Rule 4123-6-03.2 | MCO participation in the HPP -- MCO application for certification or recertification.
(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 bureaus 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 MCOs 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