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| Rule |
Rule 4123-6-01 | Definitions.
As used in this chapter: (A) "Authorization" or
"prior authorization" means: Notification that a specific treatment, service,
or equipment is medically necessary for the diagnosis or treatment of an
allowed condition. (B) "Bureau certified provider"
means: A provider who is approved by the bureau for
participation in the health partnership program (HPP) pursuant to this chapter
of Administrative Code. (C) "Certification" or
"recertification" means: A process by which the bureau approves a provider
or managed care organization (MCO) for participation in the HPP. (D) "Credentialing" or
"recredentialing" means: A process by which the bureau validates or
reviews the completed and signed application of a provider for certification or
recertification. (E) "Dispute resolution"
means: Procedures for the resolution of medical disputes
prior to filing an appeal under section 4123.511 of the Revised Code. (F) "Emergency"
means: Medical services that are required for the
immediate diagnosis and treatment of a condition that, if not immediately
diagnosed and treated, could lead to serious physical or mental disability or
death, or that are immediately necessary to alleviate severe pain. Emergency
treatment includes treatment delivered in response to symptoms that may or may
not represent an actual emergency, but is necessary to determine whether an
emergency exists. (G) "Employee"
means: As used in the rules of this chapter, the term
"employee" includes the terms "injured worker" and
"claimant" and all employees of employers covered under HPP. (H) "Health care provider" or
"provider" means: A physician or practitioner, or any person, firm,
corporation, limited liability corporation, partnership, association, agency,
institution, or other legal entity licensed, certified, or approved by a
professional standard-setting body or by medicare or medicaid to provide
medical services or supplies to an injured worker, including a qualified
vocational rehabilitation provider. (I) "Health partnership program" or
"HPP" means: The bureau of workers' compensation's
comprehensive managed care program under the direction of the chief of medical
services as provided in sections 4121.44 and 4121.441 of the Revised
Code. (J) "Hospital" means: An institution that provides facilities for
surgical and medical diagnosis and treatment of bed patients under the
supervision of staff physicians and furnishes twenty-four hour-a-day care by
registered nurses. (1) For the purposes of
this chapter relating to hospitals, "inpatient" means: An injured worker is considered to be an
inpatient when he or she has been admitted to a hospital for bed occupancy for
purposes of receiving inpatient hospital services. An injured worker is
considered an inpatient if there is a formal order for admission from the
physician. The determination of an inpatient stay is not based upon the number
of hours involved. If it later develops during the uninterrupted stay that the
injured worker is discharged, transferred to another inpatient unit within the
hospital, transferred to another hospital, transferred to another state
psychiatric facility or expires and does not actually use a bed overnight, the
order from the attending physician addressing the type of encounter will define
the status of the stay. (2) For the purposes of
this chapter relating to hospitals, "outpatient" means: The injured worker is not receiving inpatient
care, as "inpatient" is defined in paragraph (J)(1) of this rule, but
receives outpatient services at a hospital. An outpatient encounter cannot
exceed seventy-two hours of uninterrupted duration. (K) "Injury" means: For the purposes of the rules of this chapter of
the Administrative Code only, an injury as defined in division (C) of section
4123.01 of the Revised Code or an occupational disease as defined in division
(F) of section 4123.01 of the Revised Code. (L) "Managed care organization" or
"MCO" means: A vendor as defined under section 4121.44 of the
Revised Code who has contracted with the bureau to provide medical management
and cost containment services as provided in sections 4121.44 and 4121.441 of
the Revised Code. As used in these rules, a managed care organization is not a
health care provider. (M) "Medically necessary" means: Services which are reasonably necessary for the
diagnosis or treatment of disease, illness, and injury, and meet accepted
guidelines of medical practice. A medically necessary service must be
reasonably related to the illness or injury for which it is performed regarding
type, intensity, and duration of service and setting of treatment. (N) "Medication" means: The same as drug as defined by division (E) of
section 4729.01 of the Revised Code. (O) "Non-bureau certified provider"
means: A provider who is not approved by the bureau for
participation in the HPP, or whose certification has lapsed and has not been
reinstated pursuant to rule 4123-6-02.4 of the Administrative Code. (P) "Physician" means: (1) (a) A doctor of medicine, doctor of osteopathic medicine or
surgery, or doctor of podiatric medicine who holds a current, valid certificate
of licensure to practice medicine or surgery, osteopathic medicine or surgery,
or podiatry under Chapter 4731. of the Revised Code; (b) A doctor of chiropractic who holds a current, valid
certificate of licensure to practice chiropractic under Chapter 4734. of the
Revised Code; (c) A doctor of mechanotherapy who holds a current, valid
certificate of licensure to practice mechanotherapy under Chapter 4731. of the
Revised Code and who was licensed prior to November 3, 1985; (d) A psychologist who holds a current, valid certificate of
licensure to practice psychology under Chapter 4732. of the Revised Code;
or (e) A dentist who holds a current, valid certificate of licensure
to practice dentistry under Chapter 4715. of the Revised Code. (2) A physician licensed
pursuant to the equivalent law of another state shall qualify as a physician
under this rule. (Q) "Physician of record" or "attending
physician" means: Pursuant to Chapters 4121. and 4123. of the
Revised Code, the authorized physician chosen by the employee to direct
treatment. (R) "Practitioner" means: A physician, or a physical therapist,
occupational therapist, optometrist, or any other person currently licensed and
duly authorized to practice within his or her respective health care
field. (S) "Provider certification application and
agreement" means: A bureau form providers complete that requests
background information and documentation necessary for certification and which,
if completed and signed by the provider and approved by the bureau, constitutes
a written, contractual agreement between the bureau and the provider. (T) "Provider outcome measurement"
means: A medical management analysis tool used by the
bureau or MCO which at a minimum, utilizes line item detail from a medical bill
and employee specific information including, but not limited to, demographics,
diagnosis allowances, return to work and remain at work statistics, and other
data regarding treatment, to evaluate a health care provider on the basis of
cost, utilization and treatment outcomes efficiency and compliance with bureau
requirements. (U) "Qualified health plan" or "QHP"
means: A health care plan sponsored by an employer or a
group of employers which meets the standards for qualification under section
4121.442 of the Revised Code and is certified as a qualified health care plan
with the bureau. (V) "Recertification application and agreement"
means: A bureau form certified providers complete as
part of the provider recertification process that requests background
information and documentation necessary for recertification and which, if
completed and signed by the provider and approved by the bureau, constitutes a
written, contractual agreement between the bureau and the provider. (W) "Remain at work services" means: Services to support an injured worker in
continued employment where the injured worker is experiencing difficulties
performing a job as a result of conditions related to an allowed medical only
claim. (X) "Return to work services" means: Services to support an injured worker in
returning to employment where the injured worker is experiencing difficulty as
a result of conditions related to an allowed lost time claim. (Y) "Transitional work" means: A work-site program that provides an
individualized interim step in the recovery of an injured worker with job
restrictions resulting from the allowed conditions in the claim. Developed in
conjunction with the employer and the injured worker, or with others as needed,
including, but not limited to the collective bargaining agent (where
applicable), the physician of record, rehabilitation professionals, and the
MCO, a transitional work program assists the injured worker in progressively
performing the duties of a targeted job.. (Z) "Treatment guidelines" means: Guidelines of medical practice, developed through
consensus of practitioner representatives, that assist a practitioner and a
patient in making decisions about appropriate health care for specific medical
conditions. (AA) "Urgent care facility" means: A facility where ambulatory care is provided
outside a hospital emergency department and is available on a walk in,
non-appointment basis. (BB) "Utilization review" means: The assessment of an employee's medical care
by the MCO. This assessment typically considers medical necessity, the
appropriateness of the place of care, level of care, and the duration,
frequency or quality of services provided in relation to the allowed condition
being treated.
Last updated April 8, 2021 at 12:08 PM
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Rule 4123-6-01.1 | Applicability of medical rules.
Unless specifically stated otherwise, the rules of
this chapter governing payment of medical services and supplies shall apply to
payments to health care providers in all claims for work related injuries or
occupational diseases before the bureau, self-insuring employers, MCOs, QHPs,
and the industrial commission. 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.
Last updated April 8, 2021 at 12:09 PM
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Rule 4123-6-01.2 | Provisional treatment reimbursement approval -- pilot program.
Effective:
February 1, 2022
Notwithstanding any provision to the contrary in
any other rule of the bureau, the administrator may, for purposes of a pilot
program, allow one or more managed care organizations to authorize medical
treatment reimbursement requests for the first sixty days from the initial
allowance of an identified at-risk claim for any conditions within the same
body part or parts as the conditions initially allowed in the claim, and
presumed to be causally related to the same industrial injury or occupational
disease, without disclaimer, during such time as the conditions for which
treatment reimbursement is authorized but which are not yet allowed are being
considered for allowance or being adjudicated. The operation of the pilot program authorized under
this rule does not impair in any manner the right of an employer to appeal a
claim, additional allowance, or medical treatment reimbursement determination
under section 4123.511 of the Revised Code or rule 4123-6-16 of the
Administrative Code. The pilot program authorized under this rule is
extended through December 31, 2022; provided, however, that the administrator
may terminate the pilot program early at the administrator's
discretion.
Last updated February 1, 2022 at 9:31 AM
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Rule 4123-6-02 | Provider access to the HPP - generally.
(A) The bureau is authorized to certify a
provider who wishes to participate in the HPP. The bureau is authorized to
recertify a provider at least every one to three years. The bureau may, but is
not required to, recertify providers on a staggered basis, in order of the
provider's initial certification date or such other criteria as the bureau
determines appropriate. (B) A provider shall be certified or
recertified by the bureau to treat injured workers if the provider is a direct
service provider; meets and maintains credentialing criteria under rule
4123-6-02.2 of the Administrative Code; meets and maintains all other
applicable criteria under the workers' compensation statutes and rules;
and completes and signs a provider application and agreement or recertification
application and agreement with the bureau.
Last updated April 8, 2021 at 12:09 PM
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Rule 4123-6-02.2 | Provider access to the HPP - provider certification criteria.
Effective:
April 15, 2024
(A) The bureau will establish minimum criteria for provider
certification. Providers must meet all licensing, certification, or
accreditation requirements necessary to provide services in Ohio. A provider
licensed, certified, or accredited pursuant to the equivalent law of another
state qualifies as a provider under this rule in that state. However, a
provider is ineligible to participate in the health partnership program
if: (1) The state of Ohio has
denied the provider's application for a professional license or the
provider's professional license in Ohio is under revocation or suspension;
or (2) The provider's
professional license is subject to disciplinary restrictions that affect the
provider's ability to treat patients or that compromise patient
care. (B) The minimum criteria for a provider, where applicable based
upon the type of provider, are as follows. The provider shall: (1) Be currently licensed to practice, as
applicable, without disciplinary restrictions that affect the provider's
ability to treat patients or that compromise patient care. (2) Meet other general certification
criteria for the specific provider type, as provided in paragraph (C) of this
rule. (3) Not be currently excluded from
participation in medicare or Ohio medicaid for cause. (4) Not be currently ineligible to
participate in the health partnership program due to the provider having been
convicted of or pleaded guilty to a criminal offense as set forth in the
appendix to this rule. (5) Attest to and maintain professional
malpractice and liability insurance, and provide proof of such coverage to BWC
upon request. (6) Provide documentation of the
provider's malpractice history for the previous five years. (7) Not have any outstanding provider
overpayment or other indebtedness to the bureau which has been certified to the
attorney general for collection. (8) Maintain workers' compensation
coverage to the extent required under Ohio law or the equivalent law of another
state, as applicable, and provide proof of such coverage to BWC upon
request. (9) Not have been excluded or removed
from participation in other health plans for cause. (10) Not have lost hospital privileges for
cause. (C) The following minimum credentials apply to the providers
listed below as provided in this rule. (1) Adult day care
facility: Ohio department of aging PASSPORT adult day care provider
agreement. (2) Alcohol and drug
counseling clinic: certified by Ohio department of mental health and addiction
services. (3) Ambulance, ambulette, or air
ambulance service: license from Ohio state board of emergency medical, fire,
and transportation services if private; approved for medicare by the centers
for medicare and medicaid services (CMS) if government/public. (4) Ambulatory surgical center: license
from Ohio department of health and approved for medicare by CMS. (5) Anesthesiologist
assistant: license from Ohio state medical board. (6) Athletic trainer: license from Ohio
occupational therapy, physical therapy, and athletic trainers
board. (7) Audiologist: license from Ohio state
speech and hearing professionals board. (8) Certified nurse
practitioner: license from Ohio board of nursing and certified by American
nurses credentialing center or other certifying agency approved by the Ohio
board of nursing. (9) Certified registered
nurse anesthetist (CRNA): license from Ohio board of nursing and certified by
national council on certification of nurse anesthetists or other certifying
agency approved by the Ohio board of nursing. (10) Certified shoe
retailer: certified or accredited by American board for certification in
orthotics, prosthetics and pedorthics or board of
certification/accreditation. (11) Chiropractic physician (D.C.):
license from Ohio state chiropractic board. (12) Clinical nurse specialist: license
from Ohio board of nursing and certified by American nurses credentialing
center or other certifying agency approved by the Ohio board of
nursing. (13) Comprehensive pain management
services program: (free standing) commission on accreditation of rehabilitation
facilities CARF accreditation; (hospital based) CARF or joint commission
accreditation. (14) Dentist: license from Ohio state
dental board. (15) Dialysis center: license from Ohio
department of health and approved for medicare by CMS or a deeming organization
approved by CMS. (16) Durable medical equipment supplier
(excludes orthotics, prosthetics and pedorthics): approved for medicare by CMS
and state of Ohio board of pharmacy home medical equipment certificate of
registration. (17) Employment specialist: (a) (i) Certification for
American board of vocational experts (ABVE), certified rehabilitation counselor
(CRC), certified case manager (CCM), certified employment support professional
(CESP), certification for individual placement and support (CIPS), global
career development facilitator (GCDF), associate certified coach (ACC),
professional certified coach (PCC), master certified coach (MCC), certified
disability management specialist (CDMS), or CARF accreditation for employment
and community services in job development or employment supports;
or (ii) Evidence of
completion of three or more courses, seminars or workshops prior to application
for certification, totaling a minimum of eighty hours and approved by the
bureau or by an entity offering a certification referenced in paragraph
(C)(17)(a)(i) of this rule, in at least two of the following domain areas: job
development, job placement, and career and lifestyle development; vocational
consultation and services for employers; professional roles and practices,
ethics, and utilization of community resources; or (iii) Evidence of bureau
reimbursement to the provider for job placement, job development, job seeking
skills training, job club, and/or job coaching services to injured workers for
dates of service beginning not less than eighteen months prior to April 1,
2014. However, if the provider has been certified pursuant to this provision
and the provider's certification subsequently lapses, the provider must
thereafter meet the criteria of paragraph (B)(17)(a)(i) or (B)(17)(a)(ii) of
this rule for certification or recertification. (b) Employment specialists certified pursuant to paragraph
(C)(17)(a)(ii) or (C)(17)(a)(iii) of this rule must complete thirty hours of
continuing education, including three hours of ethics, every three years to
maintain certification under this rule. (18) Ergonomist: certification for
certified professional ergonomist (CPE), certified human factors professional
(CHFP), associate ergonomics professional (AEP), associate human factors
professional (AHFP), certified ergonomics associate (CEA), certified safety
professional (CSP) with "ergonomics specialist" designation,
certified industrial ergonomist (CIE), certified industrial hygienist (CIH),
assistive technology practitioner (ATP), or rehabilitation engineering
technologist (RET). (19) Hearing aid dealer: license from Ohio
state speech and hearing professionals board. (20) Home health agency: license from Ohio
department of health, and approved for medicare by CMS or a deeming
organization approved by CMS. (21) Hospice: license from Ohio department
of health, and approved for medicare by CMS. (22) Hospital: license from Ohio
department of health no later than September 30, 2024, and approved for
medicare by CMS or a deeming organization approved by CMS, or obtained CARF
accreditation for rehabilitation hospitals. The following facility types are
eligible to be credentialed and certified as hospitals: short-term general and
specialty hospitals; long-term care hospitals; rehabilitation hospitals; and
psychiatric hospitals; hospital (provider) based urgent care facilities or
clinics as designated on the hospital's medicare cost report. (23) Independent diagnostic testing
facility (IDTF): approved for medicare by CMS. (24) Laboratory: valid clinical laboratory
improvement amendments (CLIA) certificate. (25) Licensed professional clinical
counselor (LPCC) or licensed professional counselor (LPC): license from Ohio
counselor, social worker, and marriage and family therapist board. (26) Licensed social worker (LSW) or
licensed independent social worker (LISW): license from Ohio counselor, social
worker, and marriage and family therapist board. (27) Massage therapist: license from Ohio
state medical board. (28) Non-physician acupuncturist: license
to practice acupuncture or certificate to practice as an oriental medicine
practitioner from Ohio state medical board. (29) Nursing home: license from Ohio
department of health or approved for medicare by CMS. (30) Ocularist: license from Ohio state
vision professionals board. (31) Occupational
rehabilitation-comprehensive programs (work hardening): CARF
accreditation. (32) Occupational therapist: license from
Ohio occupational therapy, physical therapy, and athletic trainers
board. (33) Optician: license from Ohio state
vision professionals board. (34) Optometrist: license from Ohio state
vision professionals board. (35) Orthotist, prosthetist or pedorthist:
license from Ohio occupational therapy, physical therapy, and athletic trainers
board. (36) Physical therapist: license from Ohio
occupational therapy, physical therapy, and athletic trainers
board. (37) Physician (M.D. or D.O.): license
from Ohio state medical board. (38) Physician assistant: certified by
national commission on certification of physician assistants and license from
Ohio state medical board. (39) Podiatric physician (D.P.M.): license
from Ohio state medical board. (40) Psychologist: license from Ohio
state board of psychology. (41) Radiology services (free-standing)
registration from the Ohio department of health and approved for medicare by
CMS or a deeming organization approved by CMS. (42) Residential care/assisted living
facility: license from Ohio department of health. (43) Sleep laboratory: certified by the
American academy of sleep medicine and approved for medicare by CMS or a
deeming organization approved by CMS. (44) Speech-language pathologist: license
from Ohio state speech and hearing professionals board. (45) Traumatic brain injury (TBI) program:
CARF accreditation for brain injury services (acute or
post-acute). (46) Urgent care facility (free standing):
approved for medicare by CMS. (47) Vocational rehabilitation case
managers: certification for ABVE, occupational health nursing (COHN(S)), CRC,
CDMS, certified vocational evaluator (CVE), certified rehabilitation nurse
(CRRN), or CCM. (48) Vocational rehabilitation case
management interns: (a) Vocational rehabilitation case management may be provided by
a bureau-certified intern. An intern is a non-credentialed individual who
provides vocational case management services and is supervised by a
credentialed vocational case manager, as identified in paragraph (C)(47) of
this rule. (b) To become eligible for bureau certification and provide
service as an intern, the intern must: (i) Enroll with the bureau as an intern. (ii) Qualify to take one of the examinations to become
credentialed, as identified in paragraph (C)(47) of this rule. (c) Bureau certification of vocational rehabilitation case
management interns shall be for a period of four years. (d) Vocational rehabilitation case management interns cannot be
recertified for additional four-year periods.
View Appendix
Last updated April 15, 2024 at 8:31 AM
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Rule 4123-6-02.3 | Provider access to the HPP - provider application and certification criteria.
(A) The bureau shall make available to
each provider a provider certification application and agreement or
recertification application and agreement, as applicable, which shall require
the provider to furnish documentation as provided in rule 4123-6-02.2 of the
Administrative Code. (B) The provider application and
agreement or recertification application and agreement shall require the
provider to make statements that the provider is without impairments that would
interfere with the provider's ability to practice or that would jeopardize
a patient's health, and a statement that the application is without
misrepresentation, misstatement, or omission of a relevant fact or other acts
involving dishonesty, fraud, or deceit. The provider shall provide to the
bureau any additional documentation requested, and shall permit the bureau to
conduct a review of the provider's practice or facility. The provider
shall notify the bureau within thirty days of any change in the provider's
ownership as reported on the application and agreement, or status regarding any
of the credentialing criteria of paragraph (B) or (C) of rule 4123-6-02.2 of
the Administrative Code. (C) The bureau shall review the
application and agreement and all documentation submitted by the provider. The
bureau may cross-check data with other governmental agencies or licensing
bodies. The bureau may refer provider certification and malpractice issues to
the bureau's stakeholders health care quality assurance advisory committee
for review as provided under rule 4123-6-22 of the Administrative
Code. (D) By signing the provider application
and agreement or recertification application and agreement, the provider agrees
to, and the bureau may refuse to certify or recertify or may decertify a
provider for failure to: (1) Provide health
services that are applicable to a work related injury, and not to substantially
engage in the practice of experimental modalities of treatment. (2) Acknowledge and treat
injured workers in accordance with bureau recognized treatment
guidelines. (3) Acknowledge and treat
injured workers in accordance with the vocational rehabilitation
hierarchy. (4) Provide adequate on-call coverage for
patients. (5) Utilize bureau certified providers
when making referrals to other providers. (6) Timely schedule and treat injured
workers to facilitate a safe and prompt return to work. (7) Release information from the national
practitioner data bank or the federation of state licensing boards. The bureau
may submit a report to the appropriate state licensing board or data bank as
required in the event the provider is decertified. (8) Practice in a managed care
environment and adhere to MCO and bureau procedures and requirements concerning
provider compliance, outcome measurement data, peer review, quality assurance,
utilization review, bill submission, and dispute resolution. (9) Adhere to the
bureau's confidentiality and sensitive data requirements, and use
information obtained from the bureau by means of electronic account access for
the sole purpose of facilitating treatment and no other purpose, including but
not limited to engaging in advertising or solicitation directed to injured
workers. (10) Maintain professionalism, integrity, and civility in
the provision of services in the HPP, including in all written and oral
communications with the bureau, the industrial commission, the MCO, injured
workers, employers, and their representatives. (11) Comply with the workers'
compensation statutes and rules and the terms of the provider application and
agreement or recertification application and agreement. (E) Upon review and determination by the
bureau that the provider has met bureau credentialing requirements, the bureau
shall certify or recertify the provider as a bureau certified
provider. (F) The bureau may enter into an addendum
to a physician's provider certification application and agreement or
recertification application and agreement, offering appropriate performance
incentives to enhance physician proficiency in patient care and navigation of
the Ohio workers' compensation system, to physicians who agree
to: (1) Perform enhanced
duties as the treatment team leader in the care of injured workers, as set
forth in the addendum, and (2) Enhanced provider
outcome measurement.
Last updated April 8, 2021 at 12:09 PM
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Rule 4123-6-02.4 | Provider access to the HPP - provider and recertification.
(A) The bureau shall initiate the
recertification process by sending certified providers notice and a
recertification application and agreement, which must be completed, signed and
submitted to the bureau if the provider wishes to be considered for
recertification. (B) Except as otherwise provided in
paragraph (E) of this rule, if the bureau receives a completed and signed
recertification application and agreement from a provider, the provider's
certification shall remain in effect until the bureau issues a final order
approving or denying the provider's application for
recertification. (C) If the bureau does not receive a
completed and signed recertification application and agreement from the
provider within sixty days from the date of the notice sent in accordance with
paragraph (A) of this rule, the bureau shall send a second notice to the
provider stating that the provider has thirty days from the date of the second
notice to complete, sign and submit the recertification application and
agreement to the bureau if the provider wishes to be considered for
recertification. (D) If the bureau does not receive a
completed and signed recertification application and agreement from the
provider within thirty days from the date of the second notice sent in
accordance with paragraph (C) of this rule, the provider's certification
shall lapse. Such lapse of certification is not an adjudication order and is
not subject to appeal pursuant to rule 4123-6-17 of the Administrative
Code. (E) If the bureau receives a completed
and signed recertification application and agreement from a provider after the
provider's certification has lapsed pursuant to paragraph (D) of this
rule, the provider's certification shall remain lapsed until the bureau
issues a final order approving or denying the provider's application for
recertification. (F) All recertification applications and
agreements are subject to review as provided in rule 4123-6-02.3 of the
Administrative Code.
Last updated April 8, 2021 at 12:10 PM
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Rule 4123-6-02.5 | Provider access to the HPP - provider not certified.
(A) A provider not certified or recertified shall cure any
defects in the provider application and agreement or recertification
application and agreement within thirty days of notice by the
bureau. (B) The administrator of the bureau of workers'
compensation, pursuant to rule 4123-6-17 of the Administrative Code, may refuse
to certify or recertify or may decertify a provider where the provider has
failed to comply with the workers' compensation statutes or rules, or the
terms of the provider application and agreement or recertification application
and agreement. (C) Notwithstanding paragraph (B) of this rule, the administrator
may immediately revoke or suspend the certification and terminate the
enrollment of a provider other than a hospital, in accordance with section
4121.443 of the Revised Code. (D) The administrator may impose disciplinary sanctions upon a
provider where the provider has failed to comply with the workers'
compensation statutes or rules governing providers or the terms of the provider
application and agreement or recertification application and agreement. In
imposing a disciplinary sanction against a provider the administrator may
consider, but is not limited to, suspending all reimbursements to a
provider.
Last updated April 8, 2021 at 12:10 PM
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Rule 4123-6-02.6 | Provider access to the HPP -- selection by an MCO.
(A) The bureau shall maintain a public
list of bureau certified providers. The bureau shall make the list of bureau
certified providers available through the bureau's website. (B) An MCO may, but is not required to,
retain a panel of bureau certified providers. A bureau certified provider is
eligible to participate on an MCO's provider panel. A bureau certified
provider may participate in a single MCO panel or may participate in more than
one MCO panel. (C) A provider identified by an MCO for
temporary privileges in its panel of providers that is not a bureau certified
provider shall be assisted by the MCO in applying for bureau provider
credentialing and certification. (D) The bureau or MCO shall not
discriminate against any category of health care provider when establishing
categories of providers for participation in the HPP. However, neither the
bureau nor an MCO is required to accept or retain any individual
provider. (E) The MCO shall include in its panel or
its arrangements with providers a substantial number of the medical,
professional, and pharmacy providers currently being utilized by employees. An
MCO may limit the number of providers on its MCO provider panel or with whom
they enter into arrangements, but must do so based upon objective data approved
by the bureau, such as reasonable patient access, community needs, the
potential number of employees the MCO is applying to service, and other
performance criteria, without discrimination by provider type. (F) A bureau certified provider must
follow the medical management and return to work management approaches of the
MCO medically managing an employee's claim, whether or not the provider is
on the MCO's provider panel, or has an arrangement with the MCO. MCO
guidelines may not be more restrictive for a non-panel provider than for an MCO
panel provider.
Last updated April 8, 2021 at 12:10 PM
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Rule 4123-6-02.7 | Provider access to the HPP - provider decertification procedures.
Effective:
April 15, 2024
(A) Except as otherwise provided in
paragraph (C) of this rule, the administrator of the bureau of workers'
compensation will follow the procedures set forth in this rule to terminate the
enrollment of and decertify a non-facility provider who has failed to comply
with a workers' compensation statute or rule. (1) If the bureau
determines a provider has committed three or more reported violations of the
same workers' compensation statute or rule in a six month period, or five
or more reported violations of any workers' compensation statute or rule
in a six month period, the bureau will serve written notice of the violations
to the provider. (2) If the bureau
determines the provider has committed two or more subsequent reported
violations of any workers' compensation statute or rule for which the
provider previously received notice pursuant to paragraph (A)(1) of this rule,
and the subsequent violations occurred any time within the six month period
following the calendar month in which the provider received notice pursuant to
paragraph (A)(1) of this rule, the bureau will serve written notice of the
violations to the provider, which will include a thirty day period within which
the provider must submit and implement a correction plan signed by the
provider. The bureau will enter the correction plan into the provider's
certification file and will document that the provider is "under
correction plan" during the six month period following the calendar month
in which the provider's thirty day implementation period provided above
expires. If the provider fails to submit a correction
plan within the thirty day implementation period satisfactory to the bureau,
which satisfaction shall not be unreasonably withheld, the bureau shall send
the provider written notification of the failure by certified mail, which shall
include a notice of proposed enrollment termination and decertification
complying with rule 4123-6-17 of the Administrative Code. (3) If the bureau
determines the provider has committed two or more subsequent reported
violations of the same workers' compensation statute or rule for which the
provider previously received notice pursuant to paragraph (A)(2) of this rule
and submitted a correction plan satisfactory to the bureau, and the subsequent
violations occurred any time within the six month period following the calendar
month in which the provider's thirty day implementation period provided in
the notice sent pursuant to paragraph (A)(2) of this rule expires, the bureau
will serve written notice of the violations to the provider, which will include
a notice of proposed enrollment termination and decertification complying with
rule 4123-6-17 of the Administrative Code. (4) If the bureau
determines a provider who has twice received written notice pursuant to
paragraph (A)(1) of this rule for violation of the same workers'
compensation statute or rule has committed a subsequent reported violation of
the same workers' compensation statute or rule within three years of the
date written notification was first sent to the provider by the bureau pursuant
to paragraph (A) of this rule, the bureau will serve written notice of the
violations to the provider, which will include a notice of proposed enrollment
termination and decertification complying with rule 4123-6-17 of the
Administrative Code. (5) The bureau may, in
its discretion, consider mitigating circumstances in its application of the
procedures set forth in paragraphs (A)(1) to (A)(4) of this rule with regard to
an individual provider. Mitigating circumstances may include, but are not
limited to: (a) The violations related to the provision of emergency
treatment; (b) At the time the violations occurred, the provider was not
aware a workers' compensation claim was involved; (c) The provider was initially bureau certified within six months
prior to the violations; (d) The violations were due to bureau or MCO error; (e) The provider billed the bureau for goods or services in fewer
than five workers' compensation claims in the twelve months prior to the
violations; (f) Other documented justification as deemed sufficient by the
bureau. (6) The bureau will serve
all notices to the provider pursuant to this rule in accordance with section
119.05 of the Revised Code. (B) Providers whose enrollment is
terminated and who are decertified pursuant to paragraph (A)(2), (A)(3), or
(A)(4) of this rule are eligible to apply for and be considered for
recertification and reenrollment at any time after two years from the date of
the final administrative or judicial order of enrollment termination and
decertification. (C) The procedures set forth in
paragraphs (A)(1) to (A)(6) of this rule do not apply to, and the administrator
may proceed directly to enrollment termination and/or decertification of a
provider for, the following: (1) Violation of the
minimum provider certification criteria set forth in rule 4123-6-02.2 of the
Administrative Code. (2) Acts of
misrepresentation, misstatement, or omission of a relevant fact or other acts
involving dishonesty, fraud, or deceit on the provider's provider
application and agreement or recertification application and
agreement. (3) Acts involving breach
of the bureau's confidentiality and sensitive data requirements, including
but not limited to failure to maintain the confidentiality of injured worker
medical or claim information. (4) Acts involving misuse
of information obtained from the bureau by means of electronic account access
for a purpose other than facilitating treatment, including but not limited to
engaging in advertising or solicitation directed to injured
workers. (5) Acts involving
advertising or solicitation directed to injured workers in violation of rule
4123-6-02.9 of the Administrative Code. (6) Acts of intentional
misrepresentation, misstatement, or omission of a relevant fact or other acts
involving false, fraudulent, deceptive, or misleading information on reports,
information, and/or documentation submitted by the provider, the
provider's employees, or the provider's agents to the bureau,
industrial commission, claimant, employer, or their representatives, MCO, QHP,
or self-insuring employer in connection with a workers' compensation
claim. (7) Upon peer review
recommendation of the bureau of workers' compensation stakeholders'
health care quality assurance advisory committee (HCQAAC) pursuant to rule
4123-6-22 of the Administrative Code, the bureau of workers' compensation
pharmacy and therapeutics (P&T) committee pursuant to rule 4123-6-21.2 of
the Administrative Code, or other peer review committee established by the
bureau. (8) Revocation or suspension in
accordance with section 4121.443 of the Revised Code.
