Ohio Administrative Code Search

...(A) HPP. (1) The MCO shall accumulate medical records and bills for services rendered to injured workers for provider services and submit the bills electronically to the bureau for payment in a bureau approved format, utilizing billing policies, including but not limited to clinical editing, as set forth in the MCO contract. The MCO shall submit a bill to the bureau within seven business days of its receipt of a val...

...(A) The bureau shall review all bills received from the MCO pursuant to paragraph (A)(1) of rule 4123-6-10 of the Administrative Code for payment eligibility. The bureau's review may include, but not be limited to, verification of the following: (1) The services were delivered, rendered, or directly supervised by providers who meet bureau credentialing and licensing criteria; (2) The bills conf...

...(A) Pursuant to division (A)(1) of section 4121.441 of the Revised Code, this rule shall provide 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 exhaus...

...(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...

...(A) Pursuant 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 ...

...(A) A provider is responsible for the accuracy and legibility of all reports, information, and documentation submitted by the provider, the provider's employees, or the provider's agents to the bureau, industrial commission, injured worker, employer, or their representatives, MCO, QHP, or self-insuring employer in connection with a workers' compensation claim. The provider, the provider's emp...

...(A) A provider is responsible for the accuracy and legibility of all reports, information, and documentation submitted by the provider, the provider's employees, or the provider's agents to the bureau, industrial commission, injured worker, employer, or their representatives, MCO, QHP, or self-insuring employer in connection with a workers' compensation claim. The provider, the provider's employees, and the provider...

...(A) Except as otherwise provided in rule 4123-6-21.6 of the Administrative Code, medication must be for the treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer. The bureau may deny a drug or therapeutic class of drugs as not being reasonably related to or medically nec...

...(A) Except as otherwise provided in rule 4123-6-21.6 of the Administrative Code, medication must be for the treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer. The bureau may deny a drug or therapeutic class of drugs as not being reasonably related to or medically nec...

...(A) Except as otherwise provided in rule 4123-6-21.6 of the Administrative Code, medication must be for the treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission. The bureau may deny a drug or therapeutic class of drugs as not being reasonably related to or medically necessary for treatment of the allowed conditions in a claim. (B)...

...(A) Medication must be for treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer. (B) Medication may be prescribed by any treating provider authorized by law to prescribe such medication. (C) Drugs covered in self-insuring employer claims are limited to those that are ...

...(A) Medication must be for treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer. (B) Any treating provider authorized by law to prescribe medication may prescribe such medication. (C) Drugs covered in self-insuring employer claims are limited to those that are approved for human use in t...

...The bureau of workers' compensation pharmacy and therapeutics (P&T) committee is hereby created to advise the administrator and the chief medical officer with regard to issues involving medication therapy for injured workers. A list of physician and pharmacist providers, each holding a professional license in good standing, who have agreed to serve on the P&T committee and who would add credibility and diversity to t...

...The bureau of workers' compensation pharmacy and therapeutics (P&T) committee is hereby created to advise the administrator with regard to issues involving medication therapy for injured workers. A list of physician and pharmacist providers, each holding a professional license in good standing, who have expressed an interest in serving on the P&T committee and who would add credibility and diversity to th...

...The bureau of workers' compensation pharmacy and therapeutics (P&T) committee was created to advise the administrator, the chief of medical services, and the chief medical officer with regard to medication therapy issues for injured workers. The bureau will develop and maintain a list of physician and pharmacist providers, each holding a professional license in good standing, who have expressed an interest ...

...The bureau, or a self-insuring employer with a point-of-service adjudication system, may establish a coordinated services program (CSP) that requires an injured worker to obtain prescription medications reimbursed by the bureau or self-insuring employer from a single designated pharmacy and/or prescriber. (A) Placement in a CSP. (1) The bureau or self-insuring employer with a point-of-service adjudication system ma...

...The bureau, or a self-insuring employer with a point-of-service adjudication system, may establish a coordinated services program (CSP) that requires an injured worker to obtain prescription medications reimbursed by the bureau or self-insuring employer from a single designated pharmacy and/or prescriber. (A) Placement in a CSP. (1) The bureau or self-insuring employer with a point-of-service adjudicati...

...This rule governs the bureau's reimbursement for services to aid injured workers in discontinuing medications which may be necessary and appropriate in the treatment of work related injuries, but which may increase the risk of dependency, misuse, and substance use disorder in some injured workers if continued. Medically necessary and appropriate services to aid injured workers in discontinuing these medicat...

...This rule governs the bureau's reimbursement for services to aid injured workers in discontinuing medications which may be necessary and appropriate in the treatment of work related injuries, but which may increase the risk of dependency, misuse, and substance use disorder in some injured workers if continued. Medically necessary and appropriate services to aid injured workers in discontinuing these medications may i...

...The bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) was created to advise the administrator, the chief of medical services, and the chief medical officer with regard to medical quality issues. A list of medical providers, each holding a professional license in good standing, who have agreed to serve on the HCQAAC, and who would add credibility and dive...

...The bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) was created to advise the administrator, the chief of medical services, and the chief medical officer with regard to medical quality issues. A list of medical providers, each holding a professional license in good standing, who have expressed an interest in serving on the HCQAAC, and who would add cre...

...(A) Medical or other services to be approved for payment must be rendered as a direct result of an injury sustained or occupational disease contracted by a claimant in the course of and arising out of employment. The claim must be allowed by an order of either the bureau of workers' compensation or the industrial commission, or have been recognized by a self-insuring employer. Medical supplies and services will be c...

...(A) Medical or other services to be approved for payment must be rendered as a result of an injury sustained or occupational disease contracted by an injured worker in the course of and arising out of employment. The claim must be allowed by an order of either the bureau of workers' compensation or the industrial commission, or have been recognized by a self-insuring employer. Medical supplies an...

...(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 claim or condition is subsequently allowed, the payor shall be reimbursed upon submission of evidence of the receipt and payment for that service or supply. Except as otherwise provided in paragraphs (A)(1) and (A)(2) of this rule, ...

...(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 medica...