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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Rule 4123-6-26 | Claimant reimbursement.


(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

Supplemental Information

Authorized By: 4121.12, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Five Year Review Date: 2/1/2027
Prior Effective Dates: 2/12/1997, 6/24/2011, 11/13/2015