Last updated April 15, 2024 at 8:31 AM
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Rule 4123-6-02.8 | Provider requirement to notify of injury.
(A) HPP: Within one business day of
initial treatment or initial visit of an injured worker, a provider must report
the employee's injury or occupational disease in accordance with either
paragraph (A)(1) or (A)(2) of this rule. (1) A provider may report an injury to
the MCO responsible for medical management of the employee's treatment.
When reporting the injury to the MCO, the provider shall do so in accordance
with procedures established by the bureau. (2) A provider may report an injury to
the bureau through the bureau's website pursuant to rule 4125-1-02 of the
Administrative Code. (B) QHP: Within one business day of
initial treatment or initial visit of an injured worker, a provider must report
the employee's injury or occupational disease to the QHP or
employer. (C) Self-insuring employer (non-QHP):
Within one business day of initial treatment or initial visit of an injured
worker, a provider must report the employee's injury or occupational
disease to the self-insuring employer.
Last updated April 8, 2021 at 12:10 PM
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Rule 4123-6-02.9 | Provider access to the HPP - provider marketing.
(A) No bureau certified or enrolled
provider shall engage in any advertising or solicitation directed to injured
workers which is false, fraudulent, deceptive, or misleading. (B) No bureau certified or enrolled
provider shall hire, arrange for, or allow any other individual or entity to
engage in any advertising or solicitation directed to injured workers on behalf
of the provider which is false, fraudulent, deceptive, or
misleading. (C) No bureau certified or enrolled
provider shall pay, allow, or give, or offer to pay, allow, or give, any
consideration, money, or other thing of value to an injured worker, or to any
other person, firm, or corporation (including but not limited to free or
discounted examinations, treatment, or other goods or services) as an
inducement to or in return for the injured worker ordering or receiving from
the provider any goods or services for which payment may be made by the bureau,
MCO, QHP, or self-insuring employer under Chapter 4121., 4123., 4127., or 4131.
of the Revised Code. (D) A bureau certified provider that violates this rule may be
subject to termination of enrollment, decertification, or disciplinary
sanctions pursuant to the rules of this chapter of the Administrative
Code.
Last updated April 8, 2021 at 12:10 PM
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Rule 4123-6-02.21 | Provider access to the HPP - non-certified provider enrollment.
(A) The bureau may enroll non-certified
providers eligible under rule 4123-6-06.2 or 4123-6-10 of the Administrative
Code or division (N) of section 4121.44 of the Revised Code to receive
reimbursement for goods and services provided to injured workers, and for this
purpose may require such non-certified providers to complete and sign an
enrollment application as the bureau deems appropriate, provided such
non-certified providers meet the minimum qualifications for their provider
category as set forth in paragraph (C) of rule 4123-6-02.2 of the
Administrative Code. The provider shall notify the bureau within thirty days of
any change in the provider's ownership as reported on the enrollment
application. (B) Persons or entities who do not fall
within the provider categories set forth in paragraph (C) of rule 4123-6-02.2
of the Administrative Code are not eligible for certification as providers. The
bureau may enroll such persons or entities to receive reimbursement for goods
and services provided to injured workers, and for this purpose may require such
persons or entities to complete and sign an enrollment application as the
bureau deems appropriate. (C) The certification of providers who
fall within the provider categories set forth in paragraph (C) of rule
4123-6-02.2 of the Administrative Code shall lapse, and the provider shall be
enrolled with the bureau only, if the provider has had no billing activity with
the bureau for a period of eighteen months or longer while certified. If the
provider submits a bill while the provider's certification is lapsed
pursuant to this paragraph, the provider may apply for recertification.
However, the provider's certification shall remain lapsed until the bureau
issues a final order approving or denying the provider's application for
recertification. (D) The enrollment of a non-certified
provider, person, or entity pursuant to paragraph (A), (B), or (C) of this rule
shall expire if the non-certified provider, person, or entity has had no
billing activity with the bureau for a period of eighteen months or longer
while enrolled as a non-certified provider. (E) Lapse of provider certification pursuant to paragraph (C) of
this rule and expiration of provider certification or enrollment pursuant to
paragraph (D) of this rule do not constitute an adjudication order and are not
subject to appeal pursuant to rule 4123-6-17 of the Administrative
Code.
Last updated April 8, 2021 at 12:11 PM
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Rule 4123-6-02.22 | Provider access to the HPP - ambulatory surgical center arthroplasty center requirements.
Effective:
April 15, 2024
(A) To be eligible for participation in
the HPP as an ambulatory surgical center arthroplasty center, an ambulatory
surgical center must: (1) Be certified as an
ambulatory surgical center under paragraph (C) of rule 4123-6-02.2 of the
Administrative Code. (2) Have a formal joint
replacement program which has been in place for at least one year prior to the
date of application, and have performed a minimum of ten arthroplasty
procedures prior to the date of application. (3) Have a physician
credentialing criteria policy which includes, at a minimum: (a) A statement confirming any surgeon performing the service for
injured workers is board certified in a related surgery specialty; (b) A statement confirming any surgeon performing this service
for injured workers has performed the procedure at the facility within one year
prior to the date of application; (c) A statement confirming any surgeon performing the service for
injured workers has admitting privileges at a hospital within thirty miles of
the facility or otherwise closest hospital; (d) The facility recredentials surgeons at regular
intervals. (4) Have a patient
selection criteria policy for injured workers consistent with applicable
standards of care which includes, at a minimum: (a) The patient is American society of anesthesiologists (ASA)
physical status I (normal healthy patient) or II (patients with mild systemic
disease); (b) The patient is under sixty-five years of age; (c) The patient has a body mass index which is not likely to
affect surgical outcome; (d) The patient has no co-morbid conditions that would be likely
to affect surgical outcome; (e) The patient has one or more individuals to assist with
immediate post-surgical recovery care (home support). (5) Report quality data
measures to the centers for medicare and medicaid services (CMS) under the
ambulatory surgical center quality reporting (ASCQR) program. (6) Have an established
protocol for tracking and reporting the following Ohio association of
ambulatory surgery center (OAASC) quality data measures: (a) Number of extended stays past midnight; (b) Number of unexpected complications; (i) Vomiting which does
not respond to treatment; (ii) Severe pain not
responding to treatment; (iii) Excessive bleeding
necessitating a return to surgery or transfer; (iv) Cardiac or
respiratory arrest; (c) Number of other incidents in the following
areas: (i) Medication
errors; (ii) Medical device
errors; (iii) Unintentional
retained foreign body; (d) Post discharge complications; (i) Infections (thirty
days post-operative; implants up to one year); (ii) Emergency room visit
within forty-eight hours for related issue; (7) List on its
application the specific procedure(s) it is requesting bureau certification to
perform and receive reimbursement for under rule 4123-6-37.3 of the
Administrative Code as an ambulatory surgical center arthroplasty
center. (B) The bureau is authorized to
recredential and recertify a facility to participate in the HPP as an
ambulatory surgical center arthroplasty center in accordance with rule
4123-6-02 of the Administrative Code. (C) The administrator may decertify, or
refuse to certify or recertify the facility as an ambulatory surgical center
arthroplasty center, in accordance with rule 4123-6-17 of the Administrative
Code and Chapter 119. of the Revised Code: (1) If the facility has
failed to meet or maintain any of the criteria for bureau certification as an
ambulatory surgical center arthroplasty center set forth in paragraph (A) of
this rule; (2) Upon the
recommendation of the bureau of workers' compensation stakeholders'
health care quality assurance advisory committee (HCQAAC) or other peer review
committee established by the bureau that injured worker safety would be
compromised by the continued participation of the facility as an ambulatory
surgical center arthroplasty center in the HPP; or (3) As otherwise provided
by this chapter of the Administrative Code.
Last updated April 15, 2024 at 8:31 AM
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Rule 4123-6-02.51 | Provider access to the HPP -- Denial of provider, entity or MCO enrollment/certification based on criminal conviction or civil action.
(A) The administrator may refuse to
certify or recertify, or may decertify from participation in the HPP, any MCO
that: (1) Is owned, directly or
indirectly, by an individual or entity that has a felony conviction in any
jurisdiction, a conviction under a federal controlled substance act, a
misdemeanor conviction for an act involving dishonesty, fraud, or
misrepresentation, a conviction for a misdemeanor committed in the course of
practice, or a felony or misdemeanor conviction involving dishonesty, fraud, or
misrepresentation related to any compensation or benefits payable under Chapter
4121., 4123., 4127., or 4131. of the Revised Code. (2) Has one or more
owners, shareholders, members, partners, managing employees, officers or
directors, who have a conviction as described in paragraph (A)(1) of this rule;
and including any MCO that is no longer so described because of a transfer of
ownership or interest to an immediate family member or a member of the
person's household in anticipation of or following a conviction as
described in paragraph (A)(1) of this rule. (3) Is owned directly, or
indirectly, by an individual or entity who has engaged in specific conduct
which demonstrates financial irresponsibility. Such conduct shall include, but
not be limited to: (a) Specific examples of insolvency of businesses owned or
controlled by the individual or entity; (b) Specific examples of failures to pay debts or
judgments; (c) Specific examples of activity which has defrauded any person,
entity or organization, regardless of whether such activity has resulted in
criminal prosecution; (d) Any finding of fraud in a civil or administrative proceeding
related to any compensation or benefits payable under Chapter 4121., 4123.,
4127., or 4131. of the Revised Code or the equivalent laws of another
state. (B) The administrator may refuse to
enroll, certify or recertify, or may terminate enrollment or decertify from
participation in the HPP, any provider or entity that: (1) Is owned, directly or
indirectly, by an individual or entity that has been convicted of or pleaded
guilty to a criminal offense as set forth in the appendix to rule 4123-6-02.2
of the Administrative Code. The provider or entity is ineligible for
enrollment, certification, or recertification for the same period of
ineligibility provided in the appendix to rule 4123-6-02.2 of the
Administrative Code for the criminal offense. (2) Has one or more
owners, shareholders, members, partners, managing employees, officers or
directors who have a conviction or plea of guilty to a criminal offense as set
forth in the appendix to rule 4123-6-02.2 of the Administrative Code. The
provider or entity is ineligible for enrollment, certification, or
recertification for the same period of ineligibility provided in the appendix
to rule 4123-6-02.2 of the Administrative Code for the criminal
offense. (3) It is owned directly,
or indirectly, by an individual or entity who has engaged in specific conduct
which demonstrates financial irresponsibility as described in paragraph (A)(3)
of this rule. (C) For the purposes of paragraphs (A) and (B) of this
rule: (1) "Entity" means any sole
proprietorship, partnership, corporation, professional association, limited
liability company or any other business organization doing business in this or
any other state. (2) "Immediate family member"
means a person's spouse; natural or adoptive parent; child or sibling,
stepparent, stepchild, stepbrother or stepsister; father-, mother-, daughter-,
son-, brother- or sister-in-law; grandparent or grandchild; or spouse of a
grandparent or grandchild. (3) "Managing employee" means
an individual (including a general manager, office manager, business manager,
administrator or director) who exercises operational or managerial control over
the provider, entity or MCO or part thereof, or directly or indirectly conducts
the day-to-day operations of the provider, entity or MCO or part thereof, or is
involved in the billing functions of the provider, entity or MCO or part
thereof. (4) "Member of household"
means, with respect to a person, any individual with whom they are sharing a
common abode. (5) "Owned directly or
indirectly" means having an interest that includes ownership, as an
individual or through any other entity or entities, of five percent or more in
the provider, entity or MCO at issue. (D) Notwithstanding and in addition to the provisions set
forth in this rule, pursuant to division (C)(1) of section 4121.444 of the
Revised Code the administrator may terminate any agreement between the bureau
and a person or a health care provider or managed care organization or its
owner and cease reimbursement to, decertify and terminate the enrollment of
that person, provider, organization, or owner for services rendered if any of
the following apply: (1) The person, health
care provider, managed care organization, or its owner, or an officer,
authorized agent, associate, manager, or employee of a person, provider, or
organization is convicted of or pleads guilty to a violation of sections
2913.48 or 2923.31 to 2923.36 of the Revised Code or any other criminal offense
related to the delivery of or billing for health care benefits. (2) There exists an entry
of judgment against the person, health care provider, managed care
organization, or its owner, or an officer, authorized agent, associate,
manager, or employee of a person, provider, or organization and proof of the
specific intent of the person, health care provider, managed care organization,
or owner to defraud, in a civil action brought pursuant to section 4121.444 of
the Revised Code. (3) There exists an entry
of judgment against the person, health care provider, managed care
organization, or its owner, or an officer, authorized agent, associate,
manager, or employee of a person, provider, or organization in a civil action
brought pursuant to sections 2923.31 to 2923.36 of the Revised
Code. (E) No person, health care provider, or managed care
organization that has had its agreement with and reimbursement from the bureau
terminated by the administrator pursuant to division (C)(1) of section 4121.444
of the Revised Code, or an owner, officer, authorized agent, associate,
manager, or employee of that person, health care provider, or managed care
organization shall do either of the following: (1) Directly provide
services to any other bureau provider or have an ownership interest, as an
individual or through any other entity or entities, of five percent or more in
a provider of services that furnishes services to any other bureau
provider; (2) Arrange for, render,
or order services for claimants during the period that the agreement of the
person, health care provider, managed care organization, or its owner is
terminated as described in division (C)(1) of section 4121.444 of the Revised
Code; (F) The administrator shall not terminate the agreement or
reimbursement if the person, health care provider, managed care organization,
or owner demonstrates that the person, provider, organization, or owner did not
directly or indirectly sanction the action of the authorized agent, associate,
manager, or employee that resulted in the conviction, plea of guilty, or entry
of judgment as described in division (C)(1) of section 4121.444 of the Revised
Code. (G) Nothing in division (C) of section 4121.444 of the
Revised Code prohibits an owner, officer, authorized agent, associate, manager,
or employee of a person, health care provider, or managed care organization
from entering into an agreement with the bureau if the provider, organization,
owner, officer, authorized agent, associate, manager, or employee demonstrates
absence of knowledge of the action of the person, health care provider, or
managed care organization with which that individual or organization was
formerly associated that resulted in a conviction, plea of guilty, or entry of
judgment as described in division (C)(1) of section 4121.444 of the Revised
Code. (H) Actions taken by the administrator pursuant to this
rule shall be subject to rule 4123-6-17 of the Administrative
Code.
Last updated August 30, 2023 at 1:42 PM
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Rule 4123-6-03.2 | MCO participation in the HPP -- MCO application for certification or recertification.
Effective:
February 1, 2022
(A) Upon request, the bureau shall send
the MCO an application for certification which the MCO may complete and submit
to the bureau. (B) The application submitted to the
bureau by the MCO shall include a list of bureau certified providers in its
provider panel and/or bureau certified providers with which the MCO has
arrangements. (C) Regardless of whether the MCO elects
to retain a provider panel or enters into provider arrangements, the
application submitted to the bureau by the MCO shall include the
following: (1) A description of the
MCO's health care provider panel or provider arrangements, including a
substantial number of the medical, health care professional and pharmacy
providers currently being utilized by injured workers. The provider panel or
provider arrangements shall cover the geographic area in which the MCO plans to
compete, and may include out-of-state providers. (2) A description of how
the MCO's provider panel or provider arrangements will provide timely,
geographically convenient access to a full range of medical services and
supplies for injured workers, including access to specialized
services. (3) A description of the
MCO's process and methodology for credentialing providers in the
MCO's provider panel, if applicable, and the MCO's process and
methodology for assisting non-bureau certified providers in the MCO's
provider panel or with which the MCO has provider arrangements in applying for
bureau provider credentialing and certification. (4) A description of the
MCO's process and methodology for payment of providers in the MCO's
provider panel or under a provider arrangement. (5) A description of the
MCO's policies and procedures for sanctioning and terminating providers in
the MCO's panel, if applicable, and a description of the MCO's
methodology to notify the bureau, employers and employees of any changes in the
MCO's provider panel or provider arrangements. (6) A description of the
MCO's methodology for distributing provider panel and provider arrangement
directories and directory updates to employers and employees. (D) The application for certification
submitted to the bureau by the MCO shall include, at a minimum, the following
information and provisions: (1) A statement that the
application is without misrepresentation, misstatement, or omission of a
relevant fact or other representations involving dishonesty, fraud, or
deceit. (2) A description of the
geographic area of the state of Ohio for which the MCO wishes to be certified
by the bureau. The minimum geographic area is a county. The bureau shall
certify MCO participation on a county basis. The MCO may apply for coverage in
more than one county or statewide. (3) A description of the
MCO that includes, but is not limited to, a profile that includes a disclosure
statement regarding the MCO's organizational structure, including
subsidiary, parent and affiliate relationships, together with historical and
current data. The MCO must identify its principals; provide the MCO's date
of incorporation or formation of partnership, or limited liability company, or
business trust; provide any trade names or fictitious names the MCO is, or has
been, doing business under; provide the number of years the MCO has operated in
Ohio; identify other states in which the MCO is doing business or has done
business; provide a table of organization with the number of employees; and
identify any banking relationships, including all account information with any
financial institutions. (4) A description of the
MCO's business continuity plan. (5) A description of the
bureau approved treatment guidelines used by the MCO, including a description
of how the MCO shall implement the treatment guidelines. (6) A description of the
MCO's utilization review process. (7) A description of the
MCO's quality assurance/improvement standards program and process,
including the use of satisfaction surveys. (8) A description of the
MCO's medical dispute resolution process that meets the requirements of
rule 4123-6-16 of the Administrative Code. (9) A description of the
MCO's administrative and bill payment grievance processes. (10) A description of the
MCO's information system platforms, capabilities and capacities; a
description of the MCO's system for reporting necessary data elements,
including but not limited to those required for performance measurements; and
the MCO's measures in place to ensure data security, including back-up
systems. (11) A description of the
MCO's medical case management policies and procedures. (12) A description of the
MCO's policies and procedures regarding the protection of confidential and
sensitive records. (13) A description of the
MCO's policies and procedures regarding retention of
information. (14) A description of the
MCO's provider relations and education program. (15) A description of the
MCO's employer and employee relations and education program, including but
not limited to a description of methodologies to be used to explain options
available to injured workers, including treatment by non-network providers and
the dispute resolution process. (16) A description of the
MCO's provider bill payment processes including, but not limited to,
clinical editing software (including review criteria, process and
methodology). (17) Attestation of
intent to obtain and maintain insurance coverage as required by the MCO
contract, with proof of such coverage to be submitted to the bureau prior to
execution of the contract, and current workers' compensation
coverage. (18) Attestation of
intent to obtain and maintain professional accreditations as required by the
MCO contract, with proof of such accreditations to be submitted to the bureau
prior to execution of the contract. (19) A description of any and all
individuals and entities the MCO is affiliated with (including, but not limited
to, a subcontractor or subcontractee, vendor or vendee, joint venture or other
arrangement), and a copy of the MCO's contract or agreement with each
individual or entity. For purposes of this rule, "affiliated with the
MCO" shall have the same meaning as defined in paragraph (B) of rule
4123-6-03.9 of the Administrative Code. (20) Other descriptions and requirements
as contained in divisions (F)(1) to (F)(10) of section 4121.44 of the Revised
Code. (E) For MCO recertification, prior to the
expiration of an MCO's certification, the bureau shall send the certified
MCO an application for recertification, which must be completed and returned to
the bureau. The MCO must be able to provide proof of delivery of the completed
application to the bureau upon request. The application for recertification may
be amended from time to time at the bureau's discretion. (F) The bureau shall review the
application for certification or recertification submitted by the MCO. The
bureau reserves the right to cross-check data with other governmental agencies
or licensing or accrediting bodies. (G) During the bureau's review of
the application for certification or recertification, the MCO shall provide to
the bureau any additional documentation requested and shall permit the bureau,
upon request and with reasonable notice given, to conduct an onsite review of
the MCO. (H) An MCO may cure any defects in its
application for certification or recertification within thirty days of notice
by the bureau of such defect in its application. (I) The bureau may require that the
application be accompanied by an application fee, which shall not exceed the
amount sufficient to cover the cost of processing the application. (J) The bureau shall hold as confidential and proprietary
information contained in an MCO's application for certification or
recertification, and other information furnished to the bureau by an MCO for
purposes of obtaining certification or to comply with performance and auditing
requirements established by the administrator, in accordance with divisions
(H)(1) and (H)(2) of section 4121.44 of the Revised Code. (K) The bureau shall not accept or approve any application for
certification or recertification in which the MCO proposes to subcontract or
outsource medical case management services, other than as part of the
MCO's business continuity plan as described in paragraph (D)(4) of this
rule and approved by the bureau. However, an MCO may subcontract onsite or
out-of-state medical case management services with the prior approval of the
bureau, provided such services are conducted under the supervision of the
MCO.
Last updated February 1, 2022 at 9:30 AM
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Rule 4123-6-03.4 | MCO participation in the HPP - MCO certification.
(A) Upon review by and satisfactory to
the bureau that the managed care organization has met bureau certification
standards, the bureau shall certify an MCO as eligible to contract with the
bureau to provide medical management and cost containment services for injured
workers and employers. (B) MCO certification by the bureau shall
be for a period of two years. (C) The bureau may certify any number of
MCOs for each county or statewide. Upon approval by the bureau, an MCO may
expand its coverage area after the first year of certification and every year
thereafter. (D) The bureau shall maintain a current
list of all bureau certified MCOs. The list shall include the name and address
of each MCO and the counties in which the MCO is certified. (E) An MCO may apply to the bureau for recertification beyond the
first two years of certification.
Last updated April 8, 2021 at 12:11 PM
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Rule 4123-6-03.7 | MCO participation in the HPP - bureau's authority to decertify, to refuse to certify or recertify an MCO.
Effective:
November 13, 2015
(A) Should the administrator determine that sufficient evidence exists that an MCO has failed to maintain any of the requirements set forth in division (F) of section 4121.44 of the Revised Code, or to reasonably comply with or to perform in accordance with the terms of a contract between the bureau and the MCO entered into pursuant to division (B)(4) of section 4121.44 of the Revised Code, or has violated a rule adopted under section 4121.441 of the Revised Code, the administrator has the authority to decertify, or refuse to certify or recertify an MCO, in accordance with rule 4123-6-17 of the Administrative Code and Chapter 119. of the Revised Code. (B) Upon a final order of the administrator to decertify, or refuse to recertify an MCO, employees and employers shall not receive services from such MCO pursuant to the HPP. (C) Upon a final order of the administrator to decertify or refuse to recertify an MCO, any obligation of a provider to provide services under the HPP pursuant to a contract or agreement with such MCO shall be null and void.
Last updated May 31, 2023 at 9:50 AM
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Rule 4123-6-03.9 | MCO participation in the HPP - MCO disclosure of relationship.
Effective:
November 13, 2015
(A) If an MCO is affiliated with another individual, corporation, or entity that has had or contemplates activities of any nature with the Ohio workers' compensation system including but not limited to third party administrators, medical or vocational rehabilitation providers, professional employer organizations, and/or transitional work developers: (1) To the extent such relationship creates or presents either the opportunity for a conflict of interest or preferential treatment or the appearance of a conflict of interest or preferential treatment for the managed care organization and/or the other individual, corporation, or entity, the MCO shall provide to the bureau a written description of the resolution of such opportunity for or the appearance of a conflict of interest satisfactory to the bureau; and shall disclose the potential conflict of interest and its resolution to the employers and injured workers assigned to the MCO. (2) The MCO and the other affiliated corporation or entity shall implement complete separation of functions, offices, systems, and staff. Complete separation of staff shall include, but not be limited to, medical and vocational rehabilitation case management staff and marketing staff. (B) For purposes of this rule, an individual, corporation, or entity is "affiliated with an MCO" when it: (1) Owns, is owned by, or is under common ownership with an MCO, directly or indirectly through one or more intermediaries; (2) Controls, is controlled by, or is under common control with an MCO, directly or indirectly through one or more intermediaries; (3) Has a contractual or other business arrangement with an MCO; (4) Has one or more owners, shareholders, partners, members, officers, directors or other persons who exercise operational or managerial control in common with the MCO.
Last updated May 31, 2023 at 9:50 AM
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Rule 4123-6-03.10 | Conflict of interest.
Effective:
February 1, 2010
No individual who is an officer or employee of an MCO shall represent a claimant or employer in any matter before the industrial commission, the bureau of workers' compensation, or a court of competent jurisdiction.
Last updated May 31, 2023 at 9:50 AM
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Rule 4123-6-04.3 | MCO scope of services - MCO medical management and claims management assistance.
(A) The MCO, in conjunction with the
employer, injured worker, attending physician, and the bureau claims personnel
assigned to the claim, shall provide medical management and cost containment
services that facilitate the provision of high-quality, cost-effective medical
care focused on minimizing the physical, emotional, and financial impact of a
work related injury or illness and as appropriate, promotes a safe and timely
return to work. (B) The MCO shall educate employees and employers regarding
access to and use of medical services for work related injuries or illnesses,
and assist the bureau in educating employers and providers, whether in state or
out of state, as to bureau rules, policies and initiatives. (C) The MCO shall comply with bureau procedures for
reporting injuries to the bureau and employers, and instruct the provider to
forward to the MCO and the bureau, in accordance with rule 4123-6-15 of the
Administrative Code, all necessary data to effectuate medical and claims
management. (D) The MCO shall review all bills submitted to it for
payment by a provider consistent with the MCO's previous treatment
reimbursement determination regarding the service billed, the MCO's
utilization standards, the criteria set forth in rule 4123-6-25 of the
Administrative Code, applicable industry standards, and the requirements of the
MCO contract. The MCO shall have in place and operating a grievance hearing
procedure allowing a provider, employer, or injured worker to grieve a disputed
bill payment. (E) The MCO shall refer a medical treatment reimbursement
request in an inactive claim to the bureau, with the MCO's recommendation,
for a determination of both the causal relationship between the original injury
and the current incident precipitating the treatment request and the necessity
and appropriateness of the requested treatment as provided in rule 4123-3-15 of
the Administrative Code. (F) An MCO shall provide medical management and return to
work management services in a claim, as long as the employer remains assigned
to the MCO, regardless of the date of injury of the claim. In cases where an
injured worker has multiple claims with different employers, each claim remains
with the associated employer and is managed by that employer's current
MCO.
Last updated April 8, 2021 at 12:11 PM
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Rule 4123-6-04.5 | MCO scope of services - bureau claims management.
(A) Upon receipt of notification of a
workers' compensation claim, the bureau shall assign a claim number and
shall notify the injured worker, employer and MCO of that claim number. The
bureau shall determine the compensability of the claim and the allowed
conditions of the claim pursuant to the provisions of section 4123.511 of the
Revised Code. The bureau will notify all parties and the MCO of the allowed
conditions in the claim. (B) Upon referral from an MCO of a
medical treatment reimbursement request in an inactive claim, after considering
the MCO's recommendation the bureau will determine, as provided in rule
4123-3-15 of the Administrative Code, both the causal relationship between the
original injury and the current incident precipitating a medical treatment
reimbursement request and the necessity and appropriateness of the requested
treatment. The bureau will notify all parties and the MCO of its
determination. The employer, injured worker, or representative
may appeal the bureau's order to the industrial commission pursuant to
section 4123.511 of the Revised Code. (C) The bureau shall not make medical
payments in a disallowed claim or for conditions not allowed in a claim until
permitted to do so under the provisions of section 4123.511, 4123.512, or
4123.66 of the Revised Code or except as provided by the rules of this chapter
or Chapter 4123-18 of the Administrative Code. The bureau shall notify all
parties and the MCO when a claim or conditions are allowed or disallowed and
indicate whether treatment rendered therefore may or may not be
paid. (D) During the adjudication process, the
provider may continue to render or the MCO may continue to manage medical
services on behalf of the employee, but the bureau shall not pay for medical
services in a disallowed claim or for disallowed conditions. If the claim or
condition is disputed, the MCO shall inform the employee and the provider that
the services provided may not be covered by workers' compensation and may
be the responsibility of the employee.
Last updated April 8, 2021 at 12:12 PM
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Rule 4123-6-04.6 | Return to work assessment.
(A) The bureau may perform a
return-to-work assessment of an injured worker who has eight or more days of
lost time due to a work related injury and who has not returned to work within
an acceptable timeframe as determined by the bureau. (B) The assessment may include, but is
not limited to, the medical case management goals, identification of barriers,
return to work plan, medical stability and vocational status of the
claim. (C) All findings and conclusions of the
assessment and all recommendations for addressing deficiencies shall be
documented in writing to the MCO assigned to the claim. The assigned MCO shall
have five business days from receipt of the bureau's findings to initiate
or complete the recommended action steps identified by the bureau or propose
alternative action steps acceptable to the bureau. (D) If the assigned MCO does not carry
out the recommended action steps or if the MCO fails to propose an acceptable
alternative course of action to resolve the return-to-work barriers, the bureau
may assume the medical and vocational rehabilitation management of the
claim.
Last updated April 8, 2021 at 12:12 PM
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Rule 4123-6-05.2 | Employer access to the HPP - employer enrollment and selection of MCO.
Effective:
August 6, 2020
(A) An employer may select any bureau
certified MCO that has contracted with the bureau, and has not been placed at
capacity pursuant to the MCO contract, during an open enrollment period as
provided in this rule. The bureau shall develop a process for verifying an
employer's MCO selection. (B) The bureau shall select an MCO for a state fund employer that
fails to select an MCO, as necessary. (C) If an MCO merges into or is acquired
by another MCO, the bureau shall assign the employers formerly assigned to that
MCO to the surviving MCO. (D) If the administrator decertifies an
MCO or terminates any agreement or contract between the bureau and an MCO, the
bureau shall randomly assign the employers formerly assigned to the decertified
or terminated MCO to all remaining, eligible MCOs. (E) Selection of an MCO by an employer or
selection by the bureau shall be until the next open enrollment period. At the
bureau's discretion or upon the employer's request, the bureau may
reassign an employer from the MCO if the bureau determines that the
reassignment is in the best interest of both the employer and the
MCO. (F) Once the MCO has been selected by
either the employer or the bureau, the employer shall notify all employees of
the selection. (G) The bureau shall establish an open
enrollment period during which time an employer may change its selection of an
MCO at least once every two years, but no more than once in a year. The
administrator may waive the open enrollment period during a state of emergency
or disaster declared by the governor of Ohio or the president of the United
States. During an open enrollment period, an employer may: (1) Select a new MCO;
or (2) Continue with the
employer's current MCO. In such case, the employer is not required to
notify the bureau during the open enrollment period. (H) The bureau shall maintain and make
available to employers electronically the list of all MCOs contracting with the
bureau, and shall provide adequate notice to employers in writing of the
deadline for new MCO selection. (I) An MCO may not refuse to accept an
employer that has selected it or has been assigned to it by the bureau, unless
the MCO has placed itself at capacity pursuant to the MCO
contract.
