Ohio Administrative Code Search

...(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...

...ursuant 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 medic...

...t 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...

... 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 his or her 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 tim...

... 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 th...

...d 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 ...

...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...

... 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 chap...

...he 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. (E) Payment for physical medicine used for treatment of the allowed conditions shall be made in accordance with rule 4123-6-10 of the Administrative Code.

...riteria 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.

...(A) Acupuncture. (1) Acupuncture is a recognized method of treatment in Ohio and must be administered by a licensed doctor of medicine, doctor of osteopathic medicine and surgery, or doctor of podiatric medicine who has completed a course of study in acupuncture under the administration of an approved college of medicine, college of osteopathic medicine and surgery, or college of podiatric medicine, doctor of chirop...

...(A) Acupuncture. (1) Acupuncture must be 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....

... 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 admi...

...Effective January 1, 2018, 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 ...

...ry 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....

... 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 co...

...s with a discharge date of February 1, 2023 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 b...

...s with a discharge date of February 1, 2021 or after shall be 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 par...

...s with a discharge date of February 1, 2022 or after shall be 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 par...

...s with a discharge date of February 1, 2025 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 b...

... 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, 2025 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 hos...

...atory 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, 2023 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, 2023. Ambul...

...atory 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, 2022 or after shall 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, 2022. Ambu...

...atory 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, 2021 or after shall 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, 2021. Ambu...

...atory 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, 2025 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, 2025. Ambul...