Rule 4123-6-36 | Enhanced care program.
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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