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Rule 4123-6-05.3 | Employer access to the HPP - certain solicitation practices by MCOs prohibited.
Effective:
April 15, 2024
(A) An MCO, any individual, corporation,
or entity affiliated with the MCO as defined in rule 4123-6-03.9 of the
Administrative Code, or any other individual, corporation, or entity acting on
behalf of an MCO or for the benefit of an MCO, shall not: (1) Pay, allow, or give,
or offer to pay, allow, or give, to any prospective employer or to any other
person, firm, or corporation not an employee or agent of the MCO, either
directly or indirectly, as an inducement to or in return for an employer's
selection of the MCO, any rebate, premium, or kickback, or any special favor or
advantage, or any other valuable consideration or inducement not provided for
under Chapter 4123-6 of the Administrative Code. (2) Pay, allow, or give,
or offer to pay, allow, or give any commission, consideration, money, or other
thing of value to any person, firm, or corporation not an employee or agent of
the MCO for soliciting, negotiating, procuring, placing, writing, renewing,
forwarding, or transmitting to the bureau an employer's selection of the
MCO. (B) Notwithstanding paragraph (A) of this
rule, the MCO may reimburse to a trade or business association certain expenses
in accordance with the following: (1) The trade or business
association meets the criteria for being a sponsoring organization for group
rating pursuant to section 4123.29 of the Revised Code and rules 4123-17-61 to
4123-17-68 of the Administrative Code. (2) The MCO may reimburse
to the trade or business association only its actual and reasonable expenses
incurred in educating its member employers on bureau and MCO medical management
and cost containment services and related rules, policies, and
processes. (3) The MCO may reimburse
to the trade or business association only its actual and reasonable expenses
incurred in marketing the MCO to its member employers, subject to the limits
set forth in paragraph (B)(4) of this rule. (4) The reimbursement of a trade or
business association's actual and reasonable expenses incurred in
marketing the MCO to its member employers during a calendar year cannot exceed
sixteen one-hundredths of one per cent of the premium of those employers that
are members of the trade or business association and that have selected the
MCO. (5) The MCO and the trade or business
association shall keep accurate records of all marketing and education services
provided to its member employers for a period of four years from the date of
performance of any such service and provide the bureau with access to such
records within a reasonable time after a request for audit of such records by
the bureau. (C) Except as provided in paragraph (B)
of this rule, no person, firm, or corporation not an employee or agent of the
MCO shall knowingly receive any payment, commission, rebate, premium or
kickback, or any other valuable consideration or thing of value described in
paragraph (A) of this rule. (D) For purposes of this rule,
"affiliated with an MCO" has the same meaning as in paragraph (B) of
rule 4123-6-03.9 of the Administrative Code. (E) Agent of the MCO. (1) For purposes of this
rule, "agent" of the MCO means: (a) An insurance agent or broker contracted by the MCO and
licensed by the Ohio department of insurance pursuant to Title XXXIX of the
Revised Code; (b) A corporation or entity contracted by the MCO to conduct
non-telephonic marketing that has not had and does not contemplate having
activities of any nature with the Ohio workers' compensation system so as
to create a conflict of interest or the appearance of a conflict of interest
under rule 4123-6-03.9 of the Administrative Code; (c) A telemarketer or telemarketing firm contracted by the MCO
who has obtained a certificate of registration from the Ohio attorney general
in accordance with Chapter 4719. of the Revised Code. (2) "Agent" of
the MCO does not include the following: (a) A third party administrator, group rating sponsor, business
or trade association; (b) An individual, corporation, or entity affiliated with the MCO
that has had or contemplates having activities with the Ohio workers'
compensation system so as to create a conflict of interest or the appearance of
a conflict of interest under rule 4123-6-03.9 of the Administrative
Code.
Last updated April 15, 2024 at 8:32 AM
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Rule 4123-6-05.4 | Employer access to the HPP; payment for referrals prohibited.
(A) An MCO shall not solicit, receive, or
accept any payment, commission, consideration, money, or other thing of value,
including, but not limited to any rebate, premium, or kickback, as an
inducement to or in return for the MCO's referral of employers to any
sponsoring organization or group for the purpose of participating in a group
experience rating program authorized under section 4123.29 of the Revised Code
and rules 4123-17-61 to 4123-17-68 of the Administrative Code. (B) An MCO shall not solicit, receive, or
accept any payment, commission, consideration, money, or other thing of value,
including but not limited to any rebate, premium, or kickback, as an inducement
to or in return for the MCO's referral of employers to any individual or
entity for the provision of any goods or services. (C) An MCO shall not solicit, receive, or
accept any payment, commission, consideration, money, or other thing of value,
including but not limited to any rebate, premium, or kickback, as an inducement
to or in return for the MCO's referral of injured workers to any provider
for the provision of any goods or services. (D) An MCO that violates this rule may be
subject to decertification and/or termination of its contract pursuant to the
rules of this chapter of the Administrative Code.
Last updated April 8, 2021 at 12:12 PM
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Rule 4123-6-06.2 | Employee access to the HPP - employee choice of provider.
Effective:
February 1, 2022
(A) HPP. (1) Except as provided in
paragraph (A)(2) of this rule, an injured worker may seek medical care for a
work related injury from: (a) A bureau certified provider; or (b) A non-bureau certified provider, subject to an
employee's payment responsibilities as delineated in this
paragraph. (2) Except in cases of
emergency, injured workers may not seek medical care for work related injuries
from themselves or an immediate family member. Injured workers may not select
as physician of record, themselves or an immediate family member. The MCO,
bureau, employer, and industrial commission shall not reimburse treatment to
injured workers delivered, rendered or directly supervised by the injured
worker or an immediate family member. "Immediate family member" shall
have the same meaning as in paragraph (C)(2) of rule 4123-6-02.51 of the
Administrative Code. (3) At the time of an
injury, the injured worker may seek medical care directly from a provider or
may seek assistance from the MCO in selecting a provider. If the employee has
not already sought medical care or selected a provider, the MCO may refer the
employee to a provider or list of providers. The injured worker may, but is not
required to, seek medical care from that provider or providers. The MCO shall
not discriminate against any category of health care provider when referring
the injured worker to a provider. (4) If the injured worker
seeks medical care from a provider, the injured worker shall inform the
provider of the injured worker's MCO and/or employer. The provider shall
then report the work related injury in accordance with rule 4123-6-02.8 of the
Administrative Code. (a) If the provider is a non-bureau certified provider, the MCO
shall inform the provider that the care for the first visit will be compensated
by the MCO if the claim and the treated conditions are subsequently allowed and
that, unless otherwise permitted by paragraph (A)(5)(a) or (A)(5)(b) of this
rule, no further treatment will be authorized. (b) If the provider is a non-bureau certified provider, the
provider shall inform the injured worker upon the initial or emergency
treatment that the provider is not a participant in the HPP and that payment
will not be made by the bureau, MCO, or employer for the cost of further
treatment after the initial or emergency treatment (5) An injured worker may
continue treatment with a non-bureau certified provider under two
circumstances: (a) The MCO has determined that the treatment to be provided by
the non-bureau certified provider is not reasonably available through a like
bureau certified provider and has authorized the non-bureau certified provider
to continue to provide the treatment, or (b) The injured worker may continue to treat with the non-bureau
certified provider, but at the injured worker's own expense without
recourse against the bureau, MCO, or employer. (6) Notwithstanding any
other provision of this rule, if the injured worker's date of injury is
prior to October 20, 1993 and the injured worker's physician of record is
a non-bureau certified provider, the injured worker may continue treatment with
that non-bureau certified provider. The employer's MCO shall manage the
medical care and treatment and return to work services in the claim and shall
manage medical payment for the provider. However, if the injured worker changes
the physician of record for any reason, the injured worker shall select a
bureau certified provider as physician of record. If the injured worker selects
a physician of record who is a non-bureau certified provider, payment for the
provider shall be governed by the provisions of this rule applicable to
non-bureau certified providers. (B) QHP. (1) An injured worker of
an employer that participates in a QHP has freedom of choice of providers
within the QHP network of providers established by the employer's QHP. If
the injured worker's date of injury is prior to the establishment of the
employer's QHP, and the injured worker's physician of record is not a
provider on the panel of the QHP when established, the injured worker may
continue treatment with that physician of record. The physician of record shall
be subject to and participate in the dispute resolution process as provided in
rule 4123-6-69 of the Administrative Code. After the establishment of the QHP,
the employer's QHP shall manage the medical care and treatment in the
claim. If an injured worker changes from the physician of record who is not in
the QHP for any reason, the injured worker shall select a QHP panel provider as
the physician of record. (2) An injured worker of
an employer that participates in a QHP, who is dissatisfied with the health
care services of a provider in the QHP, after written notice to the QHP, may
request a change of providers and may select another provider within the QHP,
or any bureau certified provider. An injured worker's request for change
of provider does not require notification to the bureau, but shall contain the
reasons for the request. The QHP shall approve written requests for a change of
provider within the QHP, or to any bureau certified provider, within seven days
of receipt (3) Notwithstanding the
provisions contained in paragraph (B)(2) of this rule, an injured worker who
incurs a new medical condition, injury or claim requiring medical treatment,
not related to a prior medical condition, injury or claim, shall first seek
treatment from a provider on the panel of the injured worker's
employer's QHP. (4) Medical management of
all injured workers' claims, whether medical services are provided within
or without the QHP network of providers, shall be provided by the
employer's QHP. (5) A provider certified
to participate in the HPP shall be eligible to participate in and to treat
injured workers under the QHP system. (C) Self-insuring employer
(non-QHP). (1) In claims with a date
of injury on or after November 2, 1959, injured workers 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 with a date of injury prior to November 2, 1959, medical
services furnished by the self-insuring employer must be utilized. (2) Emergency treatment
shall not constitute an exercise of free choice of physician. (3) Once an injured
worker of a self-insuring employer goes to a physician for treatment other than
on an emergency basis, the injured worker is deemed to have made a choice of
physician and the injured worker shall notify the employer of a change of
physician. (a) 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. (b) Self-insuring employers shall approve written requests for a
change of physician within seven days of receipt.
Last updated February 1, 2022 at 9:31 AM
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Rule 4123-6-07 | Services and supplies never covered.
The following services and supplies are never
covered by, and shall not be authorized or reimbursed by, the bureau or
MCO: (A) Services and supplies that are never
covered pursuant to other bureau statutes or rules. (B) The following services and supplies,
which are never considered to be durable medical equipment by the
bureau: (1) Home furniture
including, but not limited to: (a) Reclining chairs (except for the seat lift mechanism
portion of a reclining chair); (b) Non-hospital beds, (such as a water bed, adjust-a-sleep
adjustable bed, craftmatic adjustable bed, electropedic adjustable bed, simmons
beautyrest adjustable bed); (c) Hospital bed mattresses larger than a standard (eighty
inches long, thirty-six inches wide) size, except for bariatric hospital bed
mattresses. (2) Home exercise equipment, including
but not limited to such equipment as treadmills and exercise
bikes; (3) Home whirlpools, including built-in
whirlpools and pumps, portable hydrotherapy pools, jacuzzi tubs, portable
saunas and spas, non-portable hot tubs or whirlpools, and
therasaunas. (4) Unsupervised physical reconditioning
programs, except when the criteria have been met for an injured worker who is
participating in a vocational rehabilitation or remain at work
program. (C) Self-administered sympathetic
therapy/interferential therapy. (D) Prescription smoking deterrent drugs
outside an approved smoking cessation program, except when dispensed while the
injured worker is admitted to a hospital during an approved inpatient admission
or during the course of an outpatient visit in a hospital. (E) Drug screening of injured workers
performed by employers or performed in the emergency room at the time of injury
at the request of the employer.
Last updated August 30, 2023 at 2:18 PM
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Rule 4123-6-08 | Bureau fee schedule.
(A) Pursuant to division (A)(1)(h) of
section 4121.441 of the Revised Code, the administrator of workers'
compensation, with the advice and consent of the bureau of workers'
compensation board of directors, develops, maintains, and publishes a provider
fee schedule for the various types of billing codes. The administrator hereby
adopts the professional provider fee schedule indicated in the appendix to this
rule. (B) Whether the MCO has elected to retain
a provider panel or not, an MCO may contract with providers. The MCO shall
provide an MCO fee schedule to each provider that contracts with the MCO,
describing the method of payment, and make the MCO fee schedule available to
the bureau as part of its application for certification. The bureau will
maintain the MCO fee schedule as proprietary information.
View Appendix
Last updated May 1, 2024 at 9:04 AM
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Rule 4123-6-10 | Payment to providers.
(A) HPP. (1) The MCO shall
accumulate medical records and bills for services rendered to injured workers
for provider services and submit the bills electronically to the bureau for
payment in a bureau approved format, utilizing billing policies, including but
not limited to clinical editing, as set forth in the MCO contract. The MCO
shall submit a bill to the bureau within seven business days of its receipt of
a valid, complete bill from the provider. (2) For a provider in the
MCO's panel or with whom the MCO has entered into an arrangement, other
than a hospital, the bureau shall electronically transfer to the MCO for
payment to the provider, in accordance with rule 4123-6-14 of the
Administrative Code, either the lesser of the bureau fee schedule, the MCO
contracted fee, or the charges billed by the provider for the allowed services
rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO
negotiated fee. (3) For a bureau
certified provider who is not in the MCO's panel or with whom the MCO
does not have an arrangement, other than a hospital, the bureau shall
electronically transfer to the MCO for payment to the provider, in accordance
with rule 4123-6-14 of the Administrative Code, either the lesser of the bureau
fee schedule or the charges billed by the provider for the allowed services
rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO
negotiated fee. (4) For a non-bureau
certified provider who is not in the MCO's panel or with whom the MCO does
not have an arrangement, other than a hospital, the bureau shall electronically
transfer to the MCO for payment to the provider for initial or emergency
treatment, in accordance with rule 4123-6-14 of the Administrative Code, either
the lesser of the bureau fee schedule or the charges billed by the provider for
the allowed services rendered, or, if applicable under paragraph (A)(7) of this
rule, the MCO negotiated fee. (5) For a non-bureau
certified provider who is not in the MCO's panel or with whom the MCO does
not have an arrangement, other than a hospital, the bureau shall electronically
transfer to the MCO for payment to the provider for subsequent treatment after
the initial or emergency treatment, in accordance with rule 4123-6-14 of the
Administrative Code, either the lesser of the bureau fee schedule or the
charges billed by the provider for the allowed services rendered, or, if
applicable under paragraph (A)(7) of this rule, the MCO negotiated fee, only
under the following circumstances: (a) Where the treatment provided by the non-bureau certified
provider is not reasonably available through a like bureau certified provider
and the MCO has authorized the treatment pursuant to rule 4123-6-06.2 of the
Administrative Code, or (b) Where the treatment provided by the non bureau certified
provider is reasonably available through a like bureau certified provider, the
non-bureau certified provider may only be reimbursed for the treatment if the
provider becomes bureau certified. If the provider refuses or fails to become
bureau certified, the treatment shall not be reimbursed. (6) For hospital
services, the bureau shall electronically transfer to the MCO for payment to
the hospital, in accordance with rule 4123-6-14 of the Administrative Code,
either the lesser of the applicable amount pursuant to rule 4123-6-37.1
(inpatient) or 4123-6-37.2 (outpatient) of the Administrative Code or the MCO
contracted fee, or, if applicable under paragraph (A)(7) of this rule, the MCO
negotiated fee. (7) The MCO shall have
authority to negotiate fees with providers, either by contract or on a
case-by-case basis, in the following circumstances: (a) As permitted under rule 4123-6-08 of the Administrative Code
(including the appendix to the rule); (b) As permitted under rule 4123-6-37.1, 4123-6-37.2 or
4123-6-37.3 of the Administrative Code; (c) As permitted under rule 4123-18-09 of the Administrative
Code; (d) With non-bureau certified providers outside the state, where
the treatment provided by the non-bureau certified provider is not reasonably
available through a like bureau certified provider; (e) With bureau certified providers and non-bureau certified
providers within the state, where unusual circumstances justify payment above
BWC's maximum allowable rate for the centers for medicare and medicaid
services' healthcare common procedure coding system (HCPCS) level II and
level III coded services/supplies, and such circumstances are documented and
approved by the bureau. (8) The bureau shall not
pay for missed appointments or procedures. If the provider customarily charges
for missed appointments or procedures, the provider shall inform the injured
worker upon the initial or emergency treatment that the provider charges for
missed appointments or procedures and that such charges are the responsibility
of the injured worker. Bills must only contain descriptions of services that
have been actually delivered, rendered, or directly supervised by the provider
for the actual conditions treated. A provider shall not transmit to the MCO or
bureau 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. (B) QHP. (1) Within each QHP, all
payments shall be in accordance with consistent billing and payment policies
and practices established by the QHP and consistent with the provisions
contained in paragraph (K)(5) of rule 4123-19-03 of the Administrative
Code. (2) With the exception
that no financial arrangement between an employer or QHP and a provider shall
incentivize a reduction in the quality of medical care received by an injured
worker, an employer or QHP may pay a QHP panel provider a rate that is the
same, is above or, if negotiated with the provider in accordance with rule
4123-6-46 of the Administrative Code, is below the rates set forth in the
applicable provider fee schedule rules developed by the bureau. Nothing in the
rules pertaining to the QHP system shall be construed to inhibit employers or
QHPs and providers in their efforts to privately negotiate a payment
rate. (3) An employer or QHP
shall pay a bureau certified non-QHP panel provider other than a hospital the
lesser of the bureau fee schedule or the charges billed by the provider for the
allowed services rendered, unless an alternate payment arrangement is
negotiated between an employer or QHP and the provider in accordance with rule
4123-6-46 of the Administrative Code. (4) An employer or QHP
shall pay a bureau certified non-QHP panel hospital the applicable amount under
rule 4123-6-37.1 (inpatient) or 4123-6-37.2 (outpatient) of the Administrative
Code, unless an alternate payment arrangement is negotiated between an employer
or QHP and the provider in accordance with rule 4123-6-46 of the Administrative
Code. (5) Employers'
financial arrangements with company-based providers remain intact and services
provided by company based providers need not be billed separately through QHP
arrangements. (6) An employer in the
QHP system shall authorize and pay for initial or emergency medical treatment
for an injury or occupational disease that is an allowed claim or condition
provided by a non-bureau certified provider as follows: (a) The employer shall pay a non-bureau certified provider only
for initial or emergency treatment of an injured worker for a workers'
compensation injury, unless the QHP specifically authorizes further treatment.
A non-bureau certified provider shall inform the injured worker that the
provider is not a participant in the QHP and that the injured worker may be
responsible for the cost of further treatment after the initial or emergency
treatment, unless payment for further treatment is specifically authorized by
the QHP. The injured worker may continue to obtain treatment from the
non-bureau certified provider, but the payment for the treatment shall be the
injured worker's sole responsibility, except as provided in this
paragraph. (b) An employer or QHP shall pay a non-bureau certified provider
that provides initial or emergency medical treatment or further medical
treatment that has been specifically authorized by the QHP, other than a
hospital, the lesser of the bureau fee schedule or the charges billed by the
provider for the allowed services rendered, unless an alternate payment
arrangement is negotiated between an employer or QHP and the provider in
accordance with rule 4123-6-46 of the Administrative Code. (7) An employer or QHP
shall pay a non-bureau certified hospital that provides initial or emergency
medical treatment or further medical treatment that has been specifically
authorized by the QHP the applicable amount under rule 4123-6-37.1 (inpatient)
or 4123-6-37.2 (outpatient) of the Administrative Code, unless an alternate
payment arrangement is negotiated between an employer or QHP and the provider
in accordance with rule 4123-6-46 of the Administrative Code. (8) The employer or QHP
shall not pay for missed appointments or procedures. If the provider
customarily charges for missed appointments or procedures, the provider shall
inform the injured worker upon the initial or emergency treatment that the
provider charges for missed appointments or procedures and that such charges
are the responsibility of the injured worker. Bills must only contain
descriptions of services that have been actually delivered, rendered, or
directly supervised by the provider for the actual conditions treated. A
provider shall not transmit to the employer or QHP 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. (C) Self-insuring employer
(non-QHP). (1) Payment for medical
services and supplies 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 with the provider in accordance with rule 4123-6-46 of the
Administrative Code. All payments by the self-insuring employer shall be
consistent with the provisions contained in paragraph (K)(5) of rule 4123-19-03
of the Administrative Code. (2) The self-insuring
employer shall not pay for missed appointments or procedures. If the provider
customarily charges for missed appointments or procedures, the provider shall
inform the injured worker upon the initial or emergency treatment that the
provider charges for missed appointments or procedures and that such charges
are the responsibility of the injured worker. Bills must only contain
descriptions of services that have been actually delivered, rendered, or
directly supervised by the provider for the actual conditions treated. A
provider shall not transmit to the 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. (D) Provider duty to report overpayment. A provider that
has identified an overpayment must report and return the overpayment to the
bureau, QHP or self-insuring employer within sixty days of identifying the
overpayment. Providers must exercise reasonable diligence to identify and
quantify overpayments.
Last updated June 13, 2022 at 1:19 PM
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Rule 4123-6-14 | MCO bill submission to bureau.
(A) The bureau shall review all bills
received from the MCO pursuant to paragraph (A)(1) of rule 4123-6-10 of the
Administrative Code for payment eligibility. The bureau's review may
include, but not be limited to, verification of the following: (1) The services were
delivered, rendered, or directly supervised by providers who meet bureau
credentialing and licensing criteria; (2) The bills conform to
the bureau's billing and reimbursement manual in effect on the billed
date(s) of service. (B) The bureau shall electronically transfer funds to the
MCO for allowed payments after receipt of a proper invoice and after a final
adjudication permitting payment for the bill. Upon receipt of funds from the
bureau, the MCO shall pay the provider within seven days or less. The MCO shall
pay to providers at least the amount electronically transferred by the bureau
to the MCO for reimbursement of provider services. (C) A provider that bills an MCO for services in
expectation of payment from the MCO is responsible for the accuracy of all
billing data and information the provider transmits to the MCO. The MCO is
responsible for the accuracy of translating billing data received from the
provider and the accuracy of transmitting billing data to the bureau that
results in payment to the MCO or to the provider.
Last updated April 8, 2021 at 12:16 PM
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Rule 4123-6-14.1 | Records to be retained by MCO.
(A) An MCO shall retain records received
from providers and subcontractors that are utilized by the MCO to perform its
medical management functions, to substantiate the delivery, value, necessity,
and appropriateness of goods and services provided to injured workers, and to
develop electronic billings to the bureau. (1) The MCO shall retain
records relating to a claim so long as the industrial commission and bureau of
workers' compensation have continuing jurisdiction over the claim pursuant
to section 4123.52 of the Revised Code. (2) The MCO shall also
create, maintain, and retain records documenting transactions with the injured
worker, providers, and subcontractors that do not relate to a specific claim,
including but not limited to monthly bank statements, monthly bank records
(e.g., deposit slips), account reconciliations and all supporting documentation
(e.g., monthly check registers, outstanding check lists, voided transactions),
and general and subsidiary ledger accounting records for a period of seven
years from the date of the transaction. (B) The failure of an MCO to create,
maintain, and retain such records shall be sufficient cause for the bureau to
deny payment for goods or services, or for performance fees, or for declaring
overpaid previous payments made to the MCO, and may be cause for
decertification. (C) As used in this rule,
"records" includes, but is not limited to, "record" and
"electronic record" as defined in rule 4125-1-02 of the
Administrative Code.
Last updated August 30, 2023 at 2:18 PM
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Rule 4123-6-15 | Confidentiality of records.
(A) Subject to sections 2317.02, 4123.27,
and 4123.88 of the Revised Code, certain employer premium, payroll, and claim
file information is confidential and exempt from the general open records laws
of Ohio, as set forth in section 149.43 of the Revised Code. (B) In the course of medical management
in the HPP, some confidential information may be provided by the bureau to the
MCO, and/or exchanged among the bureau, the MCO, the employer and its
representative, the injured worker and the injured worker's
representative, the provider, and the provider's employees and agents. All
such parties receiving and/or exchanging confidential information for use in
the HPP shall ensure transmission of confidential information through secured
methods approved by the bureau, including but not limited to encryption,
password protection, facsimile, and other secure methods. (C) All parties receiving and/or
exchanging confidential information for use in the HPP shall not use such
confidential information for any use other than to perform duties required by
the HPP, and shall prevent such information from further disclosure or use by
unauthorized persons. MCOs shall not release any confidential information,
other than in accordance with rule 4123-3-22 of the Administrative Code, to any
third parties (including, but not limited to, parent, subsidiary, or affiliate
companies, or subcontractors of the MCO) without the express prior written
authorization of the bureau. (D) MCOs shall comply with, and shall
assist the bureau in complying with, all disclosure, notification or other
requirements contained in sections 1347.12, 1349.19, 1349.191 and 1349.192 of
the Revised Code, as may be applicable, in the event computerized data that
includes personal information, obtained by the MCO for use in the HPP, is or
reasonably is believed to have been accessed and acquired by an unauthorized
person and the access and acquisition by the unauthorized person causes, or
reasonably is believed will cause a material risk of identity theft or other
fraud. (E) MCOs shall comply with all electronic
data security measures as may be required by Ohio law, Ohio department of
administrative services or other state agency directive, executive order of the
governor of Ohio, and/or the MCO contract.
Last updated August 30, 2023 at 2:18 PM
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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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Rule 4123-6-16.1 | HPP medical treatment guidelines.
Effective:
February 1, 2010
In reviewing medical treatment reimbursement requests pursuant to rule 4123-6-16.2 of the Administrative Code and conducting independent reviews of medical disputes pursuant to rule 4123-6-16 of the Administrative Code, the MCO and the bureau shall refer to treatment guidelines adopted by the bureau. In the event of a conflict between these guidelines and any provision of this chapter of the Administrative Code, the provisions contained in the Administrative Code shall control.
Last updated August 14, 2024 at 10:39 AM
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Rule 4123-6-16.2 | Medical treatment reimbursement requests.
Effective:
October 1, 2024
(A) Medical treatment reimbursement
requests (on form C-9 or equivalent) must be submitted by a provider eligible
to submit such requests to the MCO responsible for medical management of the
claim prior to initiating any non-emergency treatment. The following provider types are eligible to
submit medical treatment reimbursement requests to the MCO: (1) A physician as
defined in rule 4123-6-01 of the Administrative Code; (2) The following
non-physician practitioner types: (a) Advanced practice nurses; (b) Physician assistants; (c) Physical therapists; (d) Occupational therapists; (e) Optometrists; (f) Audiologists; (g) Licensed independent social workers; (h) Licensed professional clinical counselors; (i) Licensed
prosthetists. (B) Medical treatment reimbursement
requests are evaluated by the MCO using the following three-part test (all
parts must be met to authorize treatment reimbursement): (1) The requested
services are reasonably related to the industrial injury (allowed
conditions); (2) The requested
services are reasonably necessary for treatment of the industrial injury
(allowed conditions); (3) The costs of the
services are medically reasonable. (C) For informational purposes, the
bureau may require the provider to include on the medical treatment
reimbursement request the applicable codes, from the edition of the centers for
medicare and medicaid services' healthcare common procedure coding system
(HCPCS) in effect on the date of the request, for the procedures or services
being requested. However, review of the request is directed to the
treatment being requested, and is not to be construed as approving or denying
payment for the specific codes listed by the provider. (D) Medical treatment reimbursement requests in inactive claims
are processed in accordance with rule 4123-3-15 of the Administrative
Code. (E) Medical treatment reimbursement
requests submitted by a physical therapist or occupational therapist must be
accompanied by a prescription as required in paragraph (B) of rule 4123-6-30 of
the Administrative Code, and approval of such requests is valid for no longer
than thirty days unless the approval specifies a longer period and such longer
period is supported by the prescription. (F) Medical treatment reimbursement requests submitted by a
prosthetist must be accompanied by a prescription from the physician of record
or other approved treating provider licensed to practice medicine or
osteopathic medicine. (G) Approval of all medical treatment reimbursement
requests is valid for no longer than six months unless the approval specifies a
longer period. (H) The MCO may dismiss without prejudice medical treatment
reimbursement requests under the following circumstances: (1) The request has been
submitted by a provider who is not enrolled with the bureau and who refuses to
become enrolled, or who is enrolled but non-certified and is ineligible for
payment as a non-certified provider under rule 4123-6-06.2 or 4123-6-10 of the
Administrative Code or division (N) of section 4121.44 of the Revised
Code. (2) The request is not accompanied by
supporting medical documentation that the submitting provider has examined the
injured worker within thirty days prior to the request, or that the injured
worker requested a visit with the provider, and such evidence is not provided
to the MCO upon request (through form C-9A or equivalent). (3) The request duplicates a previous
request that has been denied in a final administrative or judicial
determination where the new request is not accompanied by supporting medical
documentation of new and changed circumstances impacting treatment, and such
evidence is not provided to the MCO upon request (through form C-9A or
equivalent). (4) The underlying claim has been
settled, and the dates of service requested are on or after the effective date
of the settlement. If the request includes both dates of service on or after
the effective date of the settlement and dates of services prior to the
effective date of the settlement, the MCO may dismiss without prejudice only
that portion of the request relating to dates of service on or after the
effective date of the settlement. (5) The underlying claim
has been disallowed or dismissed in its entirety, or the only allowances in the
underlying claim are for substantial aggravation of a pre-existing condition,
and the conditions have been determined in a final administrative or judicial
determination to be in a non-payable status. (6) The services or
supplies being requested are never covered by the bureau pursuant to other
bureau statutes or rules. (7) Unless otherwise
provided in this chapter of the Administrative Code, the MCO has requested from
the submitting provider (through form C-9A or equivalent) supporting medical
documentation necessary to the MCO's evaluation and determination, and
such documentation is not provided to the MCO. (8) A fee bill for the
service was not submitted to the bureau or commission within the applicable
time frame as set forth in rule 4123-3-23 of the Administrative
Code. (I) If the MCO determines that any approved medical
treatment reimbursement request is not medically indicated or necessary, is not
producing the desired outcomes, or the injured worker is not responding, the
MCO may notify the parties of its decision to discontinue payment of approved
treatment that has not already been rendered. This decision is subject to alternative dispute
resolution pursuant to rule 4123-6-16 of the Administrative Code. (J) Notwithstanding any other provision of this rule, the
bureau may reserve the authority to authorize or prior authorize reimbursement
for services including, but not limited to, return to work management services
pursuant to paragraph (D) of rule 4123-6-04.6 of the Administrative Code,
caregiver services, and home and vehicle modifications.
