Ohio Administrative Code Search

...n a public list of bureau certified providers. The bureau shall make the list of bureau certified providers available through the bureau's website. (B) An MCO may, but is not required to, retain a panel of bureau certified providers. A bureau certified provider is eligible to participate on an MCO's provider panel. A bureau certified provider may participate in a single MCO panel or may participa...

...ollment of and decertify a non-facility provider who has failed to comply with a workers' compensation statute or rule. (1) If the bureau determines a provider has committed three or more reported violations of the same workers' compensation statute or rule in a six month period, or five or more reported violations of any workers' compensation statute or rule in a six month period, the bureau sha...

...r initial visit of an injured worker, a provider must report the employee's injury or occupational disease in accordance with either paragraph (A)(1) or (A)(2) of this rule. (1) A provider may report an injury to the MCO responsible for medical management of the employee's treatment. When reporting the injury to the MCO, the provider shall do so in accordance with procedures established by the bu...

...(A) No bureau certified or enrolled provider shall engage in any advertising or solicitation directed to injured workers which is false, fraudulent, deceptive, or misleading. (B) No bureau certified or enrolled provider shall hire, arrange for, or allow any other individual or entity to engage in any advertising or solicitation directed to injured workers on behalf of the provider which is false,...

...The bureau may enroll non-certified providers eligible under rule 4123-6-06.2 or 4123-6-10 of the Administrative Code or division (N) of section 4121.44 of the Revised Code to receive reimbursement for goods and services provided to injured workers, and for this purpose may require such non-certified providers to complete and sign an enrollment application as the bureau deems appropriate, provided...

...(A) To be eligible for participation in the HPP as an ambulatory surgical center arthroplasty center, an ambulatory surgical center must comply with the following minimum criteria: (1) The facility must be bureau certified as an ambulatory surgical center under paragraph (C) of rule 4123-6-02.2 of the Administrative Code. (2) The facility must have a formal joint replacement program which has be...

... from participation in the HPP, any provider or entity that: (1) Is owned, directly or indirectly, by an individual or entity that has been convicted of or pleaded guilty to a criminal offense as set forth in the appendix to rule 4123-6-02.2 of the Administrative Code. The provider or entity is ineligible for enrollment, certification, or recertification for the same period of ineligibility p...

...hall include a list of bureau certified providers in its provider panel and/or bureau certified providers with which the managed care organization has arrangements. (C) The MCO application submitted to the bureau by the managed care organization shall include the following, whether the managed care organization elects to retain a provider panel or enters into provider arrangements: (1) A description of the managed ...

...hall include a list of bureau certified providers in its provider panel and/or bureau certified providers with which the MCO has arrangements. (C) Regardless of whether the MCO elects to retain a provider panel or enters into provider arrangements, the application submitted to the bureau by the MCO shall include the following: (1) A description of the MCO's health care provider panel or prov...

...o recertify an MCO, any obligation of a provider to provide services under the HPP pursuant to a contract or agreement with such MCO shall be null and void.

...t 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 c...

...uring the adjudication process, the provider may continue to render or the MCO may continue to manage medical services on behalf of the employee, but the bureau shall not pay for medical services in a disallowed claim or for disallowed conditions. If the claim or condition is disputed, the MCO shall inform the employee and the provider that the services provided may not be covered by workers' comp...

...CO's referral of injured workers to any provider for the provision of any goods or services. (D) An MCO that violates this rule may be subject to decertification and/or termination of its contract pursuant to the rules of this chapter of the Administrative Code.

...al injury from: (a) A bureau certified provider; or (b) A non-bureau certified provider, subject to an employee's payment responsibilities as delineated below. (2) Except in cases of emergency, an injured employee may not seek medical care for an industrial injury from himself, herself, or an immediate family member. An injured employee may not select as physician of record, himself, herself, or an immediate famil...

...ed injury from: (a) A bureau certified provider; or (b) A non-bureau certified provider, subject to an employee's payment responsibilities as delineated in this paragraph. (2) Except in cases of emergency, injured workers may not seek medical care for work related injuries from themselves or an immediate family member. Injured workers may not select as physician of record, themselves or an imme...

...s, develops, maintains, and publishes a provider fee schedule for the various types of billing codes. The administrator hereby adopts the professional provider fee schedule indicated in the appendix to this rule. (B) Whether the MCO has elected to retain a provider panel or not, an MCO may contract with providers. The MCO shall provide an MCO fee schedule to each provider that contracts with the ...

...ces 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 valid, complete bill from the provider. (2) For a provid...

...ed, rendered, or directly supervised by providers who meet bureau credentialing and licensing criteria; (2) The bills conform to the bureau's billing and reimbursement manual in effect on the billed date(s) of service. (B) The bureau shall electronically transfer funds to the MCO for allowed payments after receipt of a proper invoice and after a final adjudication permitting payment for the bill...

...njured worker's representative, the provider, and the provider's employees and agents. All such parties receiving and/or exchanging confidential information for use in the HPP shall ensure transmission of confidential information through secured methods approved by the bureau, including but not limited to encryption, password protection, facsimile, and other secure methods. (C) All parties receiv...

...n 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 ADR procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code on an MCO's decision regarding a medical treatment reimbursement request. (B) With...

...9 or equivalent) must be submitted by a provider eligible to submit such requests to the MCO responsible for medical management of the claim prior to initiating any non-emergency treatment. The following provider types are eligible to submit medical treatment reimbursement requests to the MCO: (1) A physician as defined in rule 4123-6-01 of the Administrative Code; (2) The following non-physici...

...or medical management of claim by a provider eligible to submit such requests, without just cause, for non-emergency treatment delivered, rendered, or directly supervised by the provider shall, if approved, be reimbursed at seventy-five per cent of the applicable fee schedule amount, provider may not balance bill the injured worker for the difference in amount. (B) For purposes of this rule, "jus...

...ify or recertify or may decertify a provider or MCO as provided in this chapter. (B) The bureau shall monitor and may investigate a provider or MCO, and may participate with other state or federal agencies or law enforcement authorities in gathering evidence for such matters. (C) Prior to the administrator issuing an adjudication order on the matter, the administrator shall afford the provider ...

...(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...

...as provided in this rule, a medical provider shall not assess a fee or charge the bureau, industrial commission, MCO, QHP, self-insuring employer, claimant, employer, or their representatives for the costs of completing any bureau form or providing any documentation requested pursuant to rule 4123-6-20 of the Administrative Code. (1) The bureau shall provide authorized parties to the claim ac...