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 MCOs previous treatment reimbursement determination regarding the service billed, the MCOs 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