Last updated October 1, 2024 at 9:13 AM
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Rule 4123-6-16.3 | Reimbursement of retroactive medical treatment reimbursement requests.
(A) Except as otherwise provided in
paragraph (D) of this rule, medical treatment reimbursement requests submitted
retroactively to the MCO responsible for medical management of claim by a
provider eligible to submit such requests, without just cause, for
non-emergency treatment delivered, rendered, or directly supervised by the
provider shall, if approved, be reimbursed at seventy-five per cent of the
applicable fee schedule amount, provider may not balance bill the injured
worker for the difference in amount. (B) For purposes of this rule, "just
cause" includes, but is not limited to: (1) The treatment
requested was emergency treatment; (2) The provider was not
aware that services were for a workers' compensation claim; (3) The provider was
non-bureau certified and had no established relationship with the injured
worker; (4) The provider was
initially bureau certified within six months prior to the treatment
request; (5) The treatment
requested was for a pending claim allowance or additional allowance with the
bureau or industrial commission; (6) The treatment
provided was within the bureau's presumptive authorization guidelines, or
does not require prior authorization per the bureau's provider billing and
reimbursement manual; (7) The treatment request
was submitted retroactively due to bureau or MCO error; (8) Other documented
justification as deemed sufficient by the bureau. (C) Determinations that an approved
medical treatment reimbursement request shall be reimbursed at seventy-five per
cent of the applicable fee schedule amount pursuant to paragraph (A) of this
rule shall be subject to the grievance hearing procedure for disputed bill
payments provided by rule 4123-6-04.3 of the Administrative Code. (D) Retroactive medical treatment
reimbursement requests submitted within seven calendar days of the initiation
of treatment or prior to the date of the physician of record or eligible
treating provider's next encounter with the injured worker, whichever is
earlier, shall not be subject to payment reduction under paragraph (A) of this
rule.
Last updated August 14, 2024 at 10:39 AM
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Rule 4123-6-17 | Bureau refusal to certify or recertify, action to decertify a provider or MCO - standards and procedures for adjudication hearings.
Effective:
April 15, 2024
(A) The administrator of the bureau of
workers' compensation may refuse to certify or recertify or may decertify
a provider, MCO, or QHP as provided in this chapter. (B) The bureau will monitor and may
investigate a provider, MCO, or QHP, and may participate with other state or
federal agencies or law enforcement authorities in gathering evidence for such
matters. (C) Prior to the administrator issuing an
adjudication order on the matter, the administrator will afford the provider,
MCO, or QHP an opportunity for a hearing by serving written notice to the
provider, MCO or QHP in accordance with Chapter 119. of the Revised Code. The
notice will include a statement informing the provider, MCO, or QHP that if the
bureau does not receive a request for a hearing within thirty days of the time
of the service of the written notice, the administrator may proceed with an
adjudication order concerning the provider, MCO, or QHP. (D) If no timely request for a public hearing is made by
the provider, MCO, or QHP, the administrator may issue an adjudication order
concerning the provider, MCO, or QHP. (E) If the provider, MCO, or QHP files a timely request for
a hearing, the bureau will schedule the hearing in accordance with sections
119.07 and 119.09 of the Revised Code. The hearing will be held at the bureau
central office in Columbus, but if requested by the provider, MCO, or QHP, the
bureau may hold the hearing in the bureau office closest to the place of
business of the provider, MCO, or QHP. (F) Conduct of hearing. (1) The hearing will be
conducted in accordance with Chapter 119. of the Revised Code. The
administrator may conduct the hearing personally or may delegate the hearing to
a referee, who will be an attorney at law. The referee may be from the
bureau's legal division or an attorney employed by the administrator
especially for such purpose. The bureau has the burden of proof to establish,
by a preponderance of the evidence, cause for suspending or revoking the
certification of a provider, MCO, or QHP. (G) Should the provider, MCO, or QHP be adversely affected
by the order of the administrator, the provider, MCO, or QHP may file a notice
of appeal of the decision in accordance with section 119.12 of the Revised
Code. (H) Any adjudicating order of the administrator to
decertify, or to refuse to recertify a provider, MCO, or QHP shall include a
clear indication of the beginning date of such action.
Last updated April 15, 2024 at 8:32 AM
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Rule 4123-6-18 | Data gathering and reporting.
(A) Pursuant to division (L) of section
4121.44 of the Revised Code and division (A)(1)(f) of section 4121.441 of the
Revised Code, the administrator shall require employees, employers, providers,
MCOs, and plans that participate in the workers' compensation system to
report data to be used by the administrator to: (1) Measure and perform
comparison analyses of costs, quality, appropriateness of medical care, and
effectiveness of medical care delivered by all components of the workers'
compensation system. (2) Compile data to
support activities of the MCOs and to measure the outcomes and savings of the
HPP. (3) Publish and report
compiled data on the measures of outcomes and savings of the HPP to the
governor, the speaker of the house of representatives, and the president of the
senate with the annual report prepared under division (F)(3) of section 4121.12
of the Revised Code. (B) The administrator shall compile at
least annually and make available electronically to each employer a report that
summarizes the performance of each MCO.
Last updated April 8, 2021 at 12:18 PM
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Rule 4123-6-19 | Remain at work services.
Effective:
November 13, 2015
(A) The bureau shall take measures and make expenditures, as it deems necessary, to aid injured workers who have sustained compensable injuries or contracted occupational diseases to remain at work. (B) Remain at work services. (1) An injured worker is eligible to receive remain at work services when: (a) The injury results in a medical only claim which is certified by the employer or is allowed pursuant to a bureau or industrial commission order or a lost time claim with eight or more days of lost time due to a work related injury which is certified by the employer or is allowed pursuant to a bureau or industrial commission order, but the injured worker is not receiving and has not been awarded temporary total compensation or salary continuation in the claim; and, (b) It is documented by the employer, the injured worker, or the physician of record that the injured worker is experiencing problems that are work-related and result from the allowed conditions in the claim. (2) Services provided shall be charged to the employer's risk. (3) The MCO shall determine the need for remain at work services. (4) Within five business days of completion of services, the MCO shall submit a final report to the bureau. (5) The bureau may audit the MCO's utilization of remain at work services. (C) Scope of remain at work services. (1) Remain at work services may include ergonomic study, functional capacity evaluation, job analysis, physical therapy (on site), occupational therapy (on site), physical reconditioning, transitional work, gradual return to work, on the job training, short term training, job modification, tools and equipment, and remain at work case management. (2) The bureau will not reimburse an employer for remain at work services that are provided by the employer (e.g., transitional work, on the job training, gradual return to work). (3) Remain at work services shall cease upon the occurrence of any of the following: (a) A bureau, industrial commission or court order subsequently disallowing the claim. (b) The claim changes to a lost time claim with eight or more days of lost time due to a work related injury and the injured worker receives temporary total compensation or salary continuation in the claim. (c) The effective date of lump sum settlement. (4) A claim that changes to a lost time claim with eight or more days of lost time due to a work related injury may be referred for vocational rehabilitation services as provided under Chapter 4123-18 of the Administrative Code if the injured worker is receiving or has been awarded temporary total compensation or salary continuation in the claim.
Last updated May 31, 2023 at 9:59 AM
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Rule 4123-6-20 | Obligation to submit medical documentation and reports.
(A) A provider is responsible for the
accuracy and legibility of all reports, information, and documentation
submitted by the provider, the provider's employees, or the
provider's agents to the bureau, industrial commission, injured worker,
employer, or their representatives, MCO, QHP, or self-insuring employer in
connection with a workers' compensation claim. The provider, the
provider's employees, and the provider's agents shall not submit or
cause or allow to be submitted to the bureau, industrial commission, injured
worker, employer, or their representatives, MCO, QHP, or self-insuring employer
any report, information, anddocumentation containing false, fraudulent,
deceptive, or misleading information. (B) Physician's medical reports of
work ability. (1) Physicians treating injured workers shall complete,
sign, and submit to the MCO a physician's report of work ability on form
MEDCO-14 or equivalent upon every injured worker encounter,
unless: (a) The injured worker has been awarded compensation for
permanent total disability; (b) The injured worker returns to work without restrictions
within seven days of the injury; or (c) The injured worker is seeing the treating physician
after the treating physician has submitted a MEDCO-14 or equivalent releasing
the injured worker to return to the former position of employment without
restrictions. (2) The physician's report of work
ability must include at a minimum the following: (a) The date of the report; (b) The date of the last examination; (c) The "International Classification of Disease"
diagnosis code(s) recognized in the claim for all conditions and all parts of
the body being treated that are affecting the length of disability, including a
primary diagnosis code, with a narrative description identifying the
condition(s) and specific area(s) of the body being treated; (d) Any reason(s) why recovery has been
delayed; (e) The date temporary total disability began; (f) The current physical capabilities of the injured
worker; (g) An estimated or actual return to work
date; (h) An indication of need for vocational
rehabilitation; (i) Objective findings; and (j) Clinical findings supporting the information in this
rule. (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 injured worker 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 estimated 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 that 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. (D) Supplemental reports or other bureau forms from the
attending physician and other providers may be requested by the bureau,
industrial commission, employer, MCO, QHP, or by the injured worker or
representative. These reports shall be used to determine the appropriateness of
a benefit, bill payment, or allowance. (E) In accepting a workers' compensation case, a
provider assumes the obligation to provide to the bureau, injured worker,
employer, or their representatives, MCO, QHP, or self-insuring employer, upon
written request or facsimile thereof and within five business days, all
medical, psychological, psychiatric, or vocational 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 injured worker to obtain medical services, benefits or
compensation. (F) Independent medical examinations. (1) A provider performing
an independent medical examination of a injured worker shall create, maintain,
and retain sufficient records, papers, books, and documents in such form to
fully substantiate the accuracy of the resulting report submitted to the
bureau, industrial commission, injured worker, employer, or their
representatives, MCO, QHP, or self-insuring employer in connection with a
workers' compensation claim. The provider, the provider's employees,
and the provider's agents shall keep such records in accordance with rule
4123-6-45.1 of the Administrative Code, and such records shall be subject to
audit pursuant to rule 4123-6-45 of the Administrative Code. (2) A provider performing
an independent medical examination of a injured worker shall keep confidential
all information obtained in the performance of the independent medical
examination, including but not limited to knowledge of the contents of
confidential records of the bureau, industrial commission, injured worker,
employer, or their representatives, MCO, QHP, or self-insuring employer. The
provider, the provider's employees, and the provider's agents shall
maintain the confidentiality of such records in accordance with all applicable
state and federal statutes and rules, including but not limited to rules
4123-6-15 and 4123-6-72 of the Administrative Code.
Last updated April 8, 2021 at 12:18 PM
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Rule 4123-6-20.1 | Charges for copies of medical reports.
(A) The purpose of this rule is to
provide parties to a workers' compensation claim reasonable access to and
reasonable charges for medical records necessary for the administration of the
claim. (B) Except as provided in this rule, a
medical provider shall not assess a fee or charge the bureau, industrial
commission, MCO, QHP, self-insuring employer, claimant, employer, or their
representatives for the costs of completing any bureau form or providing any
documentation requested pursuant to rule 4123-6-20 of the Administrative
Code. (1) The bureau shall provide authorized parties to the
claim access to all filed medical records without charge through secure
electronic access. (2) Where the bureau has provided access to medical records
electronically and a party requests copies of such medical records, the bureau
may charge a fee for the copies in accordance with the Ohio public records
laws. (3) Where a provider has filed copies of medical records
with the bureau or MCO and the bureau has provided access to such medical
records electronically or the provider has filed copies of medical records with
the self-insuring employer, if a party requests such medical records of the
provider, the provider may charge a fee for the copies. The provider's fee
shall not exceed the amount allowable under sections 3701.741 and 3701.742 of
the Revised Code. (C) As provided in division (B) of section 4123.651 of the
Revised Code, a claimant shall promptly provide a current signed release of
medical information, records, and reports relative to the issues necessary for
the administration of the claim when requested by the employer. The employer
shall immediately provide copies of all medical information, records, and
reports to the bureau and to the claimant or the claimant's representative
upon request.
Last updated April 8, 2021 at 12:18 PM
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Rule 4123-6-21 | Payment for outpatient medication.
Effective:
August 1, 2021
(A) Except as otherwise provided in rule
4123-6-21.6 of the Administrative Code, medication must be for the treatment of
a work related injury or occupational disease in a claim either allowed by an
order of the bureau or the industrial commission, or recognized by a
self-insuring employer. The bureau may deny a drug or therapeutic class of
drugs as not being reasonably related to or medically necessary for treatment
of the allowed conditions in a claim. (B) Medication may be prescribed by any
treating provider authorized by law to prescribe such medication; however,
reimbursement for medication shall be denied under the following
circumstances: (1) Reimbursement for
prescriptions written by providers who are not enrolled with the bureau and who
refuse to become enrolled shall be denied. (2) Reimbursement for
prescriptions written by providers who are enrolled but non-certified shall be
denied except in the following situations: (a) The prescription is written by a non-bureau certified
provider during initial or emergency treatment of the injured worker if the
injured worker's claim and treated conditions are subsequently
allowed. (b) The prescription is written by a non-bureau certified
provider who is outside the state or within the state where no or an inadequate
number of bureau certified providers exist and the MCO has determined that the
treatment to be provided by the non-bureau certified provider is not reasonably
available through a like bureau certified provider and has authorized the
non-bureau certified provider to continue to provide the
treatment. (c) The prescription is written by a non-bureau certified
provider for an injured worker with a date of injury prior to October 20, 1993,
the provider was the injured worker's physician of record prior to October
20, 1993, and the injured worker has continued treatment with that
non-bureau-certified provider. (C) Drugs covered are limited to those
that are approved for human use in the United States by the food and drug
administration (FDA) and that are dispensed by a registered pharmacist from an
enrolled pharmacy provider. (D) The bureau may require prior
authorization of certain drugs or therapeutic classes of drugs, drugs above a
certain cost threshold, drugs submitted outside a certain time frame from the
date of injury or the last prescription submitted. or drugs being prescribed
for a condition or in a manner not approved by the FDA. The bureau will publish
a list of all such drugs or therapeutic classes of drugs, cost thresholds, or
time frames for which prior authorization is required. (E) Prescriptions for compounded drug
products: (1) Prior authorization
may be required for compounded sterile drug products. (2) Compounded non-sterile
prescriptions. (a) Reimbursement for non-sterile compounded prescriptions will
be denied, except when a commercially available formulary product becomes
unavailable (listed on the "Food & Drug Administration Drug Shortages
List," or "American Society of Health-System Pharmacists Drug
Shortages List"). (b) Reimbursement for non-sterile compounded prescriptions shall
only be considered upon the submission of both: (i) A prior authorization
request, and (ii) A copy of the signed
prescription that lists all active pharmaceutical ingredients. The prescription
must comply with the Ohio state board of pharmacy requirements for a valid
prescription set forth in rules 4729-5-13 and 4729-5-30 of the Administrative
Code. (c) Approval for reimbursement of non-sterile compounded
prescriptions will be for an initial period of thirty days with subsequent
approvals contingent upon commercial product availability. Not more than one
prescription for a non-sterile compounded prescription will be approved for
reimbursement in any thirty day period. (F) Drugs which fall into one of the following categories may be
approved and reimbursed by an MCO as part of a comprehensive treatment plan
submitted by the physician of record or treating physician: (1) Drugs for the
treatment of obesity; (2) Drugs for the
treatment of infertility; (3) Non-compounded parenteral drugs not
intended for self-administration; (4) Drugs used to aid in smoking
cessation; (5) Drugs dispensed to a injured worker
while the injured worker is admitted to a hospital during an approved inpatient
admission or during the course of an outpatient visit in a
hospital. (G) Payment for medications to pharmacy providers shall include
both a product cost component and a dispensing fee component. (1) Except as provided in
this paragraph, product cost component shall be the lesser of the following:
maximum allowable cost, if applicable, or the average wholesale price (AWP) of
the commonly stocked package size minus fifteen per cent. (a) For repackaged brand name medications, the product cost
component shall be calculated using the AWP of the original
labeler. (b) For compounded prescriptions, the product cost component
shall be limited to the lesser of the maximum allowable cost, if applicable,
for each ingredient, or the AWP of the commonly stocked package size minus
fifteen per cent for each ingredient. (c) The maximum reimbursement for any one non-sterile compounded
prescription will be one hundred dollars. (2) The dispensing fee
component for non-compounded prescriptions shall be three dollars and fifty
cents. Only pharmacy providers are eligible to receive a dispensing
fee. (3) The dispensing fee
component for non-sterile compounded prescriptions shall be eighteen dollars
and seventy-five cents. (4) The dispensing fee
component for sterile compounded prescriptions shall be thirty-seven dollars
and fifty cents. (H) 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 by the bureau under paragraph (G) of this rule. The bureau shall
not reimburse any third-party pharmacy biller that submits pharmacy bills on
behalf of a pharmacy provider or that has purchased pharmacy bills from a
pharmacy provider for subsequent submission to the bureau for payment. Pharmacy
providers are required to submit for billing the NDC number 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 the bureau's pharmacy benefit manager's
payment system must be used for billing purposes. The pharmacy provider
shall: (1) Include prescriber information within
bills submitted electronically to the bureau or the bureau's pharmacy
benefits manager for payment. The prescriber information must include the
national provider identifier (NPI) or the drug enforcement administration (DEA)
number; (2) Not pay, allow, or give, or offer to
pay, allow, or give, any consideration, money, or other thing of value to an
injured worker, or to any other person, firm, or corporation (including but not
limited to free or discounted medications or other goods or services) as an
inducement to or in return for the injured worker ordering or receiving from
the provider any medications or other goods or services for which payment may
be made by the bureau, the bureau's pharmacy benefits manager, or MCO
under Chapter 4121., 4123., 4127., or 4131. of the Revised Code; (3) Comply with all applicable billing
instructions contained in the bureau's provider billing and reimbursement
manual in effect on the billed date(s) of service. (I) The bureau may establish a maximum allowable cost for single
source or multi-source 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 FDA and
designated by an "A" code value in the FDA publication,
"Approved Drug Products With Therapeutic Equivalence Evaluations" in
effect on the billed date(s) of service. The methodology used to determine a
maximum allowable cost for a qualified drug product shall be determined by the
bureau. The bureau may choose to utilize the maximum allowable cost list of a
vendor or develop its own maximum allowable cost list. (J) Injured workers 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 for which pharmaceutically
and therapeutically equivalent medication exist, as defined in paragraph (I) of
this rule, shall be liable for the product cost difference between the AWP of
the dispensed brand name drug minus fifteen percent and the established maximum
allowable cost price of the drug product. However, the bureau may approve
reimbursement of the dispensed brand name drug at the AWP of the drug minus
fifteen per cent if the following circumstances are met: (1) The injured worker
has a documented, systemic allergic reaction as a result of taking the generic
equivalent which is consistent with known symptoms or clinical findings of a
medication allergy; or (2) The injured worker
has been prescribed, and has tried, another generic equivalent and the intended
therapeutic benefit has not been achieved or an unacceptable adverse event has
occurred. (K) The following dispensing limitations may be adopted by the
bureau: (1) The bureau may publish supply
limitations for drugs which represent the maximum number of days supply that
may be dispensed at any one time for a single prescription. (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 any
published days supply limit or maximum quantity limit shall be denied. Denials
may be overridden by the bureau in cases where medical necessity and
appropriateness have been determined. (4) Refills of drugs not
scheduled by the DEA requested before eighty per cent of any published days
supply limit has been utilized will be denied. (5) Refills of drugs
scheduled by the DEA requested before ninety per cent of any published days
supply limit has been utilized will be denied. (6) Denials may be overridden by the
bureau for the following reasons with supporting documentation: (a) The injured worker's pharmacy is submitting an early
refill for a shortened days supply to support synchronizing the filling or
refilling of the prescription in a manner that allows the dispensed drug to be
obtained on the same date each month; (b) The injured worker is traveling out of the country and will
be unable to refill medications during that time; (c) The injured worker's pharmacy will be closed for more
than two days. (d) An emergency or disaster, as defined in division (O) of
section 4123.511 of the Revised Code, is declared by the governor of Ohio or
the president of the United States. (L) Except as otherwise provided in paragraph (F) of this rule,
outpatient medications shall be billed to and reimbursed through the
bureau's pharmacy benefits manager. Pharmacy providers must submit bills
for medication by an on-line point-of-service authorization terminal or a
host-to-host link with the bureau's pharmacy benefits manager's
established bill processing system as a condition of provider enrollment or
reimbursement. Submission by paper or by tape-to-tape will not be accepted by
the bureau or the bureau's pharmacy benefits manager. (M) A claimant may request outpatient medication reimbursement in
accordance with rule 4123-6-26 of the Administrative Code using form C-17 or
equivalent. Claimant reimbursement may be limited to the following
situations: (1) Claimants whose
medication is not payable under division (I) of section 4123.511 of the Revised
Code on the date of service, but later becomes payable; (2) Emergency situations
where an enrolled pharmacy provider is not available; (3) Claimants who reside
out of the country. (N) A "pharmacy provider" designation and provider
number can be obtained by a provider who meets all the following
criteria: (1) Has a valid
"terminal distributor of dangerous drugs" as defined in section
4729.01 of the Revised Code if located within Ohio; or an equivalent state
license if located outside of Ohio; and, (2) Has a valid DEA
number; and, (3) Has a licensed
registered pharmacist in full and actual charge of a pharmacy;
and, (4) Has the ability and
agrees to submit bills at the point of service. All state and federal laws and regulations
relating to the practice of pharmacy and the dispensing of medication by a duly
licensed pharmacist must be observed. (O) The bureau may contract with a pharmacy benefit manager to
perform drug utilization review and on-line bill processing, maintain a
pharmacy provider network and prior authorization program for medications, and
provide management reports. The bureau or its vendor may also contract rebate
agreements with drug manufacturers. The bureau may utilize other services or
established procedures of the pharmacy benefits manager which may enable the
bureau to control costs and utilization and detect fraud. (P) The bureau may identify circumstances under which it may
consider reimbursement for pharmacist professional services (also known as
cognitive services) when payment for such services results in a measurable,
positive outcome. The bureau shall be responsible for developing the criteria
which will be used to assess the compensability of billed pharmacist
professional services. The bureau shall be responsible for developing the
structure of the reporting of the measurable outcomes used to justify the
payment of pharmacist professional services, which may include reimbursement
for the dispensing fee component. The amount that could be reimbursed for
pharmacist professional services shall be determined by the
bureau. (Q) The bureau shall retain a registered pharmacist licensed in
the state of Ohio to act as the full-time pharmacy program director to assist
the bureau in the review of drug bills. The pharmacy program director may
assist the bureau in determining the appropriateness, eligibility, and
reasonableness of compensation payments for drug services. The bureau may adopt
a drug formulary with the recommendation of the bureau's pharmacy and
therapeutics committee established by rule 4123-6-21.2 of the Administrative
Code, and may consult with the committee on the development and ongoing annual
review of the drug formulary and other issues regarding
medications.
Last updated December 9, 2024 at 11:06 AM
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Rule 4123-6-21.1 | Payment for outpatient medication by self-insuring employer.
(A) Medication must be for treatment of a
work related injury or occupational 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 may be prescribed by any
treating provider authorized by law to prescribe such medication. (C) Drugs covered in self-insuring
employer claims are limited to those that are approved for human use in the
United States by the food and drug administration (FDA) and that are dispensed
by a registered pharmacist. (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 both a product cost component and a dispensing fee
component. (1) Except as provided in
this paragraph, product cost component shall be the lesser of the following:
maximum allowable cost established under paragraph (N) of this rule, if
applicable, or the average wholesale price (AWP) of the commonly stocked
package size minus fifteen per cent. (a) For repackaged brand name medications, the product cost
component shall be calculated using the AWP of the original
labeler. (b) For compounded prescriptions, the product cost component
shall be limited to the lesser of the the maximum allowable cost, if
applicable, for each ingredient or the AWP of the commonly stocked package size
minus fifteen per cent for each ingredient. (c) The maximum product cost component reimbursement for any one
non-sterile compounded prescription will be four hundred dollars. (2) The dispensing fee
component for non-compounded prescriptions shall be three dollars and fifty
cents, unless the self-insuring employer has negotiated a payment rate with the
pharmacy provider pursuant to rule 4123-6-46 of the Administrative Code. Only
pharmacy providers are eligible to receive a dispensing fee. (3) The dispensing fee
component for non-sterile compounded prescriptions shall be eighteen dollars
and seventy-five cents. (4) The dispensing fee
component for sterile compounded prescriptions shall be thirty-seven dollars
and fifty cents. (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 4123-6-46 of the Administrative Code. Pharmacy
providers are required to submit for billing the national drug code (NDC)
number 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
shall: (1) Include prescriber information within
bills submitted electronically to the self-insuring employer or its vendor for
payment. The prescriber information must include the national provider
identifier (NPI) or the drug enforcement administration (DEA)
number; (2) Not pay, allow, or give, or offer to
pay, allow, or give, any consideration, money, or other thing of value to an
injured worker, of to any other person, firm, or corporation (including but not
limited to free or discounted medications or other goods or services) as an
inducement to or in return for the injured worker ordering or receiving from
the provider any medications or other goods or services for which payment may
be made by the self-insuring employer or its vendor or QHP under Chapter 4121.,
4123., 4127., or 4131. of the Revised Code; (3) Comply with all applicable billing
instructions contained in the bureau's provider billing and reimbursement
manual in effect on the billed date(s) of service. (H) Claimant reimbursement for
medications shall be in accordance with rule 4123-6-26 of the Administrative
Code and 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 4123-6-46
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 thirty 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) Except as otherwise
provided in paragraph (I)(7) of this rule, 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 twenty-one 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, in accordance with the tapering schedules set
forth in the appendix to rule 4123-6-21.5 of the Administrative Code or 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 injured worker and the injured
worker's representative in writing of its decision to terminate. The
employer's notification to the injured worker and injured worker's
representative shall indicate that the injured worker 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 paragraph (K)(5) of rule 4123-19-03 of the Administrative
Code. (7) The self-insuring
employer may terminate current medications that have been removed from the
bureau's outpatient medication formulary set forth in the appendix to
rule 4123-6-21.3 of the Administrative Code without obtaining a physician drug
review. However, the tapering schedules set forth in the appendix to rule
4123-6-21.5 of the Administrative Code would apply. (J) Self-insuring employers may deny
initial requests for a drug or 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 contract with a pharmacy
benefits manager. A self-insuring employer utilizing a pharmacy benefits
manager 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
pharmacy benefits manager's established bill processing system as a
condition of reimbursement, and may refuse submission by paper or by
tape-to-tape. Self-insuring employers utilizing a pharmacy benefits manager may
refuse to reimburse any third-party pharmacy biller that submits pharmacy bills
on behalf of a pharmacy provider or that has purchased pharmacy bills from a
pharmacy provider for subsequent submission to the self-insuring employer for
payment. (L) Self-insuring employers utilizing a pharmacy benefits
manager may require prior authorization of drugs or therapeutic classes of
drugs which appear on the bureau's published list of drugs or therapeutic
classes of drugs for which prior authorization is required. Notwithstanding
rule 4123-19-03 of the Administrative Code, the self-insuring employer shall
approve or deny a prior authorization request within three business days of the
request. (M) Self-insuring employers utilizing a pharmacy benefits
manager 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 supply limitations for drugs which represent the maximum number of days
supply that may be dispensed at any one time for a single
prescription. (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 of drugs not
scheduled by the DEA requested before eighty per cent of any published days
supply limit has been utilized will be denied. (5) Refills of drugs
scheduled by the DEA requested before ninety per cent of any published days
supply limit has been utilized will be denied. (6) Denials may be overridden by the
self-insured employer for the following reasons with supporting
documentation: (a) The injured worker's pharmacy is submitting an early
refill for a shortened days supply to support synchronizing the filling or
refilling of the prescription in a manner that allows the dispensed drug to be
obtained on the same date each month; (b) The injured worker is traveling out of the country and will
be unable to refill medications during that time; (c) The injured worker's pharmacy will be closed for more
than two days. (d) An emergency or disaster, as defined in division (O) of
section 4123.511 of the Revised Code, is declared by the governor of Ohio or
the president of the United States. (N) Self-insuring employers utilizing a pharmacy benefits
manager may apply the maximum allowable cost list of the pharmacy benefits
manager. (O) Injured workers 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 for which pharmaceutically
and therapeutically equivalent medications exist, as defined in paragraph (I)
of rule 4123-6-21 of the Administrative Code, shall be liable for the product
cost difference between the AWP of the dispensed brand name drug minus fifteen
per cent and the established maximum allowable cost price of the drug product.
However, the self-insuring employer or its vendor may approve reimbursement of
the dispensed brand name drug at the AWP of the drug minus fifteen per cent if
the following circumstances are met: (1) The injured worker
has a documented, systemic allergic reaction as a result of taking the generic
equivalent which is consistent with known symptoms or clinical findings of a
medication allergy; or (2) The injured worker
has been prescribed, and has tried, another generic equivalent and the intended
therapeutic benefit has not been achieved or an unacceptable adverse event has
occurred. (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.
Last updated December 9, 2024 at 11:06 AM
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Rule 4123-6-21.2 | Pharmacy and therapeutics committee.
Effective:
August 1, 2024
The bureau of workers' compensation pharmacy
and therapeutics (P&T) committee was created to advise the administrator,
the chief of medical services, and the chief medical officer with regard to
medication therapy issues for injured workers. The bureau will develop and
maintain a list of physician and pharmacist providers, each holding a
professional license in good standing, who have expressed an interest in
serving on the P&T committee and who would add credibility and diversity to
the mission and goals of the committee . Providers may be nominated for
inclusion on the list by provider associations and organizations including but
not limited to: deans of Ohio's allopathic and osteopathic medical
schools, deans of Ohio's colleges of pharmacy, presidents of Ohio's
various allopathic and osteopathic medical associations, the Ohio pharmacists
association, the Ohio state medical board, and the Ohio state board of
pharmacy. (A) The P&T committee consists of the
bureau's pharmacy program director, chief medical officer, and not more
than thirteen nor less than five voting members who are licensed physicians and
licensed pharmacists representing the diverse group of providers that provide
medical care to the injured workers of Ohio as administered through the bureau.
Subject to approval by the administrator, the committee may create any
subcommittees the committee determines are necessary to assist the committee in
performing its duties. Subcommittees will submit their recommendations to the P
& T committee. (B) P&T committee members
must: (1) Be familiar with
issues relating to the treatment of injured workers in the Ohio workers'
compensation system. (2) Be a doctor of
medicine (MD) or doctor of osteopathic medicine (DO), if a
physician. (3) Possess significant
clinical or administrative experience in health care delivery, including but
not limited to pain management, pharmacy practice, medical quality assurance,
disease management, and utilization review. (4) Have experience with
and an understanding of the concepts of evidence-based medicine as well as
contemporary best practices in their respective areas of practice. (5) Not be, or within the
previous twenty-four months have been, an employee of any pharmaceutical
manufacturer, pharmacy benefits manager, or any non-governmental firm or entity
administering state purchased health care program benefits or pharmaceutical
rebates. (C) The appointing authority for members
of the P&T committee is the administrator or the administrator's
designee(s), who will appoint members of the committee from the list of
qualified providers developed and maintained by the bureau. Terms of membership
for individual members of the P&T committee are for one year. Individuals
may be reappointed to subsequent terms as determined by the administrator.
