if the MCO has already obtained one or more peer reviews during previous disputes involving the same treatment, the MCO may obtain a different perspective review from a licensed physician who falls outside the peer review criteria set forth in paragraph (C)(1) of this rule.
(3) If an individual health care provider not eligible to be physician of record would be providing the services requested in the dispute, peer review is to be conducted by an individual or individuals eligible to be physician of record whose scope of practice includes the services requested.
(4) If the MCO receives a dispute where the requested treatment is the same as a previous treatment request for which the MCO conducted a peer review, and the previous treatment request was ultimately denied based on the peer review, the MCO may use the previous peer review as the peer review under this paragraph, provided the peer review was conducted within six months of the current request and there are no new or changed circumstances in the injured worker's condition documented in the claim file.
(5) The MCO will submit a copy of the peer review to the bureau, and the bureau will provide the parties to the claim access to the peer review electronically.
(D) If, upon consideration of additional evidence or after agreement with the party that submitted the written medical dispute, the MCO reverses the decision under dispute or otherwise resolves the dispute to the satisfaction of the party, the MCO may issue a new decision and dismiss the dispute.
(E) The MCO will complete the ADR process and submit its recommended ADR decision to the bureau electronically within twenty-one days of the MCO's receipt of the written medical dispute, unless the injured worker is scheduled for an independent medical examination under paragraph (I) of this rule.
(F) Within two business days after receipt of a recommended ADR decision from the MCO, the bureau will publish and mail to all parties a final order, which may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. The provider and the MCO may not file an appeal of the bureau order.
(G) Notwithstanding paragraph (C) of this rule, the MCO may pend a written medical dispute under the following circumstances:
(1) If the MCO receives a written medical dispute involving a medical treatment reimbursement request that is the same as a previous treatment request for which the MCO conducted a peer review, and the previous treatment request is pending before the bureau or industrial commission, the MCO may pend the new dispute until the previous treatment request has been resolved. Once the previous treatment request has been resolved, the MCO will resume the ADR process.
(2) If the MCO receives a written medical dispute involving a medical treatment reimbursement request that is dependent upon the outcome of an additional condition request pending before the bureau or industrial commission, the MCO may pend the dispute until the earlier of the final administrative or judicial decision or the industrial commission staff hearing officer decision on the request for the additional condition, at which time the MCO will resume the ADR process.
(H) Notwithstanding paragraph (C) of this rule, an MCO may submit its recommended ADR decision to the bureau electronically without obtaining a peer review under the following circumstances:
(1) The MCO receives a written medical dispute involving a medical treatment reimbursement request relating to the delivery of medical services that have been approved by the MCO pursuant to standard treatment guidelines, pathways, or presumptive authorization guidelines.
(2) The MCO receives a written medical dispute involving a medical treatment reimbursement request clearly relating to the delivery of medical services for a condition that is not allowed in the claim, and the issue of the allowance of the additional condition is not pending before the bureau or industrial commission.
(I) Either the MCO or the bureau may schedule an independent medical examination (IME) of the injured worker to assist in the ADR process under this rule.
(1) An ADR IME will be limited to issues relating to medical treatment disputes, and will not include extent of disability issues. An ADR IME will not be conducted at the request of an employer and does not substitute for an examination permitted under section 4123.651 of the Revised Code.
(2) If an ADR IME is scheduled under this rule, the parties, and their representatives, if any, will be promptly notified as to the time and place of the examination, and the questions and information provided to the doctor. The injured worker will be reimbursed for travel expenses in accordance with rule 4123-6-40 of the Administrative Code.
(3) The scheduling of an ADR IME will toll the MCO's time frame for completing the ADR process, and in such cases the MCO will submit its recommended ADR decision to the bureau electronically within seven days after receipt of the independent medical examination report.
(4) If an injured worker refuses to attend an IME to assist in the ADR process, the MCO will refer the issue to the bureau, and the injured worker's right to benefits may be suspended during the period of refusal.
Last updated June 18, 2024 at 3:47 PM
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