Members may resign or be removed by the administrator at any time. Vacated
terms are filled in a like manner as for the full term appointments for the
remaining term of the vacated member. (D) The pharmacy program director of the
bureau is the chairperson of the P&T committee and is responsible for
providing notice of meetings to the members and for the meeting agenda. In
addition, the pharmacy program director may be self-designated as an ad hoc
member of any subcommittees of the P&T committee. However, the pharmacy
program director is only a voting member of the P&T committee and any
subcommittees in the case of tie votes. The bureau's chief medical officer
and the industrial commission's medical advisor may participate in
discussions; however, they are not voting members. The pharmacy program
director may designate an alternate to serve in the director's absence.
(E) The P&T committee will develop
and establish bylaws for the organization and operations of the committee and
subcommittees, consistent with the provisions of this rule and approval by the
administrator and the chief medical officer. (F) The P&T committee may make such
recommendations as it deems necessary to address any issue impacting the bureau
related to pharmacy or medication therapeutics. The committee is responsible
for responding to requests for recommendation on any such issue submitted by
the bureau's administrator, chief of medical services, chief medical
officer, or pharmacy program director, including: (1) Development and
review of a formulary of approved medications. (2) Development of prior authorization
criteria. (3) Review of proposed medication
treatment guidelines. (4) Review of clinical criteria related
to drug utilization review or specific medication issues. (5) Review of the bureau's pharmacy
providers' professional performance. Any peer review conducted by the
P&T committee will be in accordance with generally accepted standards of
pharmacy practice. The P&T committee may recommend sanctions as well as
termination of any pharmacy provider determined to have consistently failed to
meet such standards. (6) Review of any of the bureau's
medical providers' medication prescribing patterns and practices. Any peer
review conducted by the P&T committee will be in accordance with generally
accepted standards of medical practice applicable to medication prescribing.
The P&T committee may recommend sanctions as well as decertification of any
provider determined to have consistently failed to meet such standards. Any
decertification or sanction of a provider by the bureau pursuant to
recommendation of the P&T committee will be conducted in accordance with
rule 4123-6-17 of the Administrative Code. (7) Review of the bureau's pharmacy
benefit manager's performance and conduct regarding its management of
prescription benefit services for the bureau. (G) The P&T committee will hold at
least two meetings annually. The P&T committee and all subcommittees will
keep written records of the agenda and minutes of each meeting, which will be
maintained by the bureau. (H) The P&T committee will submit an
annual report of its activities and recommendations to the administrator.
(I) Each member of the P&T committee
and its respective subcommittees may be paid such fees as approved by the
administrator or the administrator's designee. The expenses incurred by
the P&T committee and its subcommittees and the fees of their members are
paid in the same manner as other administrative costs of the
bureau.
Last updated December 9, 2024 at 11:06 AM
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Rule 4123-6-21.3 | Outpatient medication
formulary.
Effective:
August 1, 2024
(A) The administrator hereby adopts the
formulary indicated in the appendix to this rule, developed with the
recommendation of the bureau's pharmacy and therapeutics
committee. (B) Except as otherwise provided in
paragraph (F) of this rule, the formulary indicated in the appendix to this
rule shall constitute the complete list of medications that are approved for
reimbursement by the bureau for the treatment of a work related injury or
disease in an allowed claim when dispensed to an injured worker by a registered
pharmacist from an enrolled outpatient pharmacy provider. (C) The formulary indicated in the
appendix to this rule also contains specific reimbursement, prescribing or
dispensing restrictions that have been placed on the use of listed drugs. The
formulary will be reviewed and updated as necessary. The most current version
will be electronically published by the bureau. (D) The administrator will consider
current medical literature and best practices and the recommendations of the
bureau's pharmacy and therapeutics committee when making additions,
deletions, or modifications of coverage of medications listed in the
formulary. (E) The bureau shall provide an expedited
review process for clinically or therapeutically unique medications when
necessary. (F) Notwithstanding paragraph (B) of this
rule, in cases of medical necessity supported by medical documentation and
evidence of need the bureau may reimburse for: (1) New drugs approved
for use in the United States by the food and drug administration (FDA) on or
after the effective date of the formulary, and for new indications approved by
the FDA on or after the effective date of the formulary for existing drugs that
are not on the formulary, with prior authorization, for a period not to exceed
one hundred eighty days from the adjudication date of the first prescription
for the requested drug. (2) Antineoplastic drugs
prescribed for treatment of an allowed cancer condition in a claim.
(3) Antiretroviral drugs
prescribed for: (a) Treatment of an allowed condition of human immunodeficiency
virus in a claim; or (b) Post exposure treatment in an allowed claim or pursuant to
section 4123.026 of the Revised Code. (G) Notwithstanding the appendix to this
rule, in cases of medical necessity supported by medical documentation and
evidence of need the bureau may reimburse for new dosage forms or strengths
approved by the FDA on or after the effective date of the formulary for
existing drugs that are on the formulary, with prior authorization, for a
period not to exceed one hundred eighty days from the adjudication date of the
first prescription for the requested drug.
View Appendix
Last updated December 9, 2024 at 11:06 AM
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Rule 4123-6-21.4 | Coordinated services program.
Effective:
February 1, 2022
The bureau, or a self-insuring employer with a
point-of-service adjudication system, may establish a coordinated services
program (CSP) that requires an injured worker to obtain prescription
medications reimbursed by the bureau or self-insuring employer from a single
designated pharmacy and/or prescriber. (A) Placement in a CSP. (1) The bureau or
self-insuring employer with a point-of-service adjudication system may review
an injured worker for possible placement in a CSP if a review of the claim
indicates the injured worker meets one or more of the following
criteria: (a) Use of three or more different prescribers to obtain
prescriptions of the same or comparable medications per three month time
frame; (b) Receipt of prescription drugs from more than two different
pharmacies per three month time frame; (c) Monthly receipt of three or more prescriptions including
refills for drugs identified by therapeutic drug class as a narcotic analgesic
per three month time frame; (d) Monthly receipt of more than two concurrent narcotic
analgesics in the same therapeutic drug class per three month time
frame; (e) Monthly receipt of more than two narcotic analgesics in the
same therapeutic drug class, more than one benzodiazepine, and more than one
sedative-hypnotics per three month time frame. (2) Upon identification
of an injured worker meeting one or more of the criteria identified in
paragraphs (A)(1)(a) to (A)(1)(e) of this rule, the bureau or self-insuring
employer with a point-of-service adjudication system shall obtain a physician
review of the injured worker's most recent twelve months history of
prescription medications reimbursed by the bureau or self-insuring
employer. (3) If, based on this
physician review, the bureau or self-insuring employer with a point-of-service
adjudication system determines that the injured worker's utilization of
prescription medications during this period was at a frequency or in an amount
that was not medically necessary or appropriate under the criteria set forth in
paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code, or
was potentially unsafe, the bureau or self-insuring employer may place the
injured worker in a CSP. (4) Notwithstanding
paragraphs (A)(1) to (A)(3) of this rule, if the bureau or self-insuring
employer with a point-of-service adjudication system determines that an injured
worker has been convicted of or pled guilty to an offense under Chapter 2925.
of the Revised Code or any other criminal offense related to the misuse of
drugs, the bureau or self-insuring employer may place the injured worker in a
CSP. (5) Placement in a CSP
shall be for an initial period of eighteen months. The bureau or self-insuring
employer with a point-of-service adjudication system may place the injured
worker in the CSP for additional eighteen month periods in accordance with
paragraph (A)(6) of this rule. (6) The bureau or
self-insuring employer with a point-of-service adjudication system may evaluate
an injured worker's medication utilization at the conclusion of each
eighteen month period in the CSP. If the bureau or self-insuring employer
determines that the injured worker's medication utilization continues to
meet the criteria set forth in paragraphs (A)(1) to (A)(4) of this rule, the
bureau or self-insuring employer may place the injured worker in the CSP for an
additional eighteen month period. (7) If an injured worker
placed in the CSP enters a nursing home, residential care/assisted living
facility, or hospice program, the injured worker shall be released from the
CSP. If the injured worker is subsequently discharged from the nursing home,
residential care/assisted living facility, or hospice program during the CSP
period, the bureau or self-insuring employer with a point-of-service
adjudication system may place the injured worker back into the
CSP. (B) Selection of designated pharmacy
and/or prescriber. (1) An injured worker
placed into a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule shall be
given the opportunity to select a designated pharmacy from a list of
participating pharmacies maintained by the bureau or self-insuring employer. If
an injured worker fails to select a designated pharmacy, or selects a
designated pharmacy that is unable or unwilling to accept the injured worker,
the bureau or self-insuring employer may select a designated pharmacy for the
injured worker. (2) An injured worker
placed in a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule may only
change from one designated pharmacy to another in the following
circumstances: (a) The designated pharmacy becomes inaccessible to the injured
worker due to relocation or incapacity of the injured worker or closing of the
designated pharmacy, (b) The designated pharmacy chooses to no longer participate in
the CSP or to provide services to the injured worker in accordance with
paragraph (D)(4) of this rule. (c) The injured worker requests to be assigned to another
designated pharmacy due to personal preference. Not more than one change due to
personal preference shall be approved in a rolling twelve-month
period. (3) An injured worker
placed in the CSP pursuant to paragraph (A)(4) of this rule shall be given the
opportunity to select a designated prescriber from among those bureau certified
providers who meet the definition of physician under paragraph (P) of rule
4123-6-01 of the Administrative Code. If an injured worker fails to select a
designated prescriber, or selects a designated prescriber that is unable or
unwilling to accept the injured worker, the bureau or self-insuring employer
may select a designated prescriber for the injured worker. (4) An injured worker
placed in a CSP pursuant to paragraph (A)(4) of this rule may only change from
one designated prescriber to another in the following
circumstances: (a) The designated prescriber becomes inaccessible to the injured
worker due to relocation or incapacity of the injured worker or closing of the
designated prescriber's practice, (b) The designated prescriber chooses to no longer provide
services to the injured worker, (c) The injured worker requests to be assigned to another
designated prescriber due to personal preference. Not more than one change due
to personal preference shall be approved in a rolling twelve-month
period. (5) All requests for
change of designated pharmacy or designated prescriber must be submitted in
writing to the bureau or self-insuring employer. (C) Operation of the CSP. (1) An injured worker
placed in a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule must obtain
covered prescription medications from the injured worker's designated
pharmacy. During the period the injured worker is placed in the CSP, the bureau
or self-insuring employer shall deny reimbursement for prescription medications
obtained from a pharmacy other than the injured worker's designated
pharmacy, except in cases of emergency as set forth in paragraph (C)(2) of this
rule. (2) Emergency
prescription fills shall be allowed in the following situations: (a) The injured worker is unable to get to their designated
pharmacy, (b) The injured worker's designated pharmacy does not have
the prescribed medication in stock. (3) Emergency
prescription fills shall be limited to a four-day supply. Records of dispensing
for emergency prescription fills are subject to review by the
bureau. (4) An injured worker
placed in a CSP pursuant to paragraph (A)(4) of this rule must obtain all
prescriptions for covered medications from the injured worker's designated
prescriber. During the period the injured worker is placed in the CSP, the
bureau or self-insuring employer shall deny reimbursement for prescriptions
written by providers other than the injured worker's designated
prescriber, except: (a) In cases of emergency as defined in paragraph (F) of rule
4123-6-01 of the Administrative Code; (b) With prior authorization, prescriptions written by a
specialist in cases where the injured worker has been referred to a specialist
for care. (D) Pharmacies participating in the
bureau's CSP. (1) The bureau shall
maintain a list of pharmacies participating in the bureau's CSP that are
eligible for selection by an injured worker as a designated pharmacy. To
participate in the bureau's CSP, a pharmacy must meet the following
criteria: (a) The pharmacy must be enrolled with the bureau and have a
signed agreement with the bureau's pharmacy benefits
manager. (b) The pharmacy must enter into a CSP agreement with the
bureau. (2) Pharmacies
participating in the bureau's CSP agree to perform the following
monitoring activities: (a) For each injured worker in the bureau's CSP for whom the
pharmacy is the designated pharmacy, the pharmacy shall conduct a bimonthly
review of the injured worker's OARRS report from the Ohio board of
pharmacy (or a similar automated prescription monitoring report from the
injured worker's state of residence). (b) The pharmacy shall notify the injured worker's
prescribing physician of any critical findings discovered in the report.
Critical findings are indications of any prescription related activity that
could cause harm to the patient, including but not limited to: (i) Duplication of
therapy, (ii) Excessive doses of
concurrent medications, (iii) Potential drug
interactions or potentiation of side effects. (c) The pharmacy shall notify BWC in writing whenever reports are
made under paragraph (D)(2)(b) of this rule. (d) BWC may request quarterly documentation of the
pharmacy's monitoring activities under paragraphs (D)(2)(a) to (D)(2)(d)
of this rule. (3) Pharmacies
participating in the CSP may receive compensation from the bureau under the CSP
agreement for services provided as part of the CSP. (4) Pharmacies
participating in the bureau's CSP may terminate their CSP agreement with
the bureau and discontinue their participation in the bureau's CSP at any
time upon not less than thirty days written notice to the bureau. Pharmacies
participating in the bureau's CSP may discontinue providing services to an
individual injured worker at any time upon not less than thirty days written
notice to the bureau, the injured worker, and the injured worker's
authorized representative. (5) The bureau may
terminate the CSP agreement of a pharmacy participating in the bureau's
CSP in accordance with the terms of the CSP agreement. (E) Pharmacies participating in a
self-insuring employer's CSP. (1) A self-insuring
employer with a point-of-service adjudication system who establishes a CSP
shall maintain a list of pharmacies participating in the self-insuring
employer's CSP that are eligible for selection by an injured worker as a
designated pharmacy. The list of participating pharmacies shall cover a
geographic area sufficient to provide the self-insuring employer's injured
workers with reasonable access to pharmacy providers. (2) Pharmacies
participating in a self-insuring employer's CSP shall provide not less
than thirty days written notice to an injured worker and the injured
worker's authorized representative prior to discontinuing services to the
injured worker. (F) Disputes. (1) Decisions by the
bureau regarding an injured worker's placement in the bureau's CSP,
assignment of a designated pharmacy or designated prescriber, or denial of an
injured worker's request for change of designated pharmacy or designated
prescriber may be appealed to the industrial commission in accordance with
section 4123.511 of the Revised Code. (2) Decisions by a
self-insuring employer regarding an injured worker's placement in the
self-insuring employer's CSP, assignment of a designated pharmacy or
designated prescriber, or denial of an injured worker's request for change
of designated pharmacy or designated prescriber shall indicate that the injured
worker has the right to request a hearing before the industrial
commission.
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Rule 4123-6-21.5 | Standard dose tapering schedules.
Effective:
February 1, 2022
(A) The bureau hereby adopts the standard
dose tapering (weaning) schedules for the prescription medications indicated in
this rule, and the appendix to this rule. (B) These weaning schedules apply to denials for payment of
the indicated medications by the bureau, self-insuring employers, MCOs, QHPs,
and the industrial commission when: (1) The medication has been previously allowed for
treatment of an allowed condition in the claim; (2) The denial is based upon a finding that the medication
is no longer medically necessary or appropriate for treatment of the allowed
condition; and (3) The prescriber has submitted a written treatment plan
reflecting an intention to discontinue the medication and a request for
reimbursement of the weaning period. (C) The approved weaning duration will be the weaning
period requested by the prescriber, or the weaning period outlined in this rule
or the appendix to this rule, whichever is less. (D) Weaning from opioids: Upon denial of reimbursement for
an opioid, reimbursement for a weaning period will only be approved if the
prescribed total daily morphine equivalent dose is sixty or greater.
(1) The approved duration of the opioid weaning period must
allow for a ten percent reduction of the total daily morphine equivalent dose
per week, or a larger reduction with a shorter duration as requested by the
prescriber. (2) Requests to approve additional time for weaning for
rates slower than a ten per cent dose reduction per week will be denied.
(E) Weaning from benzodiazepines: The weaning period for
benzodiazepines is set forth in the appendix to this rule.
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Rule 4123-6-21.6 | First fill of outpatient medications.
Effective:
August 1, 2024
(A) In accordance with division (B) of
section 4123.66 of the Revised Code, the administrator has established a
program to make immediate payment, under the circumstances set forth in this
rule, for the first fill of prescription drugs for medical conditions
identified in an application for compensation or benefits under section 4123.84
or 4123.85 of the Revised Code that occurs prior to the date the administrator
issues an initial determination order under division (B) of section 4123.511 of
the Revised Code. (B) The appendix to this rule shall
constitute the complete list of medications, and the maximum quantity of such
medications, that are approved for reimbursement by the bureau for first fill
prior to issuance of an initial determination order. Except as otherwise
provided in paragraph (C) of this rule, drugs not listed in the appendix to
this rule are not eligible for reimbursement by the bureau under the first fill
program. (C) Notwithstanding paragraph (B) of this
rule, in cases of medical necessity supported by clinical documentation and
evidence of need the bureau may, with prior authorization, reimburse for the
first fill of medications that are eligible for reimbursement under rule
4123-6-21.3 of the Administrative Code but are not listed in the appendix to
this rule. (D) Reimbursement of outpatient
medications by the bureau under the first fill program shall be subject to the
following limitations: (1) Approval for
reimbursement of medications under the first fill program will be limited to
the quantity limits listed in the appendix to this rule, and no refills will be
approved; (2) With the exception of
antivirals, antiretrovirals, and antibiotics, approval for reimbursement of
medications under the first fill program will be limited to one drug per
therapeutic drug class listed in the appendix to the rule; (3) Extemporaneous
compounded prescriptions are not eligible for reimbursement by the bureau under
the first fill program. (E) Pharmacy providers shall be
reimbursed for dispensing drugs under this rule in the manner described in rule
4123-6-21 of the Administrative Code provided that the prescriber, or their
agent has indicated the prescription is for a work related injury and signed
the prescription blank. A pharmacist or pharmacy intern who receives a
telephone prescription may also write and sign that it is work related on the
prescription. (F) If a claim in which the first fill of
outpatient medication was reimbursed by the bureau pursuant to this rule is
ultimately disallowed in a final administrative or judicial order, and if the
employer is a state fund employer who pays assessments into the surplus fund
account created under section 4123.34 of the Revised Code, the payment for
outpatient medication made pursuant to this rule shall be charged to and paid
from the surplus fund account and not charged through the state insurance fund
to the employer against whom the claim was filed.
View Appendix
Last updated December 9, 2024 at 11:06 AM
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Rule 4123-6-21.7 | Reimbursement of opioids in the treatment of pain for a work related injury or occupational disease.
Effective:
September 1, 2020
This rule governs the bureau's reimbursement
of opioid prescriptions used to treat acute, subacute, and chronic pain in a
work related injury or occupational disease. (A) Definitions. For purposes of this rule: (1) "Acute
pain," "chronic pain," "morphine equivalent dose
(MED)," and "subacute pain" have the same meanings as defined in
rule 4731-11-01 of the Administrative Code. (2) "OARRS"
means the "Ohio Automated Rx Reporting System" drug database
established and maintained pursuant to section 4729.75 of the Revised
Code. (3) "Opioid"
has the same meaning as "opioid analgesic" as defined in section
3719.01 of the Revised Code. (B) Reimbursement for opioid
prescriptions used to treat a work related injury or occupational disease is
limited to claims in which current best medical practices as implemented by
rules 4731-11-13 and 4731-11-14 of the Administrative Code and this rule are
followed. The bureau will not reimburse for any further
prescriptions for opioids if the applicable criteria of rules 4731-11-13 and
4731-11-14 of the Administrative Code and this rule are not met. A
prescriber's failure to comply with these rules may be subject to peer
review by the bureau of workers' compensation pharmacy and therapeutics
(P&T) committee pursuant to rule 4123-6-21.2 of the Administrative Code,
the bureau of workers' compensation stakeholders' health care quality
assurance advisory committee (HCQAAC) pursuant to rule 4123-6-22 of the
Administrative Code, or other peer review committee established by the bureau,
or subject to decertification pursuant to rule 4123-6-02.7 of the
Administrative Code. (C) Opioid utilization for acute pain.
Reimbursement for ongoing opioid prescriptions
for acute pain will only be provided when the prescriber has both complied with
rule 4731-11-13 of the Administrative Code and has documented in the medical
record the appropriateness and safety of the medication in the same manner as
in paragraphs (A) and (B) of rule 4731-11-14 of the Administrative Code. (D) Opioid utilization for subacute and
chronic pain. (1) Ongoing reimbursement
for opioid prescriptions for subacute and chronic pain will only be provided
when the prescriber has complied with rule 4731-11-14 of the Administrative
Code. (2) In addition to
paragraph (D)(1) of this rule, when prescribing opioids at or above an average
daily dose of fifty MED per day, the prescriber must complete and document in
the patient records: (a) A validated risk assessment, not less than every three
months; and (b) Urine drug screens, with frequency based upon the
results of the validated risk assessment and upon presence or absence of
aberrant behaviors or other indications of substance misuse, abuse, substance
use disorder, or diversion. (E) Paragraph (D) of this rule does not
apply when the opioid is prescribed for an injured worker in the situations
described in paragraph (H) of rule 4731-11-14 of the Administrative Code.
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Rule 4123-6-21.8 | Reimbursement for Services to Assist in the Discontinuation of Medications.
Effective:
September 1, 2020
This rule governs the bureau's reimbursement
for services to aid injured workers in discontinuing medications which may be
necessary and appropriate in the treatment of work related injuries, but which
may increase the risk of dependency, misuse, and substance use disorder in some
injured workers if continued. Medically necessary and appropriate services to
aid injured workers in discontinuing these medications may include services
which provide functional restoration and pharmacologic and non-pharmacologic
treatment alternatives. (A) Assessment services will be
reimbursed when the medical documentation reflects: (1) The injured worker is
currently receiving a medication prescribed for and reimbursed in the injured
worker's claim; (2) The injured worker
has expressed a desire to discontinue the medication(s) and is willing to
participate in a treatment program; and (3) The physician of
record determines, based on clinical observation and other factors, that a
dependency assessment may be appropriate. (B) Ongoing services, subject to
paragraph (C) of this rule, will be reimbursed when the results of the
dependency assessment indicate treatment is medically necessary and appropriate
to aid in the discontinuation of the medication and a treatment plan and
monthly documentation of the injured worker's participation and progress
in the treatment plan are submitted. (C) The bureau will reimburse outpatient,
inpatient, or any combination of inpatient and outpatient treatment for the
purpose of discontinuing medication for: (1) Up to a total of
forty-two days of inpatient care during the life of the claim; and (2) Up to a total of
eighteen months of outpatient care during the life of the claim. (D) The bureau will reimburse medically
necessary and appropriate medications prescribed for assisting the injured
worker's discontinuance of the targeted medication.
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Rule 4123-6-22 | Stakeholders' health care quality assurance advisory committee.
Effective:
February 1, 2022
The bureau of workers' compensation
stakeholders' health care quality assurance advisory committee (HCQAAC)
was created to advise the administrator, the chief of medical services, and the
chief medical officer with regard to medical quality issues. A list of medical
providers, each holding a professional license in good standing, who have
expressed an interest in serving on the HCQAAC, and who would add credibility
and diversity to the mission and goals of the HCQAAC shall be developed and
maintained by the the bureau. Providers may be nominated for inclusion on the
list by provider associations and organizations including but not limited to:
deans of Ohio's allopathic and osteopathic medical schools, deans of
Ohio's colleges of pharmacy, deans of Ohio's dental schools, the dean
of the Ohio college of podiatric medicine, the Ohio state medical association,
the Ohio state osteopathic association, the Ohio state chiropractic
association, specialty board associations of Ohio, the Ohio podiatric medical
association, the Ohio psychological association, the Ohio dental association,
the Ohio pharmacists association, the Ohio hospital association, the Ohio state
medical board, the Ohio state chiropractic board, the Ohio state psychology
board, the Ohio state pharmacy board, and the Ohio state dental board. (A) The HCQAAC shall consist of the
bureau's chief medical officer, the chief of medical services and not more
than thirteen nor less than five voting members representing the diverse group
of providers that provide medical care to the injured workers of Ohio as
administrated through the bureau. The committee may create any subcommittees
that the committee determines are necessary to assist the committee in
performing its duties. Any subcommittee recommendations shall be submitted to
the HCQAAC committee. (B) HCQAAC members must meet the
following requirements: (1) Providers must be
familiar with issues relating to the treatment of injured workers in the Ohio
workers' compensation system. (2) Providers must
possess significant clinical or administrative experience in health care
delivery, including but not limited to, medical quality assurance, disease
management, and utilization review. (3) Providers must have
experience with and an understanding of the concepts of evidence based medicine
as well as contemporary best practices in their respective areas of
practice. (C) The appointing authority for members
of the HCQAAC shall be the administrator or the administrator's
designee(s), who shall appoint members of the HCQAAC from the list of qualified
providers developed and maintained by the bureau. Terms of membership for
individual members of the HCQAAC shall be for one year. Individuals may be
reappointed to subsequent terms as determined by the administrator. Vacated
terms shall be filled in a like manner as for the full term appointments and
shall be for the remaining term of the vacated member. (D) The chief medical officer of the
bureau shall be the chairperson of the HCQAAC and shall provide notice of
meeting to the members and be responsible for the meeting agenda. In addition,
the chief medical officer and chief of medical services may be self-designated
as an ad hoc member of any subcommittees of the HCQAAC. However, the chief of
medical services is not a voting member of the HCQAAC or any subcommittee, and
the chief medical officer is a voting member of the HCQAAC and any
subcommittees only in the case of tie votes. The industrial commission's
medical advisor, and one physician chosen by the MCOs may participate in
discussions; however, they are not voting members. (E) The HCQAAC shall develop and
establish bylaws for the organization and operations of the committee and
subcommittees, subject to the requirements of this rule and approval by the
administrator and the chief medical officer. (F) The HCQAAC shall be responsible to
respond to requests for recommendation on any medical quality assurance issue
submitted by the bureau's administrator, chief of medical services, or
chief medical officer including : (1) Review of medical
treatment guidelines referred to the bureau; (2) Review of any of the
bureau's policies and procedures related to medical quality assurance
issues; (3) Review of any of the
bureau's medical providers' professional performance and conduct,
including bureau certification and malpractice issues. Any peer review
conducted by the HCQAAC will be in accordance with generally accepted standards
of medical practice. The HQAAC may recommend sanctions as well as
decertification of any provider determined to have consistently failed to meet
such standards . Any decertification or sanction of a provider by the bureau
pursuant to recommendation of the HCQAAC will be conducted in accordance with
rule 4123-6-17 of the Administrative Code; (4) Review of any of the
bureau's managed care organizations' professional performance and
conduct regarding the management of medical services for the bureau. This may
include interfacing with any quality assurance committee of any of the
individual managed care organizations. The HCQAAC may make such recommendations as it
deems necessary to address any medical quality assurance issue impacting the
bureau. (G) The HCQAAC shall hold at least
quarterly meetings. The HCQAAC and all subcommittees shall keep written records
of the agenda and minutes of each meeting, which will be maintained by the
bureau. (H) The HCQAAC shall submit an annual
report of its activities and recommendations to the administrator.
(I) Each member of the HCQAAC and its
respective subcommittees may be paid such fees as approved by the administrator
or administrator's designee. The expenses incurred by the HCQAAC and its
subcommittees and the fees of their members shall be paid in the same manner as
other administrative costs of the bureau.
Last updated February 1, 2022 at 9:34 AM
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Rule 4123-6-25 | Payment for medical supplies and services.
Effective:
February 1, 2022
(A) Medical or other services to be
approved for payment must be rendered as a result of an injury sustained or
occupational disease contracted by an injured worker in the course of and
arising out of employment. The claim must be allowed by an order of either the
bureau of workers' compensation or the industrial commission, or have been
recognized by a self-insuring employer. Medical supplies and services will be considered
for payment when they are reasonably related to the work related injury, the
requested services are reasonably necessary for treatment of the work related
injury, and the costs of the services are medically reasonable. Payment for
services rendered to an injured worker shall be paid to a health care provider
only when the provider has either delivered, rendered or supervised the
examination, treatment, evaluation or any other medically necessary and related
services. Provider supervision of services shall comply with the requirements
of the provider's regulatory board and the centers for medicare and
medicaid services (CMS), if applicable, for supervision of the service, as in
effect on the billed date of service, unless otherwise specified in the
bureau's provider billing and reimbursement manual in effect on the billed
date of service. By submitting any fee bill to the bureau, in either hardcopy
or electronic format, the health care provider affirms that medical supplies
and services have been provided to the injured worker as required by this
rule. Providers billing for services rendered shall
follow the procedures set forth in the bureau's provider billing and
reimbursement manual in effect on the billed date of service. (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 edition of the CMS
healthcare common procedure coding system (HCPCS) in effect on the billed date
of service 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 in
effect on the billed date of service (date of discharge for inpatient
services). (c) 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) Diagnosis
codes. Providers must use the appropriate
"International Classification of Diseases, clinical modification"
codes for the condition(s) treated to indicate diagnoses. (D) Prior to services being delivered, the provider must make
reasonable effort to notify the injured worker, 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 work
related 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-insured
employer for services that are not related to the claimed or allowed
condition(s) related to the work related 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 injured worker for services determined as medically unnecessary through the
use of bona fide peer review based on accepted treatment guidelines.
Last updated February 1, 2022 at 9:34 AM
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Rule 4123-6-26 | Claimant reimbursement.
Effective:
February 1, 2022
(A) When the claimant or any other person
making payment on behalf of the claimant, including a volunteer, pays for
medical services or supplies directly to a health care provider and the medical
services or supplies meet the criteria in paragraph (B) of rule 4123-6-16.2 of
the Administrative Code, the payor shall be reimbursed upon submission of
evidence of the receipt and payment for that medical service or supply. Except
as otherwise provided in paragraphs (A)(1) and (A)(2) of this rule, the payor
will receive no more than the amount that would have been paid to the health
care provider as provided by this chapter. (1) In cases where the
payor is the claimant's health insurer, if the claimant seeks
reimbursement for an out-of-pocket copayment, the claimant may be reimbursed
for the copayment and the claimant's health insurer may be reimbursed up
to the amount that would have been paid to the health care provider as provided
by this chapter. (2) In cases where the
claimant pays a pharmacy out of pocket for an outpatient medication because the
medication is not payable under division (I) of section 4123.511 of the Revised
Code on the date of service, if the medication later becomes payable, the
claimant may be reimbursed the full amount of the claimant's out-of-pocket
payment. (B) When the bureau has already made
payment to the health care provider, the payor shall be informed to seek
reimbursement from the provider. The bureau shall inform a claimant or payor
whether a health care provider participates in the HPP or QHP. (C) Requests for reimbursement pursuant
to this rule shall be subject to the timeframes set forth in division (B) of
section 4123.52 of the Revised Code and in rule 4123-3-23 of the Administrative
Code.
Last updated February 1, 2022 at 9:35 AM
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Rule 4123-6-27 | Treatment by more than one physician.
Effective:
February 12, 1997
Promulgated Under:
Ch 119.
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 in advance of treatment. This rule does not apply in cases of emergency, or where the physician of record's approved treatment plan indicates the necessity for multidisciplinary services.
Last updated May 31, 2023 at 11:03 AM
Supplemental Information
Authorized By:
–
Amplifies:
–
Five Year Review Date:
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Rule 4123-6-29 | Request for information by the treating provider.
Effective:
February 1, 2010
A provider treating an injured worker may, at any time, make a request in writing, facsimile, or e-mail, in accordance with the bureau's confidentiality and sensitive data requirements, for relevant information concerning conditions, treatment or history for the claim. The request for information shall be accompanied by an appropriate patient release of medical information. A prompt response will be given to this request.
Last updated May 31, 2023 at 11:03 AM
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Rule 4123-6-30 | Payment for physical medicine.
Effective:
February 1, 2022
(A) "Physical medicine" is the
evaluation and treatment of an injured worker by physical measures and the use
of rehabilitative procedures, with or without assistive devices, for the
purpose of preventing, correcting, or alleviating any work related disability.
Physical medicine includes the establishment and modification of physical
rehabilitation programs, treatment planning, instruction, and consultative
services. "Physical measures" include massage, heat, cold, air,
light, water, electricity, sound, manipulation, and the performance of tests of
neuromuscular function as an aid to such treatment. Physical medicine 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 medicine includes, but not
limited to, chiropractic treatments, physiotherapy, and physical
therapy. (B) Physical medicine must be prescribed
by the physician of record or other approved treating provider licensed to
practice medicine, osteopathy, chiropractic, mechanotherapy, dentistry,
podiatry, or a certified registered nurse anesthetist, nursing clinical nurse
specialist, certified nurse midwife, certified nurse practitioner, or physician
assistant. Physical medicine may be provided in the physician's office or
referred to another licensed provider. (C) To be eligible for reimbursement,
physical medicine services must be provided by a physician or chiropractic
physician, or a physical therapist, occupational therapist, massage therapist,
athletic trainer, or other qualified non-physician provider practicing within
the scope of their license, certification, or registration. (D) Fees for up to twelve physical
medicine treatments within sixty days following the date of injury may be
reimbursed without prior authorization, provided the treatments are for allowed
soft tissue and musculoskeletal conditions in allowed claims and the criteria
set forth in paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the
Administrative Code are met. Otherwise, physical medicine treatment must be
prior authorized.
Last updated February 1, 2022 at 9:35 AM
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Rule 4123-6-31 | Payment for miscellaneous medical services and supplies.
(A) Acupuncture. Acupuncture is eligible for reimbursement when
prior authorized and administered by a licensed doctor of medicine, doctor of
osteopathic medicine and surgery, or doctor of podiatric medicine, a doctor of
chiropractic who holds a certificate to practice acupuncture from the Ohio
state chiropractic board, or a non-physician acupuncturist licensed pursuant to
and practicing in compliance with Chapter 4762. of the Revised Code. (B) Orthotic devices. (1) Payment is made only
for those orthotic devices prescribed in writing by the physician of record or
treating physician for treatment of an allowed injury or occupational disease.
(2) Orthotic devices are
eligible for reimbursement only when 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 will be made within sixty
days of fitting and application without additional charge by the supplier of
the orthotic device. (3) Measurement,
transportation, or other expenses incurred by the supplier-orthotist are not
eligible for reimbursement, except when the supplier-orthotist needs to travel
beyond the limits of the metropolitan community in which they maintain their
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 in those circumstances will be paid for traveling expenses
on a round-trip basis when 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. (C) Dental care. (1) Payment for dental
care will be made in the following cases: (a) Where the work related accident causing the injury also
results in the damage or loss of the injured worker's artificial teeth or
other denture. Once the artificial teeth or other denture(s) have been
repaired, replaced, or adjusted, no further repair, replacement, or adjustment
will be approved. (b) Where a work related injury or occupational disease has
caused damage or adversely affected the injured worker's natural
teeth. (2) 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 caused by an allowed injury or occupational
disease. (D) Eyeglasses and contact
lenses. (1) Payment for
eyeglasses or contact lenses will be made in the following cases: (a) Where the work related accident causing the injury also
results in the damage or loss of the injured worker's eyeglasses or
contact lenses. Once the eyeglasses or contact lenses have been repaired,
replaced, or adjusted, no further repair, replacement, or adjustment will be
approved. (b) Where loss of vision is the result of an allowed injury or
occupational disease. (2) Refractions will be approved in
situations described in paragraph (D)(1)(b) of this rule. (3) When medical evidence indicates a
need due to an allowed injury or occupational disease contact lenses may be
approved instead of eyeglasses. (4) Glasses or contact lenses will be
approved for treatment purposes, when necessary, as a result of the allowed
injury or occupational disease. Any subsequent adjustment or change in an
injured worker's glasses or contact lenses, if medically necessary for
treatment of the allowed injury or occupational disease, will also be
approved. (E) Hearing aids. Payment for hearing aids will be made in the
following cases: (1) Where the work
related accident causing the injury also results in the damage or loss of the
claimant's hearing aid(s) Once the hearing aid(s) have been repaired,
replaced, or adjusted, no further repair, replacement or adjustment will be
approved. (2) When a partial loss
of hearing is the result of an allowed injury or occupational
disease. (F) Diagnostic testing, nerve injections,
and imaging. (1) Requests for
diagnostic electromyography (EMG), nerve conduction study (NCS), epidural
injections, nerve blocks, and medical imaging will be reimbursed when medical
evidence shows that the diagnostic EMG, NCS, epidural injection, nerve block,
or medical imaging is medically necessary either to develop a plan of treatment
for, or to pursue more specific diagnoses reasonably related to, an allowed
condition and the criteria of paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2
of the Administrative Code are met. (2) When the results of
the diagnostic EMG, NCS, epidural injections, nerve block, or medical imaging
indicate a non-allowed condition, therapeutic treatment for such non-allowed
condition will not be reimbursed unless the condition is additionally allowed
in the claim. (3) Requests for
duplicative diagnostic EMG, NCS, or medical imaging will not be reimbursed
absent evidence of new or changed medical circumstances since the last
diagnostic EMG, NCS, or medical imaging, or other medical evidence supporting
the need for additional diagnostic testing or imaging that meets the criteria
of paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative
Code. (4) With medical evidence
supporting the necessity, reimbursement for diagnostic epidural injections or
nerve blocks: (a) May include up to three spinal levels, unilaterally or
bilaterally, contiguous to the level of the allowed condition; and (b) May include one repeat diagnostic injection to confirm
a pain relief response prior to submission of requests for reimbursement of
therapeutic treatment at the allowed level. (5) Medical imaging
includes magnetic resonance imaging (MRI), computed tomography scan (CT),
discogram, positron emission tomography (PET), myelogram, X-ray, and
ultrasound. (G) Once payment for orthotic devices,
artificial teeth or other dentures, eyeglasses, contact lenses, or hearing aids
has been made, replacement requests may be denied in instances of malicious
damage, neglect, culpable irresponsibility, or wrongful
disposition.
Last updated June 3, 2024 at 8:32 AM
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Rule 4123-6-32 | Payment for lumbar fusion surgery.
Effective:
February 1, 2022
Reimbursement for lumbar fusion surgery for
treatment of allowed conditions in a claim resulting from an allowed industrial
injury or occupational disease shall be limited to claims in which current best
medical practices as implemented by this rule are followed. This rule governs the bureau's reimbursement
of lumbar fusion surgery to treat a work related injury or occupational
disease. It is not meant to preclude, or substitute for, the surgeon's
responsibility to exercise sound clinical judgment in light of current best
medical practices when treating injured workers. A provider's failure to comply with the
requirements of this rule may constitute endangerment to the health and safety
of injured workers, and claims involving lumbar fusion surgery not in
compliance with this rule may be subject to peer review by the bureau of
workers' compensation stakeholders' health care quality assurance
advisory committee (HCQAAC) pursuant to rule 4123-6-22 of the Administrative
Code or other peer review committee established by the bureau. Medical treatment reimbursement requests (on form
C-9 or equivalent) for lumbar fusion surgery are not subject to dismissal by
the MCO pursuant to paragraph (F)(7) of rule 4123-6-16.2 of the Administrative
Code. (A) Prerequisites to consideration of
lumbar fusion surgery. Except as otherwise provided in paragraph (A)(4)
of this rule, authorization for lumbar fusion shall be considered only in cases
in which the following criteria are met: (1) Conservative
care. (a) The injured worker must have had at least sixty days of
conservative care for low back pain, with an emphasis on: (i) Physical
reconditioning; (ii) Avoidance of
opioids, when possible; and (iii) Avoidance of
provider catastrophizing the explanation of lumbar MRI findings. (b) The injured worker's comprehensive conservative care
plan may include, but is not limited to, one or more of the
following: (i) Relative
rest/ice/heat; (ii) Anti-inflammatories; (iii) Pain management /
physical medicine rehabilitation program; (iv) Chiropractic /
osteopathic treatment; (v) Physical medicine
treatment as set forth in rule 4123-6-30 of the Administrative
Code; (vi) Interventional spine
procedures / injections. (2) The operating surgeon
requesting authorization for lumbar fusion surgery must have personally
evaluated the injured worker on at least two occasions prior to requesting
authorization for lumbar fusion surgery. (3) The injured worker
must have undergone a comprehensive evaluation, coordinated by both the injured
worker's physician of record or treating physician and the operating
surgeon, in which all of the following have been documented: (a) Utilization and correlation of all of the following
tools: (i) Visual analog scale
(VAS); (ii) Pain
diagram; (iii) Oswestry low back
disability questionnaire. (b) A comprehensive orthopedic / neurological examination,
including documentation of all of the following categories: (i) Gait; (ii) Spine (deformities,
range of motion, palpation); (iii) Hips and sacroiliac
joints; (iv) Motor; (v) Sensation; (vi) Reflexes; (vii) Upper motor neuron
signs. (c) Diagnostic testing. (i) Lumbar X-rays
(including flexion and extension views) and a lumbar MRI or lumbar CT (with or
without myelography) must be performed; (ii) Electromyography
(EMG) / nerve conduction study (NCS) may be performed if questions still remain
during surgical planning. (d) Discussion and consideration of opportunities for vocational
rehabilitation. (e) Review of current and previous medications
taken. (i) If opioid management
is in process, review for best practices; (ii) Consider impact of
surgery on opioid load. (f) Health behavioral assessment (pre-surgical). Biopsychosocial factors that may affect
treatment of the injured worker's allowed lumbar conditions are considered
modifiable conditions that may change the need for surgery or improve surgical
outcomes if appropriately addressed, and must be addressed if identified in the
assessment. The health behavioral assessment and any identified interventions
may be ordered by the injured worker's physician of record or treating
physician, or the operating surgeon. (g) Accounting and assessment of the following co-morbidities to
stratify additional associated risks: (i) Smoking; (ii) Body mass index
(BMI); (iii) Diabetes; (iv) Coronary artery
disease; (v) Peripheral vascular
disease. The co-morbidities indicated above are
considered modifiable conditions that may improve surgical outcomes if
appropriately addressed, and must be addressed if identified in the
assessment. (h) The injured worker and the physician of record, the treating
physician, or the operating surgeon must have reviewed and signed the
educational document, "What BWC Wants You to Know About Lumbar Fusion
Surgery," attached as an appendix to this rule. (4) The prerequisites to
consideration of lumbar fusion surgery set forth in paragraphs (A)(1) to (A)(3)
of this rule may be waived in cases of: (a) Progressive functional neurological deficit; (b) Spinal fracture; (c) Tumor; (d) Infection; (e) Trauma care; (f) Emergency as defined in rule 4123-6-01 of the Administrative
Code; and/or (g) Other catastrophic spinal pathology causally related to the
injured worker's allowed conditions. (B) Authorization for lumbar fusion
surgery where the injured worker has no prior history of lumbar surgery at the
level for which the fusion is requested. (1) Authorization for
lumbar fusion shall be considered in cases where the injured worker has no
prior history of lumbar surgery only when the injured worker remains highly
functionally impaired despite a trial of at least sixty days of conservative
care as provided in paragraph (A)(1)(a) of this rule (unless waived pursuant to
paragraph (A)(4) of this rule) and one or more of the following are
present: (a) Mechanical low back pain with instability of the lumbar
segment and no history of lumbar surgery. (b) Spondylolisthesis of twenty-five per cent or more with one or
more of the following: (i) Objective
signs/symptoms of neurogenic claudication; (ii) Objective
signs/symptoms of unilateral or bilateral radiculopathy, which are corroborated
by neurologic examination and by MRI or CT (with or without
myelography); (iii) Instability of the
lumbar segment. (c) Lumbar radiculopathy with stenosis and bilateral
spondylolysis. (d) Lumbar stenosis necessitating decompression in which
facetectomy of greater than or equal to fifty per cent or more is
required. (e) Primary neurogenic claudication and/or radiculopathy
associated with lumbar spinal stenosis in conjunction with spondylolisthesis or
lateral translation of three mm or greater or bilateral pars
defect. (f) Degenerative disc disease (DDD) associated with significant
instability of the lumbar segment. (g) Spinal stenosis, disc herniation, or other neural compressive
lesion requiring extensive, radical decompression with removal of greater than
fifty per cent of total facet volume at the associated level. The surgeon must document why the surgical
lesion would require radical decompression through the pars interarticularis
(critical stenosis, recurrent stenosis with extensive scarring, far lateral
lesion). (2) For purposes of this
paragraph, instability of the lumbar segment is defined as at least four mm of
anterior/posterior translation at L3-4 and L4-5, or five mm of translation at
L5-S1, or eleven degrees greater end plate angular change at a single level,
compared to an adjacent level. (C) Request for lumbar fusion surgery
where the injured worker has a history of prior lumbar surgery at the level for
which the fusion is requested. (1) If a trial of at
least sixty days of conservative care as provided in paragraph (A)(1)(a) of
this rule has failed to relieve symptoms (or has been waived pursuant to
paragraph (A)(4) of this rule) and the injured worker has had a prior
laminectomy, discectomy, or other decompressive procedure at the same level,
lumbar fusion should be considered for approval only if the injured worker has
one or more of the following: (a) Mechanical (non-radicular) low back pain with instability at
the same or adjacent levels. (b) Mechanical (non-radicular) low back pain with
pseudospondylolisthesis, rotational deformity, or other condition leading to a
progressive, measureable deformity. (c) Objective signs/symptoms compatible with neurogenic
claudication or lumbar radiculopathy that is supported by EMG/NCS, lumbar MRI,
or CT and detailed by a clinical neurological examination in the presence of
instability of three mm lateral translation with at least two prior
decompression surgeries at the same level. (d) Evidence from post laminectomy structural study of
either: (i) One hundred per cent
loss of facet surface area unilaterally; or (ii) Fifty per cent
combined loss of facet surface area bilaterally. (e) Documented pseudoarthrosis or nonunion, with or without
failed hardware, in the absence of other neural compressive
lesion. (2) For purposes of this
paragraph, instability of the lumbar segment is defined as at least four mm of
anterior/posterior translation at L3-4 and L4-5, or five mm of translation at
L5-S1, or eleven degrees greater end plate angular change at a single level,
compared to an adjacent level. (D) Lumber fusion surgical after
care. The physician of record or treating physician
must follow the injured worker until the injured worker has reached maximum
medical improvement (MMI) for the allowed lumbar conditions. The operating surgeon must follow the injured
worker until the injured worker has reached a plateau relative to the lumbar
fusion and the surgeon has determined no further surgical related treatment is
medically necessary. (1) In the first six
months post-operatively, the injured worker must be seen by both the physician
of record or treating physician and the operating surgeon at least every two
months to monitor the injured worker's progress, rehabilitation needs,
behavioral patterns or changes, and return to work willingness and/or
status. During this period, the physician of record or
treating physician and the operating surgeon shall determine the
following: (a) Fusion status; (b) Pain and functional status; (c) MMI status of injured worker; (d) Residual level of functional capacity; (e) Appropriateness for vocational rehabilitation. (2) From six months to
one year post-operatively, if the injured worker continues to experience
significant functional impairment despite the lumbar fusion, the following
actions are recommended: (a) Pain and functional status (repeat VAS / pain diagram /
Oswestry) (b) Repeat baseline orthopedic / neurological
examination; (c) Repeat health behavioral assessment; (d) Revisit appropriate diagnostic imaging. (e) Coordinate with MCO to develop a plan of care / return to
functional status.
Last updated February 1, 2022 at 9:36 AM
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Rule 4123-6-33 | Payment for health and behavior assessment and intervention services.
Effective:
February 1, 2022
This rule governs the bureau's reimbursement
for health behavior assessment and intervention (HBAI) services offered to
injured workers who may benefit from an assessment that focuses on identifying
behavioral barriers impeding the injured worker's recovery which may be
addressed through intervention services. (A) An injured worker shall be eligible
for consideration of HBAI services if the injured worker has the capacity to
understand and respond meaningfully during the health behavior assessment
process and: (1) The injured
worker's physician of record determines: (a) The injured worker is not progressing with their injury after
the initial course of treatment; and (b) The injured worker's healing appears to be delayed due
to behavioral barriers; or (2) The injured worker
is being evaluated by the physician of record, treating physician or operating
surgeon for lumbar fusion surgery pursuant to rule 4123-6-32 of the
Administrative Code. References in this rule to "physician of
record" shall also include the "treating physician or operating
surgeon" with regard to HBAI services requested or performed in connection
with lumbar fusion surgery pursuant to rule 4123-6-32 of the Administrative
Code. (B) Providers must indicate the
appropriate "International Classification of Diseases, clinical
modification" codes for the injured worker's allowed physical
condition(s) being treated, and must utilize the applicable codes, from the
edition of the centers for medicare and medicaid services' healthcare
common procedure coding system (HCPCS) in effect on the date of the request,
for the services being requested: (1) Provider types who
are eligible to bill evaluation and management codes must utilize evaluation
and management codes when billing for HBAI services; (2) Provider types who
are not eligible to bill evaluation and management codes must utilize the
applicable HBAI service codes when billing for HBAI services; (3) HBAI services must be
directed toward, and billed with, the injured worker's allowed physical
condition(s); (4) The bureau of
workers' compensation shall not reimburse any HBAI services rendered to
diagnose or treat psychological conditions, as the focus of these services is
not on mental health but on factors impacting the prevention, treatment, or
management of physical health problems and treatments. (C) Health behavior assessment
services. (1) The physician of
record requesting a health behavior assessment must submit a medical treatment
reimbursement request for the assessment (on form C-9 or equivalent) to the
injured worker's MCO. (2) The physician of
record must document the following to support the request for the
assessment: (a) History of the industrial injury or occupational disease
resulting in the allowed conditions in the claim; (b) Recognized behavioral barriers impeding the injured
worker's recovery from the allowed conditions in the claim; (c) Documentation of the initial course of treatment, including
all treatment and diagnostic studies as of the date of the request, including
all results; (d) The assessment is not duplicative of other provider
assessments. (3) The health behavior
assessment may be performed by any provider whose professional scope of
practice as defined under state law includes health behavior assessment
services. (4) The provider
conducting the health behavior assessment must provide a written summary report
to the physician of record indicating the findings of the assessment and
appropriate recommendations for intervention services, if any. The report shall
include at a minimum the following: (a) History of the industrial injury or occupational disease
resulting in the allowed conditions in the claim; (b) Overview of treatment and diagnostic studies to date and
results; (c) Use of one or more currently accepted and validated screening
tools; (d) Assessment conclusions/findings including, at a
minimum: (i) Identification and/or
validation of existence of behavioral barriers; (ii) A statement as to
whether the injured worker's healing or recovery progress from the allowed
conditions is impeded by the identified behavioral barriers; (iii) Recommendation of
possible intervention services and goals to address the identified behavioral
barriers; and (iv) The expected
duration of the recommended intervention services; (5) Except as otherwise
provided in rule 4123-6-32 of the Administrative Code, only one health behavior
assessment per year may be approved for an injured worker. (6) Health behavior
re-assessment services. (a) One re-assessment per year may be approved for an injured
worker who has undergone health behavior intervention services. (b) A physician of record requesting a re-assessment
must: (i) Submit a medical
treatment reimbursement request for the reassessment (on form C-9 or
equivalent) to the injured worker's MCO; and (ii) Provide clear
rationale for why a re-assessment is required, including new and changed
circumstances in the injured worker's physical status. (7) The provider
conducting the health behavior assessment or re-assessment of an injured worker
may not provide health behavior intervention services for the same injured
worker. (D) Health behavior intervention
services. (1) After review of the
assessment, the physician of record shall: (a) Determine the medically necessary and appropriate health
behavior intervention services to be provided; and (b) Submit a medical treatment reimbursement request for the
services (on form C-9 or equivalent) to the injured worker's
MCO. (2) The health behavior
intervention services may be performed by any provider whose professional scope
of practice as defined under state law includes health behavior intervention
services. (3) Health behavior
intervention services are limited to coaching and counseling services that
address the behavioral barriers identified or validated in the
assessment. (4) Documentation for
each intervention encounter must include the following: (a) Goals; (b) Progress, or lack thereof, toward goals and
objectives; (c) Description of injured worker engagement; and (d) Time in and time out and duration of services. (5) Health behavior
intervention services shall be limited to up to six hours in a twelve month
period. Additional intervention services may be approved during the twelve
month period, if the physician of record provides documentation the additional
services are medically necessary.
Last updated February 1, 2022 at 9:36 AM
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Rule 4123-6-34 | Payment for treatment of concussion injuries.
Effective:
January 1, 2020
This rule governs the bureau's reimbursement
for services in an allowed claim related to concussion. It is not meant to
preclude, or substitute for, the health care provider's responsibility to
exercise sound clinical judgment in light of current best medical practices
when treating injured workers. (A) As used in this rule,
"concussion" means a type of traumatic brain injury induced by
external force, which might include a bump or blow to the head, or a jolt or
hit to the body, which causes the brain to bounce around or twist in the skull,
causing chemical changes in the brain and sometimes stretching and damaging
brain cells. (1) Concussion is
manifest by at least one of the following: (a) Any alteration in mental state at the time of the
accident (feeling dazed, disoriented, or confused); (b) Any period of loss of consciousness; (c) Any loss of memory for events immediately before or
after the accident; or (d) Focal neurological deficit that may or may not be
transient, but where the severity of the injury does not exceed the
following: (i) A loss of
consciousness for approximately thirty minutes or less; (ii) After thirty
minutes, an initial "Glasgow Coma Score" of 13-15; or (iii) Post-traumatic
amnesia not greater than twenty-four hours. (2) A concussion may
involve different symptoms, clinical profiles and subtypes, and different
recovery trajectories, which may be influenced by a variety of risk factors.
Kontos, Anthony P. and Michael W. Collins. Concussion: a clinical profile
approach to assessment and treatment. Washington, DC: American psychological
association (2018), p.5. Adapted with permission. (3) In concussion, even
though by definition brain injury has occurred, standard imaging studies such
as CT scan and MRI will commonly be normal. (B) As used in this rule, "clinical
domains" related to concussion means the following group of signs or
symptoms related to a specific body part or system: (1) Anxiety and mood:
including ruminating thoughts, difficulty concentrating, hypervigilance, or
fastidiousness. (2) Vestibular: including
impaired balance and equilibrium, dizziness, nausea, or environmental
sensitivity, (3) Ocular: including
impaired vision and visual tracking, impaired comprehension, trouble focusing,
or distractibility. (4) Sleep: including
trouble falling asleep or sleeping more or less than usual. (5) Cervical: including
neck pain, stiffness, or reduced range of motion. (6) Cognitive fatigue:
including impaired thinking abilities, feeling slow or "one step
behind", physical and mental fatigue, general headache, or sleep
disturbance. (7) Headache (migraine,
cervicogenic, and tension headache): including variable and intermittent severe
headache, nausea, photosensitivity, or vestibular migraine. (8) Cognitive impairment:
including impairment in attention, memory, executive function, language
processing, or visual perception and processing. (C) Notwithstanding any provision to the
contrary in any other rule of the bureau, medical treatment reimbursement
requests relating to the clinical domains set forth in paragraph (B) of this
rule, submitted within six months from the date of injury, for treatment not to
exceed six months from the date of injury, may be authorized in an allowed
claim, without disclaimer, when: (1) The documented
mechanism of injury in the claim included a bump or blow to the head, or a jolt
or hit to the body: and (2) Signs or symptoms
related to the clinical domains have manifested within six weeks of the date of
injury; and (3) The requested medical
treatment is determined to be medically necessary and appropriate, and
reasonably related to treatment of concussion, based on the medical
evidence. (D) When concussion or other conditions
relating to the clinical domains set forth in paragraph (B) of this rule and
treated pursuant to paragraph (C) of this rule are determined to require
ongoing treatment beyond six months, the physician of record or treating
provider may request these conditions be additionally allowed in the
claim.
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Rule 4123-6-35 | Payment for spinal cord stimulator.
Effective:
September 1, 2022
Reimbursement for a spinal cord stimulator for
treatment of allowed conditions in a claim resulting from an allowed work
related injury or occupational disease is limited to claims in which current
best medical practices as implemented by this rule are followed. This rule governs the bureau's reimbursement
of a spinal cord stimulator to treat a work related injury or occupational
disease. It is not meant to preclude, or substitute for, the treating
physician's responsibility to exercise sound clinical judgment in light
of current best medical practices when treating injured workers. A provider's failure to comply with this rule
may constitute endangerment to the health and safety of injured workers, and
claims involving a spinal cord stimulator not in compliance with this rule may
be subject to peer review by the bureau of workers' compensation
stakeholders' health care quality assurance advisory committee (HCQAAC)
pursuant to rule 4123-6-22 of the Administrative Code or other peer review
committee established by the bureau. Medical treatment reimbursement requests (on form
C-9 or equivalent) for a spinal cord stimulator are not subject to dismissal by
the MCO pursuant to paragraph (F)(7) of rule 4123-6-16.2 of the Administrative
Code. (A) Authorization for a spinal cord stimulator will be
considered only in cases in which the following criteria are met: (1) Allowed conditions. The injured worker has one or more
of the following conditions allowed in their claim: (a) Failed thoracic or
lumbar spinal surgery. (b) Complex regional pain
syndrome. (c) Non-operable
peripheral vascular disease/limb ischemia. (d) Neuropathic pain
post-thoracic or post-lumbar surgery. (e) Chronic thoracic or
lumbar radiculopathy. (f) Spinal cord injury
dysesthesias. (2) Conservative care. The injured worker has undergone at
least sixty days of conservative care, which may include but is not limited
to: (a) Anti-inflammatory
medication(s) treatment; (b) Chiropractic or
osteopathic treatment; (c) Epidural steroid
injection therapy; (d) Pain management
program participation; (e) Physical medicine
rehabilitation program participation; or (f) Physical
therapy. (3) Surgeon evaluation. The injured worker has been
personally evaluated by the operating surgeon and undergone a comprehensive
evaluation, in which all of the following have been documented: (a) Date of
injury; (b) Mechanism of
injury; (c) Past medical history,
including: (i) Prior surgeries; (ii) List of current medical and psychological
conditions; (iii) List of current medications; (iv) List of drug allergies. (d) Physical
examination; (e) Pertinent
neurological and vascular testing; (f) Completion of a
health behavioral assessment and, when appropriate, identified intervention
services; (g) Consideration of
vocational rehabilitation services. (4) Education. The injured worker and physician of record,
treating physician, or operating surgeon have reviewed and signed the
educational document, "What BWC Wants You to Know About Spinal Cord
Stimulators," attached as an appendix to this rule. (5) Spinal cord stimulator trial. Having met the criteria
outlined in paragraphs (A)(1) to (A)(4) of this rule, and prior to implantation
of a spinal cord stimulator, the injured worker has completed an approved
seven-day spinal cord stimulator trial, with documented improvement in a
majority of the following areas: (a) Activities of daily
living, documented through use of an evidence-based tool (e.g., "OSWESTRY
Disability Index Questionnaire or Roland Morris Disability
Questionnaire"); (b) Gait; (c) Mood and
affect; (d) Pain level,
documented through use of an evidence-based pain scale (e.g., visual analog
scale) and a decrease of use of the morphine equivalent dosage of any
pre-procedure opioid analgesic; and (e) Sleep. (B) BWC will not reimburse for a spinal cord
stimulator: (1) For the treatment of failed cervical spine surgery,
neuropathic pain post-cervical surgery, or cervical radiculopathy; (2) When the injured worker has an implanted pacemaker or
defibrillator, metabolic or alcoholic neuropathy, or somatization disorder;
or (3) When any of the following documented conditions are
uncontrolled or untreated: (a) Substance use
disorder; (b) Psychosis;
or (c) Bipolar
disorder.
Last updated September 1, 2022 at 8:29 AM
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Rule 4123-6-36 | Enhanced care program.
Effective:
January 1, 2023
This rule governs the bureau's enhanced care
program for injured workers who have sustained a compensable knee injury. The
program is designed to simplify the claims management process and encourage
higher quality, better coordinated care for eligible claims that results in
improved outcomes. (A) Notwithstanding any provision to the
contrary in any other rule of the bureau, the administrator may, for purposes
of the enhanced care program, allow one or more managed care organizations to
authorize medical treatment reimbursement requests for the first sixty days
from the initial allowance of an eligible claim for any conditions within the
same knee as the conditions initially allowed in the claim, and presumed to be
causally related to the same industrial injury or occupational disease, without
disclaimer, during such time as the conditions for which treatment
reimbursement is authorized but which are not yet allowed are being considered
for allowance or being adjudicated. (B) Claims meeting the following criteria
are eligible for inclusion in the enhanced care program: (1) The injured
worker's claim is a work-related knee only injury as documented by the
medical evidence in the claim, and is allowed for knee conditions
only; (2) The injured
worker's physician of record is certified to participate in the HPP, and
has signed and agrees to comply with the "Enhanced Care Program Provider
Addendum" to the provider certification application and agreement or
recertification application and agreement, in accordance with rule 4123-6-02.3
of the Administrative Code; and (3) The injured
worker's employer of record is not: (a) A state agency; or (b) A self-insuring employer providing compensation and
benefits pursuant to section 4123.35 of the Revised Code. (C) The operation of the enhanced care
program does not impair in any manner the right of an employer, injured worker,
or their representatives to appeal a claim, additional allowance, or medical
treatment reimbursement determination under section 4123.511 of the Revised
Code or rule 4123-6-16 of the Administrative Code. However, if the employer,
injured worker, or their representatives exercises its right to appeal a claim,
additional allowance, or medical treatment reimbursement determination, the
claim will be removed from the enhanced care program.
Last updated January 3, 2023 at 9:45 AM
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Rule 4123-6-37 | Payment of hospital bills.
Effective:
February 1, 2022
(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 cost to charge ratios or
percent of allowed charges. (2) Except in cases of
emergency, prior authorization must be obtained in advance of all
hospitalizations. The hospital must notify the bureau, the injured
worker's MCO, QHP, or self-insuring 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 bureau, MCO, QHP, or self-insuring 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), 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.
Last updated February 1, 2022 at 9:37 AM
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Rule 4123-6-37.1 | Payment of hospital inpatient services.
(A) HPP. Except as provided in paragraphs (A)(7) and
(A)(8) of this rule, reimbursement for hospital inpatient services with a
discharge date of February 1, 2024 or after will be calculated as
follows: (1) (a) Reimbursement for hospital inpatient services, other than
outliers as defined in paragraph (A)(3) of this rule, services provided by
hospitals subject to reimbursement under paragraph (A)(4) of this rule, or
acute or subacute inpatient detoxification services subject to reimbursement on
a per diem basis under paragraph (A)(7) of this rule, will be calculated using
the applicable medicare severity diagnosis related group (MS-DRG) reimbursement
rate for the hospital inpatient service under the medicare inpatient
prospective payment system multiplied by a payment adjustment factor of 1.181
plus a new technology add-on payment (if applicable), according to the
following formula: MS-DRG reimbursement rate x 1.181 + new
technology add-on payment (if applicable) = bureau reimbursement for hospital
inpatient service. (b) In the event the centers for medicare and medicaid services
makes subsequent adjustments to the medicare reimbursement rates under the
medicare inpatient prospective payment system as implemented by the materials
specified in paragraph (A)(10) of this rule other than technical corrections,
including but not limited to adjustments related to federal budget
sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2
U.S.C. 900 to 907d as amended as of the effective date of this rule, the
"applicable medicare severity diagnosis related group (MS-DRG)
reimbursement rate for the hospital inpatient service under the medicare
inpatient prospective payment system" as specified in this paragraph will
be determined by the bureau without regard to such subsequent
adjustments. (2) In addition to the payment specified
by paragraph (A)(1) of this rule, hospitals operating approved graduate medical
education programs and receiving additional reimbursement from medicare for
costs associated with these programs will receive an additional per diem amount
for direct graduate medical education costs associated with hospital inpatient
services reimbursed by the bureau. Hospital specific per diem rates for direct
graduate medical education will be calculated annually by the bureau effective
February first of each year, using the most current cost report data available
from the centers for medicare and medicaid services, according to the following
formula: 1.181 x [(total approved amount for resident
cost + total approved amount for allied health cost)/ total inpatient days] =
direct graduate medical education per diem. Direct graduate medical education per diems
will not be applied to outliers as defined in paragraph (A)(3) of this rule,
services provided by hospitals subject to reimbursement under paragraph (A)(4)
of this rule, or acute or subacute inpatient detoxification services subject to
reimbursement on a per diem basis under paragraph (A)(7) of this rule. (3) (a) Reimbursement for outliers as determined by medicare's
inpatient prospective payment system outlier methodology will be calculated
using the applicable medicare severity diagnosis related group (MS-DRG)
reimbursement rate for the hospital inpatient service under the medicare
inpatient prospective payment system multiplied by a payment adjustment factor
of 1.181 plus the applicable medicare operating outlier amount and medicare
capital outlier amount plus a new technology add-on payment (if applicable),
according to the following formula: (MS-DRG reimbursement rate x 1.181) +
medicare operating outlier amount + medicare capital outlier amount + new
technology add-on payment (if applicable) = bureau reimbursement for hospital
inpatient service outlier. (b) In the event the centers for medicare and medicaid services
makes subsequent adjustments to the medicare reimbursement rates under the
medicare inpatient prospective payment system as implemented by the materials
specified in paragraph (A)(10) of this rule other than technical corrections,
including but not limited to adjustments related to federal budget
sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2
U.S.C. 900 to 907d as amended as of the effective date of this rule, the
"applicable medicare severity diagnosis related group (MS-DRG)
reimbursement rate for the hospital inpatient service under the medicare
inpatient prospective payment system" as specified in this paragraph will
be determined by the bureau without regard to such subsequent
adjustments. (4) Reimbursement for inpatient services
provided by hospitals and distinct-part units of hospitals designated by the
medicare program as exempt from the medicare inpatient prospective payment
system will be determined as follows: (a) For hospitals the department of health and human services,
centers for medicare and medicaid services maintains hospital-specific
cost-to-charge ratio information on, reimbursement will be equal to the
hospital's allowable billed charges multiplied by the hospital's
reported operating cost-to-charge ratio information referenced in paragraph
(A)(10)(c) of this rule multiplied by a payment adjustment factor of 1.14, not
to exceed seventy per cent of the hospital's allowed billed
charges. (b) For hospitals the department of health and human services,
centers for medicare and medicaid services does not maintain hospital-specific
cost-to-charge ratio information on, reimbursement will be equal to the
hospital's allowable billed charges multiplied by the applicable fiscal
year 2024 urban or rural statewide average operating cost-to-charge ratio set
forth in table 8A of the federal rule referenced in paragraph (A)(10)(b) of
this rule (the Ohio average operating cost-to-charge ratio will be used for
hospitals outside the United States) multiplied by a payment adjustment factor
of 1.14, not to exceed seventy per cent of the hospital's allowed billed
charges. (5) Reimbursement for
inpatient services provided by hospitals and distinct-part units of hospitals
that do not participate in the medicare program will be calculated in
accordance with the applicable provisions of paragraphs (A)(1) and (A)(3) of
this rule using the national standardized amount for fiscal year 2024, full
update, as found at 88 Fed. Reg. 59356 (2023). (6) Reimbursement for
inpatient services provided by "new hospitals" as defined in 42
C.F.R. 412.300(b) as published in the October 1, 2023 Code of Federal
Regulations will be calculated in the same manner as provided under paragraph
(A)(4)(b) of this rule. (7) Reimbursement for
acute or subacute inpatient detoxification services will be calculated in
accordance with the applicable provisions of paragraph (A) of this rule, unless
the hospital elects to be reimbursed for these services on a per diem basis, in
which case the hospital will be reimbursed the lesser of the charges billed by
the hospital for the allowed services rendered, the all-inclusive per diem
rates set forth in Table 1 of the appendix to this rule, or the rate the MCO
contracted or negotiated with the hospital. (8) Except for services
subject to reimbursement on a per diem basis under paragraph (A)(7) of this
rule, if the MCO has contracted or negotiated a different payment rate with a
hospital pursuant to rule 4123-6-10 of the Administrative Code, reimbursement
will be at the contracted or negotiated rate. (9) For purposes of this rule, hospitals
must report the applicable inpatient revenue codes for accommodation and
ancillary services set forth in Table 2 of the appendix to this
rule. (10) For purposes of this rule, the
"medicare severity diagnosis related group (MS-DRG) reimbursement
rate," "medicare operating outlier amount," "medicare
capital outlier amount," and "new technology add-on payment"
will be determined in accordance with the medicare program established under
Title XVIII of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1395 to
1395lll as amended as of the effective date of this rule, excluding 42 U.S.C.
1395ww(m), as implemented by the following materials, which are incorporated by
reference: (a) 42 C.F.R. Part 412 as published in the October 1, 2023 Code
of Federal Regulations; (b) Department of health and human services, centers for medicare
and medicaid services' "42 CFR Parts 411, 412, 419, 488, 489 and 495
medicare program; hospital inpatient prospective payment systems for acute care
hospitals and the long-term care hospital prospective payment system and policy
changes and fiscal year 2024 rates; quality programs and medicare promoting
interoperability program requirements for eligible hospitals and critical
access hospitals; rural emergency hospital and physician-owned hospital
requirements; and provider and supplier disclosure of ownership; and medicare
disproportionate share hospital (DSH) payments: counting certain days
associated with section 1115 demonstrations in the medicaid fraction final
rule," 88 Fed. Reg. 58640 - 59438 (2023). (c) The department of health and human services, centers for
medicare and medicaid services' hospital-specific cost-to-charge ratio
information as of the July 2023 update to the department of health and human
services, centers for medicare and medicaid services' inpatient provider
specific file (IPSF). (B) QHP or self insuring employer
(non-QHP): A QHP or self-insuring employer may reimburse
hospital inpatient services at: (1) The applicable rate
under the methodology set forth in paragraph (A) of this rule; or (2) (a) For hospitals the department of health and human services,
centers for medicare and medicaid services maintains hospital-specific
cost-to-charge ratio information on, the hospital's allowable billed
charges multiplied by the hospital's reported operating cost-to-charge
ratio information referenced in paragraph (A)(10)(c) of this rule multiplied by
a payment adjustment factor of 1.14, not to exceed seventy per cent of the
hospital's allowed billed charges; (b) For hospitals the department of health and human services,
centers for medicare and medicaid services does not maintain hospital-specific
cost-to-charge ratio information on, the hospital's allowable billed
charges multiplied by the applicable fiscal year 2024 urban or rural statewide
average operating cost-to-charge ratio set forth in table 8A of the federal
rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average
operating cost-to-charge ratio will be used for hospitals outside the United
States) multiplied by a payment adjustment factor of 1.14, not to exceed
seventy per cent of the hospital's allowed billed charges; or (3) The rate negotiated
between the hospital and the QHP or self-insuring employer in accordance with
rule 4123-6-46 of the Administrative Code.
View Appendix
Last updated November 1, 2024 at 8:45 AM
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Rule 4123-6-37.2 | Payment of hospital outpatient services.
(A) HPP: Unless an MCO has negotiated a different payment
rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code,
reimbursement for hospital outpatient services with a date of service of May 1,
2024 or after will be the applicable rate set forth in this rule as
follows: (1) Except as otherwise
provided in this rule, reimbursement for hospital outpatient services will be
equal to the applicable medicare reimbursement rate for the hospital outpatient
service under the medicare outpatient prospective payment system as implemented
by the materials specified in paragraph (A)(10) of this rule, multiplied by a
bureau-specific payment adjustment factor, which will be 2.758 for
children's hospitals and 1.485 for all hospitals other than
children's hospitals, plus the add-on payments set forth in paragraph
(A)(4) of this rule, if applicable. BWC will use the medicare integrated outpatient
code editor and medicare medically unlikely edits in effect as implemented by
the materials specified in paragraph (A)(9) of this rule and table 8 of the
appendix to this rule to process bills for hospital outpatient services under
this rule; however, BWC will not apply the outpatient code edits identified in
table 1 of the appendix to this rule. BWC will not apply the annual medicare
outpatient prospective payment system outlier, hold harmless, and exempt cancer
hospital reconciliation processes to payments for hospital outpatient services
under this rule. For purposes of this rule, hospitals are
identified as critical access hospitals, rural sole community hospitals,
essential access community hospitals and exempt cancer hospitals based on the
hospitals' designation in the medicare outpatient provider specific file
in effect implemented by the materials specified in paragraph (A)(10) of this
rule. For purposes of this rule, the following
hospitals are recognized as "children's hospitals": nationwide
children's hospital (Columbus), Cincinnati children's hospital
medical center, shriners hospital for children (Cincinnati), university
hospitals rainbow babies and children's hospital (Cleveland), Toledo
children's hospital, children's hospital medical center of Akron, and
children's medical center of Dayton. Reimbursement for any hospital outpatient
services identified in table 6 of the appendix to this rule will be determined
using the medicare outpatient prospective payment system methodology as set
forth in this paragraph, applying the status indicator and ambulatory payment
classification specified for the service in table 6 of the appendix to this
rule. In the event the centers for medicare and
medicaid services makes subsequent adjustments to the medicare reimbursement
rates under the medicare outpatient prospective payment system as implemented
by the materials specified in paragraph (A)(10) of this rule, other than
technical corrections, including but not limited to adjustments related to
federal budget sequestration pursuant to the Budget Control Act of 2011, 125
Stat. 239, 2 U.S.C. 900 to 907(d) as amended as of the effective date of this
rule, the "applicable medicare reimbursement rate for the hospital
outpatient service under the medicare outpatient prospective payment
system" as specified in this paragraph will be determined by the bureau
without regard to such subsequent adjustments. (2) Services reimbursed
via fee schedule. These services will not be wage index adjusted. (a) Services reimbursed via fee schedule to which the
bureau-specific payment adjustment factor will be applied. Except as otherwise provided in paragraphs
(A)(2)(b)(ii) and (A)(2)(b)(iii) of this rule, hospital outpatient services
reimbursed via fee schedule under the medicare outpatient prospective payment
system will be reimbursed under the applicable medicare fee schedule in effect
as implemented by the materials specified in paragraph (A)(10) of this rule,
plus the add-on payments set forth in paragraph (A)(4) of this rule, if
applicable. (b) Services reimbursed via fee schedule to which the
bureau-specific payment adjustment factor will not be applied. The following services will be reimbursed the
lesser of the charges billed by the hospital for the allowed services rendered,
the applicable fee schedule rates set forth in tables 2, 3, 4 and 5 of the
appendix to this rule, or the rate the MCO contracted or negotiated with the
hospital: (i) Hospital outpatient
vocational rehabilitation services for which the bureau has established a fee
as set forth in table 2 of the appendix to this rule. (ii) Hospital outpatient
services reimbursed via fee schedule under the medicare outpatient prospective
payment system that the bureau has determined will be reimbursed at a rate
other than the applicable medicare fee schedule in effect as implemented by the
materials specified in paragraph (A)(10) of this rule, for which the bureau has
established a fee as set forth in table 3 of the appendix to this
rule. (iii) Hospital outpatient
services not reimbursed under the medicare outpatient prospective payment
system that the bureau has determined are necessary for treatment of injured
workers, for which the bureau has established a fee as set forth in tables 4
and 5 of the appendix to this rule. (3) Services reimbursed
at reasonable cost. To calculate reasonable cost, the line item charge will be
multiplied by the hospital's outpatient cost to charge ratio from the
medicare outpatient provider specific file in effect as implemented by the
materials specified in paragraph (A)(10) of this rule. These services will not
be wage index adjusted. (a) Services reimbursed at reasonable cost to which the
bureau-specific payment adjustment factor will be applied. Notwithstanding any other reimbursement
methodology set forth in this rule, critical access hospitals will be
reimbursed at one hundred one per cent of reasonable cost for all payable line
items. (b) Services reimbursed at reasonable cost to which the
bureau-specific payment adjustment factor will not be applied. (i) Services designated
as inpatient only under the medicare outpatient prospective payment
system. (ii) Hospital outpatient
services reimbursed at reasonable cost as identified in tables 3 and 4 of the
appendix to this rule. (4) Add-on payments
calculated using the applicable medicare outpatient prospective payment system
methodology and formula in effect as implemented by the materials specified in
paragraph (A)(10) of this rule. These add-on payments will be applied after the
application of the bureau-specific payment adjustment factor. (a) Outlier add-on payment. An outlier add-on payment will be
provided on a line item basis for partial hospitalization services and for
ambulatory payment classification reimbursed services for all hospitals other
than critical access hospitals. (b) Rural hospital add-on payment. A rural hospital add-on
payment will be provided on a line item basis for rural sole community
hospitals, including essential access community hospitals; however, drugs,
biological, devices reimbursed via pass-through and reasonable cost items will
be excluded. The rural add-on payment will be calculated prior to the outlier
add-on payment calculation. (c) Hold harmless add-on payment. A hold harmless add-on payment
will be provided on a line item basis to exempt cancer centers and
children's hospitals. The hold harmless add-on payment will be calculated
after the outlier add-on payment calculation. (5) Providers not
participating in the medicare program. Reimbursement for outpatient services provided
by hospitals and distinct-part units of hospitals that do not participate in
the medicare program will be calculated in accordance with the methodologies
set forth in this rule, using the applicable FY24 urban or rural statewide
average outpatient cost-to-charge ratio adopted by the medicare program
pursuant to the federal rule referenced in paragraph (A)(10)(b) of this rule
(the Ohio average cost-to-charge ratio will be used for hospitals outside the
United States). (6) Reimbursement for
outpatient services provided by "new hospitals" as defined in 42
C.F.R. 412.300(b) as published in the October 1, 2023 Code of Federal
Regulations shall be calculated in the same manner as provided under paragraph
(A)(5) of this rule. (7) For purposes of this
rule, hospitals are to report the applicable outpatient revenue codes for
accommodation and ancillary services set forth in table 7 of the appendix to
this rule. (8) For purposes of this
rule, coverage status for designated hospital outpatient services is set forth
in table 9 of the appendix to this rule. (9) For purposes of this rule, services subject to always
and sometimes therapy editing are set forth in table 10 of the appendix to this
rule. (10) For purposes of this rule, the
"applicable medicare reimbursement rate for the hospital outpatient
service under the medicare outpatient prospective payment system " and the
"medicare outpatient prospective payment system " will be determined
in accordance with the medicare program established under Title XVIII of the
Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1395 to 1395lll as amended,
as of the effective date of this rule, as implemented by the following
materials, which are incorporated by reference: (a) 42 C.F.R. Part 419 as published in the October 1, 2023 Code
of Federal Regulations; (b) Department of health and human services, centers for medicare
and medicaid services' "42 CFR Parts 405, 410, 416, 419, 424, 485,
488, 489 Medicare Program: Hospital Outpatient Prospective Payment and
Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Payment
for Intensive Outpatient Services in Hospital Outpatient Departments, Community
Mental Health Centers, Rural Health Clinics, Federally Qualified Health
Centers, and Opioid Treatment Programs; Hospital Price Transparency; Changes to
Community Mental Health Centers Conditions of Participation, Proposed Changes
to the Inpatient Prospective Payment System Medicare Code Editor; Rural
Emergency Hospital Conditions of Participation Technical Correction" final
rule 88 Fed. Reg. 81540 - 82185 (2023). (c) The department of health and human services, centers for
medicare and medicaid services' hospital-specific cost-to-charge ratio
information as of the October 2023 update to the department of health and human
services, centers for medicare and medicaid services' outpatient-provider
specific file (OPSF). (B) QHP or self-insuring employer
(non-QHP): A QHP or self-insuring employer may reimburse
hospital outpatient services at: (1) The applicable rate
under the methodology set forth in paragraph (A) of this rule; or (a) For hospitals the department of health and human services,
centers for medicare and medicaid services maintains hospital-specific
cost-to-charge ratio information on, the hospital's allowable billed
charges multiplied by the hospital's cost-to-charge ratio information
referenced in paragraph (A)(10)(c) of this rule multiplied by a payment
adjustment factor of 1.16, not to exceed sixty per cent of the hospital's
allowed billed charges. (b) For hospitals the department of health and human services,
centers for medicare and medicaid services does not maintain hospital-specific
cost-to-charge ratio information on the hospital's allowable billed
charges multiplied by the applicable FY24 urban or rural statewide average
outpatient cost-to-charge ratio adopted by the medicare program pursuant to the
federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average
cost-to-charge ratio will be used for hospitals outside the United States)
multiplied by a payment adjustment factor of 1.16, not to exceed sixty per cent
of the hospital's allowed billed charges; or (2) The rate negotiated between the
hospital and the QHP or self-insuring employer in accordance with rule
4123-6-46 of the Administrative Code. (C) Provider-based status The bureau may request information from any
facility billing the bureau for services as a provider-based facility as may be
necessary to establish whether the facility meets the criteria for
provider-based status under 42 C.F.R. 413.65 as published in the October 1,
2023 Code of Federal Regulations. The information requested may include an
attestation by the facility.
View Appendix
Last updated July 24, 2024 at 4:18 PM
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Rule 4123-6-37.3 | Payment of ambulatory surgical center services.
Unless an MCO has negotiated a different payment
rate with an ambulatory surgical center pursuant to rule 4123-6-10 of the
Administrative Code, reimbursement for ambulatory surgical center services with
a date of service of May 1, 2024 or after will be equal to the lesser of the
ambulatory surgical center's allowable billed charges or the fee schedule
amount indicated in the appendix to this rule, developed with provider and
employer input and effective May 1, 2024. Ambulatory surgical centers determined as of the
effective date of this rule by the centers for medicare and medicaid services
(CMS) to not meet quality measures for the calendar year 2024 full payment
update under the CMS ambulatory surgical center quality reporting (ASCQR)
program, established by 42 U.S.C. 1395l as in effect as of the effective date
of this rule and 42 C.F.R. Part 416, Subpart H as published in the October 1,
2023 Code of Federal Regulations, will be subject to a two per cent reduction
to the BWC 2024 ambulatory surgical center fee schedule amounts indicated in
the appendix to this rule. However, if such an ambulatory surgical center,
upon reconsideration, is subsequently determined by CMS to meet quality
measures for the calendar year 2024 full payment update under the CMS ASCQR
program, upon the ambulatory surgical center's request the ambulatory
surgical center will no longer be subject to the two per cent reduction, and
the bureau will adjust any bills for dates of service on or after the effective
date of this rule that were previously reduced pursuant to this rule.
View Appendix
Last updated May 9, 2024 at 8:40 AM
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Rule 4123-6-38 | Payment for home health nursing services and home health aide services.
Effective:
February 1, 2022
(A) Except as provided in rule
4123-6-38.1 of the Administrative Code, home health nursing services and home
health aide services shall be provided by registered nurses or licensed
practical nurses and home health aides employed by a home health agency meeting
the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the
Administrative Code. (B) Authorization for home health nursing services and home
health aide services. (1) Authorization for home health nursing services will be
considered only in cases where, as the result of an allowed injury or
occupational disease: (a) The injured worker is
mentally or physically incapable of independently performing activities of
daily living; or (b) Home health nursing
services or home health aide services are ordered for discharge follow-up or by
a treating physician as part of a written treatment plan. (2) The request for authorization from the physician of
record or treating physician must include a written treatment plan that
identifies the reason for home health nursing services or home health aide
services, the period of time the services will be needed, the specific services
needed, and the number of hours per day that are needed. (3) Authorization must be obtained prior to rendering home
health nursing services or home health aide services, except in cases of
emergency or where the injured worker's allowed conditions could be
endangered by the delay of services. (C) Except as otherwise provided in paragraph (D) of this
rule, only part-time or intermittent home health nursing services or home
health aide services will be authorized, in accordance with the written
treatment plan. Part-time or intermittent care means that total home health
nursing services and home health aide services do not exceed eight hours per
day. (D) When more than eight hours of total home health nursing
services or home health aide services are medically necessary, the bureau will
consider more appropriate alternative settings. In exceptional cases, the
bureau may authorize more than eight hours of total home health nursing
services or home health aide services when medically necessary and appropriate.
(E) Authorized home health aide services may
include: (1) Bathing, dressing, grooming, hygiene, including
shaving, skin care, foot care, ear care, hair, nail, and oral care needed to
facilitate care or prevent deterioration of the injured worker's
health. (2) Feeding, assistance with elimination including
administering enemas (unless the skills of a home health nurse are necessary),
routine catheter care, routine colostomy care, assistance with ambulation,
changing position in bed, and assistance with transfers. (3) Performing a selected nursing activity or task
delegated in accordance with Chapter 4723-13 of the Administrative Code and
performed as specified in the written treatment plan. (4) Assisting with activities such as routine maintenance
exercises and passive range of motion as specified in the written treatment
plan developed by either a licensed therapist or a licensed registered nurse
within their scope of practice. These activities are directly supportive of
skilled therapy services but do not necessitate the skills of a therapist to be
safely and effectively performed. (5) Performing routine care of prosthetic and orthotic
devices. (F) Incidental services performed by a home health aide for
the injured worker, such as laundry, minor meal preparation, or light
housekeeping, are not direct health care services and will not be reimbursed,
except to the extent they are ancillary to providing direct health care
services. Incidental services may not extend the service hours provided, and
may only be performed for the injured worker, not other members of the
household. (G) The services of an adult day care facility meeting the
qualifications specified in paragraph (C) of rule 4123-6-02.2 of the
Administrative Code may be utilized in lieu of home health nursing services or
home health aide services. The hours of such adult day care facility services
will be included in the calculation of service hours referenced in paragraph
(C) of this rule. (H) A
physical examination of the injured worker must be conducted by the physician
of record or treating physician no less than annually to ensure that home
health nursing services or home health aide services, and the number of service
hours requested, are medically necessary and appropriate as a result of the
allowed injury or occupational disease. In extraordinary circumstances when an
in-person physical examination is not reasonably possible, BWC may accept a
telemedicine visit with the physician of record or treating physician.
(I) Home health agency providers must maintain records
which fully document the extent of services provided to each injured worker, in
compliance with rule 4123-6-45.1 of the Administrative Code. The bureau may
request detailed hourly descriptions of care delivered to an injured worker to
review care needs, medical necessity and appropriateness, and billing
accuracy.
Last updated February 1, 2022 at 9:38 AM
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Rule 4123-6-38.1 | Payment for nursing and caregiver services provided by persons other than home health agency employees.
Effective:
February 1, 2022
(A) Nursing services provided prior to
December 14, 1992. (1) Registered nurses and
licensed practical nurses who are not employed by a home health agency a home
health agency certified in accordance with rule 4123-6-02.2 of the
Administrative Code may continue to provide authorized services to an injured
worker if the services began prior to December 14, 1992. (2) The need for nursing
services must be the 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 home health agency
certified in accordance with rule 4123-6-02.2 of the Administrative
Code. (B) Non-licensed caregiver
services. (1) Requests for
extension of non-licensed caregiver services initially provided prior to
December 14, 1992. (a) Prior to December 14, 1992, caregiver services provided by a
non-licensed person including injured worker's spouse, friend or family
member were considered for reimbursement in cases where the injured worker, as
a 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
injured worker from caring for their own body needs or was otherwise unable to
take care of their 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 related to maintaining a
household, including but not limited to care or upkeep to the inside or outside
of the residence, washing clothes, preparing meals, or running errands, are not
considered nursing services, and will not be reimbursed, except to the extent
such services are incidental to care of the injured worker. (b) Requests for an extension of caregiver services initially
approved prior to December 14, 1992, delivered by a non-licensed person, other
than an attendant, aide, or injured worker's spouse, but including other
family members or friends, will be approved only if: (i) The injured worker
does not have a spouse because the injured worker is not married, or the
injured worker's spouse is deceased, or the claimant's spouse is
physically or mentally incapable of caring for the injured worker;
and, (ii) The approved home
health agency is greater than thirty-five miles from the injured worker's
location and the home health agency refuses to provide services to the injured
worker. (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 a home health agency certified in
accordance with rule 4123-6-02.2 of the Administrative Code. (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 of caregiver services delivered by a
non-licensed person, other than an attendant, aide, or injured worker's
spouse were considered for reimbursement only if the injured worker did not
have a spouse or the spouse was physically or mentally incapable of caring for
the injured worker, or an approved home health agency was greater than
thirty-five miles from the injured worker'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
home health aides or attendants, but who are currently approved to provide
caregiver services to an injured worker, 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 shall only be considered when
services are rendered by a home health agency home health 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 home health agency certified in
accordance with rule 4123-6-02.2 of the Administrative Code. (C) All covered home health services must
comply with rule 4123-6-38 of the Administrative Code, except as otherwise
provided in this rule. (D) A review of the claim or assessment
of the injured worker will be conducted at least annually to ensure that
nursing or caregiver services are necessary as a result of the allowed injury
or occupational disease.
Last updated February 1, 2022 at 9:38 AM
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Rule 4123-6-38.2 | Payment of nursing home and residential care/assisted living services.
Effective:
February 1, 2022
(A) Payment to a nursing home or
residential care/assisted living facility for the care of an injured worker who
sustained an injury or contracted an occupational disease in the course of and
arising out of employment shall be made only when the need for such care is the
direct result of the allowed conditions in the claim. (B) Payment will be made only for care
provided in nursing homes and residential care/assisted living facilities
meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of
the Administrative Code. (C) Nursing home or residential
care/assisted living facility 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 an injured worker 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 bureau, MCO, QHP, or self-insuring
employer. (2) Nursing home care
shall be provided on a semiprivate bed basis, unless a situation exists when
the use of a private room is medically necessary due to the allowed condition.
In these cases, the use of such a private room must be pre-authorized, except
in cases of emergency, as defined in rule 4123-6-01 of the Administrative Code,
or where the injured worker's condition would be endangered by
delay. (3) Prescription
medication provided to an injured worker in a nursing home for the treatment of
an allowed injury or occupational disease is included in the nursing
home's per diem rate, and is not separately payable.
Last updated February 1, 2022 at 9:38 AM
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Rule 4123-6-39 | Payment for prosthetic device or other artificial appliances.
Effective:
February 1, 2022
(A) For purposes of this
rule: (1) "Amputee
clinic" means an interdisciplinary group of professional providers led by
a physician with a specialty in physical medicine and rehabilitation,
orthopedic surgery or vascular surgery knowledgeable in the field of
prosthetics and physical disabilities, comprised of members that may include a
podiatrist, physical therapist, occupational therapist, kinesiotherapist,
prosthetist and other medical specialists that serves individuals requiring
prosthetic devices. (2) "Artificial
appliance" means any item that replaces a body part or function of a body
part of an injured worker who has received a scheduled loss or facial
disfigurement award for that body part under division (B) of section 4123.57 of
the Revised Code, and that the amputee clinic at the Ohio state university
medical center, the opportunities for Ohioans with disabilities agency, or a
multidisciplinary amputee clinic or prescribing physician approved by the
administrator or the administrator's designee determines is needed by the
injured worker. Examples of artificial appliances include, but are not limited
to, prosthetic devices, artificial eyes, wheelchairs, canes, crutches, walkers,
braces, etc. (3) "Prosthetic
device" means a custom fabricated or fitted medical device that is a type
of artificial appliance used to replace a missing appendage or other external
body part. It includes an artificial limb, hand, or foot, but does not include
devices implanted into the body by a physician, artificial eyes, intraocular
lenses, dental appliances, ostomy products, cosmetic devices such as breast
prostheses, eyelashes, wigs, or other devices that do not have a significant
impact on the musculoskeletal functions of the body. (B) In all cases arising under division
(B) of section 4123.57 of the Revised Code, the bureau will pay the cost of
purchasing or repairing an artificial appliance out of the surplus fund,
regardless of whether the artificial appliance is part of the injured
worker's vocational rehabilitation, or if the injured worker has, or will
ever be able, to return to work, if an injured worker requires the purchase or
repair of an artificial appliance as determined by any one of the
following: (1) The amputee clinic at
the Ohio state university medical center; (2) The opportunities for
Ohioans with disabilities agency; (3) A multidisciplinary
amputee clinic or prescribing physician approved by the administrator or the
administrator's designer. (C) The bureau is responsible for processing requests for
artificial appliance and travel expenses associated with the artificial
appliance in all self-insured claims. When an artificial appliance is needed in
a self-insured claim, the provider will send a request for the artificial
appliance and/or request for repair, as well as the subsequent bills, to the
bureau. (D) It is the prosthetist's
responsibility to ensure that any prosthetic device fits properly for three
months from the date of dispensing. Any modifications, adjustments, or
replacements within three months from the date of dispensing are the
responsibility of the prosthetist who supplied the item and the bureau will not
reimburse for those services. The provision of these services by another
provider will not be separately reimbursed. (E) Once payment for the artificial
appliance has been made, replacement requests may be denied in instances of
malicious damage, neglect, culpable irresponsibility, or wrongful
disposition. (F) The bureau will not pay the cost of
purchasing or repairing a prosthetic device that is designed solely to enable
the injured worker to engage in sports, hobbies, or other recreational
activities.
Last updated February 1, 2022 at 9:39 AM
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Rule 4123-6-40 | Payment of claimant travel expenses.
Effective:
February 1, 2022
(A) An injured worker's reasonable
and necessary travel expenses shall be paid, upon the filing of a proper
request, under the following circumstances: (1) When the injured
worker has been ordered or authorized to undergo a medical examination outside
of the city or community limits where he resides. The injured worker shall be
reimbursed for travel only if the travel distance exceeds forty-five miles
round trip. (2) When treatment
necessary for the allowed work related condition cannot be obtained within the
city or community where the injured worker resides, and the treatment has been
pre-authorized and approved. The injured worker shall be reimbursed for travel
only if the travel distance exceeds forty-five miles round trip. (3) When the injured
worker's allowed conditions require taxicab or other special
transportation for treatment or examination on account of an allowed injury or
occupational disease. Taxicab or other special transportation must be
pre-authorized. (4) When travel expenses
are authorized as part of an approved vocational rehabilitation assessment
plan, comprehensive vocational rehabilitation plan, or job retention plan
pursuant to rule 4123-18-08 of the Administrative Code. (B) In situations described in paragraphs (A)(1), (A)(2), and
(A)(4) of this rule, the injured worker will be reimbursed for the
following: (1) If the injured worker is traveling by
automobile, mileage on a per mile basis if the mileage exceeds the distance
established as provided under paragraph (A) of this rule, portal to portal,
using the most direct and practical route; (2) If the claimant is traveling by
airplane, railroad or bus, the actual and necessary airplane, railroad or bus
fare; (3) The reasonable cost of necessary
meals, based on distance traveled; (4) Necessary lodging bills at reasonable
actual cost. Lodging must be pre-authorized; and (5) The actual and
necessary cost of tolls and parking. (C) When the injured worker has been
requested to undergo a medical examination by a physician of the
employer's choice, travel expenses incurred as a result of the examination
are to be paid by the employer immediately upon the receipt of the bill.
Payment of the bill shall not require an order of the bureau or commission,
unless there is a dispute. The employer shall provide the injured worker with a
proper form to be completed by the injured worker for reimbursement of
traveling expenses. The minimum mileage provision of paragraphs (A)(1) and
(A)(2) of this rule shall not apply for reimbursement of examinations under
this paragraph (C) of this rule. (D) The payment rates for meals, lodging, and travel are
available at
https://www.bwc.ohio.gov/downloads/blankpdf/C-60-A.pdf. (E) This rule applies to all claims for work related injuries or
occupational diseases, regardless of whether the employer is part of the state
fund, is self-insuring, is non-complying, etc.
Last updated February 1, 2022 at 9:39 AM
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Rule 4123-6-41 | No legal relationship between the industrial commission or bureau and a health care provider.
Effective:
February 1, 2022
(A) Direct payment to a health care
provider or other person by the industrial commission, self-insuring employer,
bureau of workers' compensation, or their agent, for medical care rendered
to an injured worker does not imply or create a legal relationship between the
provider or person and the commission, self-insuring employer, bureau, or their
agent. (B) The services rendered to the injured
worker are the legal obligation of the injured worker. The direct payment to
the health care provider is a discretionary method by which the award made to
the injured worker for medical expenses may be discharged. (C) Except as prohibited by division (O)
of section 4121.44 of the Revised Code, when payment is made to the injured
worker, the sole legal recourse of the health care provider is against the
injured worker.
Last updated February 1, 2022 at 9:40 AM
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Rule 4123-6-42 | Interest on late payments for equipment, materials, goods, supplies or services in state insurance fund, public work relief employees' compensation fund, coal workers pneumoconiosis fund, and marine industry fund claims.
Effective:
February 1, 2010
(A) Payment is made for equipment, materials, goods, supplies, or services incurred by the claimant in connection with claims against the state insurance fund, public work relief employees' compensation fund, coal workers pneumoconiosis fund, or marine industry fund in accordance with section 126.30 of the Revised Code. For the purpose of this rule, the required payment date is the date on which payment is due under the terms of a written agreement between the bureau, or its agent, and the provider. Payment will be made either thirty days after the bureau, or its agent, receives a proper invoice for the amount of the payment due, or thirty days after the final adjudication allowing payment of an award to the claimant, whichever is later. (1) A "proper invoice" includes but is not limited to the claimant's name, claim number, date of injury or occupational disease, employer's name, provider's name and address and assigned payee number, a description of the service provided, the procedure code for the service provided, the date provided, and the amount of the charge. If more than one item has been included in the invoice, each item is to be considered separately to determine if it is a proper invoice. (2) If the bureau or its agent determines that an invoice is improper, the bureau or its agent shall send notification to the provider through the MCO at least fifteen days prior to what would be the required payment date if the invoice did not contain an error. The notice shall describe the error and the additional information needed to correct the error. The required payment date shall be redetermined upon receipt of a proper invoice. (3) If an invoice is for payment of either a condition not allowed in a claim, or for a claim that is not allowed, the payment date is thirty days after final adjudication of allowance of the condition or claim. As defined in section 126.30 of the Revised Code, "final adjudication" is the date that the decision of the bureau, industrial commission, or court becomes final, with no further right of appeal. If any section of the Revised Code contains a faster timetable for payments, however, such provisions shall not be superseded by this rule. (B) Interest shall be paid based on division (E) of section 126.30 of the Revised Code. Any interest charges payable under section 126.30 of the Revised Code are to be paid by the bureau of workers' compensation.
Last updated May 31, 2023 at 11:04 AM
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Rule 4123-6-43 | Payment for transcutaneous electrical nerve stimulators and neuromuscular electrical stimulators.
Effective:
February 1, 2022
(A) Payment will be approved for a
transcutaneous electric nerve stimulator (TENS) unit for treatment of allowed
conditions in a claim resulting from an allowed work related injury or
occupational disease, as provided in this rule. (1) Prior authorization
is required for TENS units and supplies. An injured worker shall be provided
only one TENS unit at a time. For each TENS unit request approved, the unit
shall be rented for a thirty day trial period before purchase of the TENS unit.
This trial period is to evaluate the medical necessity and effectiveness of the
TENS treatment. TENS treatment will be discontinued at the end of the thirty
day trial period where the treatment has not proven to be medically necessary
or effective. Reimbursement of rental costs will be considered only for that
portion of the trial period that the TENS unit was actually used if treatment
was discontinued early. For each TENS unit provided, payment shall be limited
to necessary disposable or rechargeable batteries, but not both. (2) The bureau shall
apply all rental payments previously made to the purchase price of the TENS
unit. A TENS unit purchased and furnished to the injured worker is not the
personal property of the injured worker, but remains the property of the bureau
or self-insuring employer. The bureau or 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
bureau or self-insuring employer will reimburse for repair or replacement of
the unit upon submission of a request from the physician of record or treating
provider that includes medical documentation substantiating the continued
medical necessity and effectiveness of the unit. (3) To be eligible for
reimbursement under this rule, the TENS unit must be prescribed by a physician
and furnished by a provider holding a current, valid, license or certificate of
registration from the state of Ohio board of pharmacy to sell or rent home
medical equipment. (B) The injured worker's MCO shall
regularly determine the specific TENS supplies needed by the injured worker
throughout the period of time authorized for TENS use. The TENS provider must
receive authorization from the injured worker's MCO prior to the delivery
of supplies and/or equipment. The TENS provider shall then deliver the supplies
and bill the injured worker's MCO after authorization is received. A
self-insuring employer may, but is not required to, follow the same procedure
as an MCO under this rule; provided, however, that in no event shall a
self-insuring employer require a injured worker to submit a written request for
TENS supplies and/or equipment. The injured worker's MCO shall retain
documentation of the contact with the injured worker substantiating the injured
worker's need for supplies in accordance with the time frames set forth in
rule 4123-6-14.1 of the Administrative Code. The TENS provider's bill must
indicate the actual date of service, reflecting the date that services or
supplies were provided. The bureau, MCO, QHP, or 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 for audit upon request: (1) Authorizations of
TENS supplies or equipment received from the injured worker's MCO, and all
other documentation relating to the injured worker's need for TENS
supplies or equipment received by the provider prior to the delivery of the
supplies or equipment, including any requests received from the injured worker,
if applicable; (2) Records of the
provider's wholesale purchase of TENS supplies or equipment; (3) Records of delivery
of supplies to injured workers and of the delivery or return of TENS units;
and (4) The TENS
provider's current, valid, license or certificate of registration from the
state of Ohio board of pharmacy to sell or rent home medical
equipment. Upon request, the provider shall supply copies
of the record information to the requester at no cost. Failure to provide the
requested records may result in denial or adjustment of bills related to these
records. (D) The bureau shall not pay for the rental or sale of devices
that are labeled by the food and drug administration (FDA) for over-the-counter
use and are identified with the FDA product code
"NUH.OTC.TENS." (E) Payment will be approved for a
neuromuscular electrical stimulator (NMES) unit for treatment of allowed
conditions in a claim resulting from an allowed work related injury or
occupational disease, as provided in the bureau's provider billing and
reimbursement manual in effect on the billed date of service.
Last updated February 1, 2022 at 9:40 AM
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Rule 4123-6-44 | Bureau fees for provider services rendered by in-state and out-of-state providers.
Effective:
February 1, 2022
Bureau fees for in-state or out-of-state providers
will be established by the bureau. The bureau may establish different fees for
in-state and out-of-state providers. The methods of payment may include rates
based on resource based relative value scale (RBRVS), per cent of allowed
charges, or usual, customary and reasonable fee maximas, as determined by the
bureau. Rates will be reviewed at least annually by the bureau to determine the
need for appropriate adjustment. Payment for provider services will be made in
accordance with rule 4123-6-10 of the Administrative Code.
Last updated February 1, 2022 at 9:40 AM
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Rule 4123-6-45 | Audit of providers' patient and billing related records.
Effective:
February 1, 2022
(A) Providers' patient and billing
related records, including but not limited to those records described in rule
4123-6-45.1 of the Administrative Code, may be reviewed by the bureau or the
MCO to ensure workers are receiving proper and necessary medical care, and to
ensure compliance with the bureau's statutes, rules, policies, and
procedures. (1) Based on division
(B)(15)(c) of section 4121.121 of the Revised Code, provider records may be
reviewed before, during, or after the delivery of services. Reviews may be
random, with no unreasonable infringement of provider rights, or may be for
cause. Reviews may include the utilization of statistical sampling
methodologies and projections based upon sample findings. Records reviews may
be conducted at or away from the provider's place of
business. (2) Based on division
(B)(15)(c) of section 4121.121 of the Revised Code, legible copies of
providers' records may be requested. Providers shall furnish copies of the
requested records within thirty calendar days of receipt of the request. The
bureau shall establish a schedule for payment of reasonable costs for copying
records, which shall be published in the health care provider billing and
reimbursement manual. (3) Original records
shall not be removed from the provider's premises, except upon court order
or subpoena issued by the bureau pursuant to section 4121.15 or 4123.08 of the
Revised Code. (B) Upon any finding of improper or
unnecessary medical care, the administrator shall, if requested by the
provider, appoint a subcommittee of the stakeholders' health care quality
assurance advisory committee to review and advise the administrator as provided
in paragraph (F) of rule 4123-6-22 of the Administrative Code. The
administrator may sanction, suspend, or exclude a health care provider from
participation in the workers' compensation system based on rule 4123-6-17
of the Administrative Code. (C) The bureau or the MCO may deny
payment for services or declare as overpaid previous payments to providers who
fail to provide records or access to records to either the bureau or the MCO.
The bureau may decertify a health care provider that fails to provide records
requested pursuant to Chapters 2913., 4121., and 4123. of the Revised
Code.
Last updated February 1, 2022 at 9:41 AM
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Rule 4123-6-45.1 | Records to be retained by provider.
Effective:
February 1, 2022
(A) A health care provider shall
create, maintain, and retain sufficient records, papers, books, and documents
in such form to fully substantiate the delivery, value, necessity, and
appropriateness of goods and services provided to injured workers under the HPP
or of significant business transactions. The provider shall retain such records
for a minimum period of five years from the date of payment for said goods or
services, or five years from the date of referral to a certified or
non-certified provider, or until any initiated audit or investigation is
completed, whichever is longer. The provider shall create and maintain the
records at the time the goods or services are delivered or within seven days
from the date the service was rendered. (B) The provider shall retain records
documenting the following minimum information concerning the goods or services
provided to injured workers: (1) Date the service was
provided; (2) Description of service, treatment
or product provided; (3) Record of patient appointments,
if appropriate; (4) Dates where injured worker
canceled or failed to appear for a scheduled examination, treatment, or
procedure; (5) Treatment plans; (6) Subjective and objective
complaints, if the provider is the practitioner or physician of
record; (7) Injured worker's progress,
if the provider is the practitioner or physician of record; (8) Wholesale purchase records, if
goods, products, or prescriptions are delivered; (9) Delivery records, if goods,
products, or prescriptions are delivered by way of a third party; (10) The identity and qualifications
of any individual involved in the delivery of health care or billing for
services to injured workers on behalf of the provider billing for the
services. (C) A provider's failure to
create, maintain, and retain such records shall be sufficient cause for the
bureau to deny payment for goods or services, to declare overpaid previous
payments made to the provider, or to decertify the provider.
Last updated February 1, 2022 at 9:41 AM
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Rule 4123-6-46 | Standardized or negotiated payment rates for services or supplies.
Effective:
November 13, 2015
(A) The bureau or self-insuring employer may negotiate payment rates with health care providers for services and supplies provided in the treatment of workers' compensation claims. (B) The bureau or self-insuring employer may enter into volume-based or optional-use contracts with medical providers for services including, but not limited to, the purchase or rental of durable medical equipment and supplies and catastrophic claim services. (C) The bureau or self-insuring employer may inform injured workers of the availability of services, supplies, or equipment from particular health care providers with whom a contract for services or supplies, a negotiated payment rate for services or supplies, or a contract for cost-effective payment levels or rates has been entered into, so long as access to quality and convenient medical services or supplies for injured workers is maintained.
Last updated May 31, 2023 at 11:04 AM
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Rule 4123-6-51 | Employer participation in the QHP system - bureau certification of QHPs.
Effective:
November 13, 2015
(A) A health plan that satisfies the QHP certification requirements of this chapter shall be certified by the bureau as a QHP to manage medical treatment, direct care or provide services or supplies to or on behalf of an employee for an injury or occupational disease that is compensable under Chapter 4121., 4123., or 4131. of the Revised Code. (B) An employer may establish a bureau certified QHP, that shall comply with the thirteen standards set forth in divisions (A)(1) to (A)(13) of section 4121.442 of the Revised Code, division (P) of section 4121.44 of the Revised Code, and rules 4123-6-53 and 4123-6-54 of the Administrative Code. (C) The bureau is authorized to recertify QHPs at least every three years. (D) The bureau, at least annually, shall develop and make available information that describes employer and employee rights under the QHP. (E) The bureau shall continue to certify health plans and shall periodically, at least annually, update its list of certified QHPs.
Last updated May 31, 2023 at 11:04 AM
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Rule 4123-6-52 | Employer participation in the QHP system - bureau recertification of QHPs.
Effective:
November 13, 2015
(A) The bureau shall initiate the recertification process by sending certified QHPs a recertification application, which must be completed, signed and submitted to the bureau if the QHP wishes to be considered for recertification. (B) Except as otherwise provided in paragraph (E) of this rule, if the bureau receives a completed and signed recertification application from a QHP, the QHP's certification shall remain in effect until the bureau issues a final order approving or denying the QHP's application for recertification. (C) If the bureau does not receive a completed and signed recertification application from the QHP within sixty days from the date of the notice sent in accordance with paragraph (A) of this rule, the bureau shall send a second notice to the QHP stating that the QHP has thirty days from the date of the second notice to complete, sign and submit the recertification application to the bureau if the QHP wishes to be considered for recertification. (D) If the bureau does not receive a completed and signed recertification application from the QHP within thirty days from the date of the notice sent in accordance with paragraph (C) of this rule, the QHP's certification shall lapse. Such lapse of certification is not an adjudication order and is not subject to appeal pursuant to rule 4123-6-17 of the Administrative Code. (E) If the bureau receives a completed and signed recertification application from a QHP after the QHP's certification has lapsed pursuant to paragraph (D) of this rule, the QHP's certification shall remain lapsed until the bureau issues a final order approving or denying the QHP's application for recertification.
Last updated May 31, 2023 at 11:04 AM
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Rule 4123-6-53 | Employer participation in the QHP system - QHP quality assurance program required.
Effective:
November 13, 2015
(A) Each QHP shall have a quality assurance program that monitors the operation and measures the effectiveness of peer review, utilization review, and dispute resolution within the QHP. Data collected from the quality assurance program shall be used to assist an employer in determining the quality, efficiency and effectiveness of the employer's QHP and the QHP system in accordance with division (A) of section 4121.442 of the Revised Code. (B) Each quality assurance program shall include a mechanism for monitoring and the methodology for measuring and improving the QHP's compliance with each of the following eleven elements: (1) Peer review and evaluation of clinical performance; (2) Credentialing and recredentialing and use of provider profiling; (3) Utilization management to determine the appropriateness of care; (4) Evaluation of employee and provider dispute resolution procedures and outcomes; (5) Evaluation of outcomes of care based on clinical data; (6) Procedures for remedial action for inappropriate or substandard services; (7) Evaluation of employee satisfaction with the plan; (8) Evaluation of provider satisfaction with the plan; (9) Evaluation of employer satisfaction with the plan; (10) Periodic evaluation of medical records and office procedures; and (11) Practice patterns compared to accepted medical criteria. (C) The quality assurance program shall include a quality assurance committee or other mechanism adequate to evaluate the outcomes of each of the eleven elements listed in paragraph (B) of this rule.
Last updated May 31, 2023 at 11:04 AM
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Rule 4123-6-54 | Employer participation in the QHP system - QHP certification application.
Effective:
August 1, 2020
(A) Upon request by an employer or
health plan seeking certification, the bureau shall mail the employer or health
plan seeking certification a QHP application for certification. (B) The QHP application for
certification shall include a list of bureau certified providers in the
QHP's provider network. (C) The QHP application for
certification shall include, at a minimum, the following provisions, as more
fully detailed within the QHP certification application itself: (1) A statement that the application
is without misrepresentation, misstatement, or omission of a relevant fact or
other acts involving dishonesty, fraud, or deceit; (2) Proof that a self-insured
employer has been granted status as a self-insured employer in accordance with
section 4123.35 of the Revised Code; (3) A description of the geographic
or regional area of the state of Ohio to be serviced by the QHP, taking into
account the unique circumstances of the individual employer, such as multiple
locations, and/or the need for a statewide network; (4) A description of the role of each
vendor that will be a component of the QHP including, but not limited to, the
following: if an employer uses or anticipates using company-based providers, a
description of the role of company-based providers as distinguished from QHP
network providers; if an employer uses or anticipates using a third party
administrator, a description of the role of the third party
administrator; (5) If an employer contemplates
contracting with a vendor that has been certified by the bureau under Chapter
4123-6 of the Administrative Code to provide services under the employer's
QHP, proof that certification has been granted by the bureau and that such
certification is current; (6) A description of the structure of
the medical management component and the health care provider network to be
offered by the QHP; (7) A description of the QHP's
plan and methodology for providing, at least annually, QHP network provider
information, by provider type, and updated QHP network provider directories to
employees; (8) A description of the QHP's
quality assurance program, including but not limited to, the proposed structure
and operation and a description of the mechanism for monitoring and the
methodology for measuring and improving the QHP's compliance with the
elements listed in paragraph (B) of rule 4123-6-53 of the Administrative
Code; (9) A description of the QHP's
employee education program. The description shall include but shall not be
limited to: a description of the process to be used to educate employees
regarding their rights and responsibilities in the QHP system; a description of
the process to be used to explain the time, place and manner of services to be
delivered under the QHP; and a description of the process to be used to explain
options available to injured workers, including the process for changing
providers within the QHP and referral and transfer to the HPP; and (10) A description of the plan
satisfactory to the bureau to be implemented by the QHP in the event a final
order to revoke certification, or to refuse to recertify a QHP is issued by the
administrator, pursuant to rule 4123-6-55 of the Administrative Code, that
includes, but is not limited to, a plan that describes continuation and
continuity of care of injured workers and a plan that describes payment of
providers for medical services rendered prior to revocation of certification or
refusal to certify. The injured worker may continue receiving medical services
from the same provider or may choose a provider in a new approved plan for
delivery of medical services, both of whom shall accept medical management of
the medical services through the employer's new approved
plan. (D) The bureau shall review the
application for certification submitted by the health plan seeking
certification. The bureau reserves the right to cross-check data with other
governmental agencies or licensing or accrediting bodies. (E) The bureau shall hold as
confidential and proprietary the vendor's descriptions of process,
methodology, policies, procedures and systems as required for the application
for certification, to the extent such qualify as a "trade secret"
under division (D) of section 1333.61 of the Revised Code.
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Rule 4123-6-55 | Employer participation in the QHP system - bureau's authority to decertify, to refuse to certify or recertify a QHP.
Effective:
April 15, 2024
(A) The bureau is authorized to
decertify, to refuse to certify or recertify a QHP from participation in the
QHP system. (B) Should the bureau determine that
sufficient evidence exists that an employer or QHP has failed to comply with
applicable workers' compensation statutes or rules governing QHPs, the
bureau will take one of two courses of action: (1) The bureau will serve
written notice to the employer, employee representative and QHP of the facts
and issues relating to the bureau's determination that the employer or QHP
has failed to comply with applicable workers' compensation statutes or
rules governing QHPs. Such notice will set forth a period of time for the
employer or QHP to resolve or correct the problem. Failure of the employer or
QHP to resolve or correct the problem within the time period will result in the
bureau serving notice to the employer and QHP in writing of administrative
action that might result in a bureau determination to revoke certification,
refusal to certify or recertify, and the employer's and QHP's right
to a hearing within thirty days of the notice, if requested by the employer or
QHP, pursuant to rule 4123-6-17 of the Administrative Code. (2) Serve written notice
to the employer, employee representative and QHP of administrative action that
might result in a bureau determination to revoke certification, refusal to
certify or recertify, and the employer's and QHP's right to a hearing
within thirty days of the notice, if requested by the employer or QHP, pursuant
to rule 4123-6-17 of the Administrative Code. (3) For the purpose of
this rule, "employee representative" does not include the
employee's attorney. (4) The bureau will serve all notices pursuant to this rule
in accordance with section 119.05 of the Revised Code. (C) Upon a final order of the administrator to decertify, refuse
to recertify, or revoke or suspend the certification of a QHP, employees and
employers cannot receive services from such QHP pursuant to the QHP
system.
Last updated April 15, 2024 at 8:32 AM
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Rule 4123-6-58 | Provider access to the QHP system - provider participation in QHP system and other related health care program not linked.
Effective:
February 1, 2010
A QHP or vendor that provides medical management and cost containment services shall not require a provider to participate in a workers' compensation network of providers in order to maintain membership in a related health care program. If the QHP utilizes a leased provider network, the QHP shall not apply the discounted payment rates of the leased network to services rendered by the provider in the QHP unless the signed, written consent of the provider has been obtained.
Last updated May 31, 2023 at 11:30 AM
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Rule 4123-6-59 | Provider access to the QHP system - QHP provider selection.
Effective:
August 1, 2020
(A) An employer that develops a QHP, a vendor within the QHP
system, or a QHP shall develop and implement standards of credentialing of
providers in the QHP network that meet but may exceed the bureau credentialing
requirements in the HPP. (B) An employer that develops a QHP may selectively contract with
providers or contract with a vendor that selectively contracts with
providers. (C) Only a bureau certified provider is eligible for selection by
an employer that develops a QHP, by a QHP as a QHP panel provider or by a
vendor as a panel provider to participate in the QHP system. A provider
identified by a QHP for inclusion in its panel of providers that is not a
bureau certified provider may be assisted by the QHP in applying for bureau
provider credentialing and certification. (D) The bureau, an employer, a QHP or a vendor shall not
discriminate against any category of health care provider when establishing
categories of providers for participation in the QHP system. However, an
employer, a QHP or a vendor is not required to accept or retain any individual
provider in the QHP system. (E) The bureau, an employer, a QHP and a vendor shall comply with
state and federal laws prohibiting discrimination based on race, color,
religion, sex, age, disability, military status as defined in section 4112.01
of the Revised Code, national origin, ancestry, or sexual orientation.
(F) A QHP shall include in its panel a substantial number of the
medical, professional, and pharmacy providers currently being utilized by
employees. A QHP may limit the number of providers on its provider panel, but
shall do so based upon objective data that demonstrates that the fundamental
needs of the employer and employees are met based on reasonable standards such
as historical claims data or other geographic information approved by the
bureau. In addition, a QHP shall include in its application for QHP
certification information including reasonable patient access, the potential
number of employees the QHP is applying to service, and other performance
criteria, without discrimination by provider type. A QHP seeking QHP
certification may select out-of-state providers as members of the QHP
panel.
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Rule 4123-6-65 | Payment in the QHP system - employer payment to vendor that provides medical management and cost containment services and/or QHPs.
Effective:
September 5, 1996
Promulgated Under:
Ch 119.
The bureau shall not interfere with nor impose restrictions upon an arrangement for payment negotiated between an employer and a vendor that provides medical management and cost containment services and/or a QHP under the QHP system, except that no financial arrangement between an employer and a vendor that provides medical management and cost containment services and/or a QHP shall incentivize a reduction in the quality of medical care received by an injured worker.
Last updated May 31, 2023 at 11:30 AM
Supplemental Information
Authorized By:
–
Amplifies:
–
Five Year Review Date:
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Rule 4123-6-69 | QHP dispute resolution process.
Effective:
August 1, 2020
(A) This rule shall provide time frames
and procedures for review of requests for the delivery of medical services and
for the resolution of disputes that may arise between an employee and an
employer, an employee and a provider, or an employer and a provider. This rule
applies to, but is not limited to, reviews of records, medical disputes arising
over issues such as, but not limited to, quality assurance, utilization review,
a determination that a service provided to an employee is not covered, is
covered or is medically unnecessary; or disputes involving individual health
care providers. (B) Initial review and decision upon
requests for the delivery of medical services that include, but are not limited
to, medical treatment, major diagnostic testing, hospitalization, surgery and
physical therapy, shall be completed by the QHP. The employee, employer and
provider shall be notified verbally of the outcome of the initial review within
forty-eight hours of the request. Within seven working days of the verbal
notification, the verbal notification shall be committed to writing and mailed
to the employee, employer and provider. (C) A QHP shall have a dispute resolution
process beyond initial review that includes one independent level of
professional review. (D) A QHP dispute resolution process
shall be completed and the QHP shall notify the parties to the dispute and
their representatives in writing within twenty-one days of the initial written
notice of a dispute, unless an extension of time is otherwise agreed to by the
parties. If the QHP schedules the injured worker for an independent medical
examination for the independent level of professional review, the twenty-one
day time frame shall be tolled, and in such cases the QHP shall complete the
dispute resolution process within seven days after receipt of the independent
medical examination report. (E) The dispute resolution process shall
begin upon written notice of the dispute by the party maintaining the dispute
to the parties of the dispute. (1) If an individual health care provider eligible to be
physician of record would be providing the services requested in the dispute,
the independent level of professional review shall consist of a peer review
conducted by an individual or individuals licensed pursuant to the same section
of the Ohio Revised Code as the health care provider who would be providing the
services requested. (2) Notwithstanding paragraph (E)(1) of this rule, if the
QHP has already obtained one or more peer reviews during previous disputes
involving the same or similar treatment, the QHP may obtain a different
perspective review from a licensed physician who falls outside the peer review
criteria set forth in this paragraph. (3) ) If an individual health care provider not eligible to
be physician of record would be providing the services requested in the
dispute, the independent level of professional review shall consist of a
provider review conducted by an individual or individuals eligible to be
physician of record whose scope of practice includes the services
requested. (4) If the QHP receives a dispute where the requested
treatment appears to be the same as or similar to a previous treatment request
for which the QHP conducted a professional review, and the previous treatment
request was ultimately denied based on the professional review, the QHP may use
the previous professional review to satisfy the independent level of
professional review requirement of this paragraph. (F) A dispute unresolved by a QHP dispute
resolution process may be appealed to the industrial commission pursuant to
section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the
dispute resolution procedures of this rule prior to filing an appeal under
section 4123.511 of the Revised Code. (G) Notwithstanding the requirements set
forth in paragraph (F) of this rule, a dispute unresolved by a QHP providing
medical management and cost containment services for a state fund employer
shall be referred by the QHP to the bureau within seven working days of the
final decision rendered within the QHP dispute resolution process. Within
fourteen days of receipt of an unresolved medical dispute, the bureau shall
conduct an independent review of the unresolved medical dispute received from
the QHP and enter a final bureau order pursuant to section 4123.511 of the
Revised Code. This order shall be mailed to all parties and may be appealed to
the industrial commission pursuant to section 4123.511 of the Revised Code.
Parties to a dispute shall exhaust the dispute resolution procedures of this
rule prior to filing an appeal under section 4123.511 of the Revised
Code.
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Rule 4123-6-70 | Evaluation of the QHP system by the bureau; reporting requirements by employers and QHPs.
Effective:
February 1, 2010
(A) To enhance the quality of the QHP system, and pursuant to division (A)(9) of section 4121.442 of the Revised Code, the administrator shall require employers and QHPs that participate in the workers' compensation QHP system to report data to be used by the administrator to measure and perform comparison analyses of costs, quality, appropriateness of medical care, and effectiveness of medical care delivered by all components of the workers compensation system. (B) The bureau shall evaluate the effectiveness of the QHP system based on standardized data and reporting requirements developed by the bureau. (C) The bureau shall receive, define and publish data elements and data collection techniques that meet the thirteen standards set forth in divisions (A)(1) to (A)(13) of section 4121.442 of the Revised Code and are necessary to evaluate the effectiveness of the QHP system. Performance indicators used by the bureau to evaluate the effectiveness of the QHP system may include, but shall not be limited to, the following: customer satisfaction; system cost drivers; improvements in quality, and cost reductions.
Last updated May 31, 2023 at 11:30 AM
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Rule 4123-6-72 | Confidentiality.
Effective:
November 13, 2015
Subject to the requirements and protections contained in Ohio law pertaining to release of confidential and/or privileged information, in the course of medical management in the QHP system, confidential information may be exchanged among the bureau, the QHPs, an employer and its representative, an employee and his or her representative, and the provider. All parties providing or requiring such confidential information for use in the QHP system shall not provide or use such confidential information for any purpose other than to perform duties required under the QHP system, and shall prevent such information from further disclosure or use by unauthorized persons.
Last updated May 31, 2023 at 11:30 AM
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