Ohio Administrative Code Search

...n may be prescribed by any treating provider authorized by law to prescribe such medication; however, reimbursement for medication shall be denied under the following circumstances: (1) Reimbursement for prescriptions written by providers who are not enrolled with the bureau and who refuse to become enrolled shall be denied. (2) Reimbursement for prescriptions written by providers who are en...

...n may be prescribed by any treating provider authorized by law to prescribe such medication; however, reimbursement for medication shall be denied under the following circumstances: (1) Reimbursement for prescriptions written by providers who are not enrolled with the bureau and who refuse to become enrolled shall be denied. (2) Reimbursement for prescriptions written by providers who are en...

...n 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 approved for human use in the United States by the food and drug administration (FDA) and that are dispensed by a registered pharmacist. (D) A self-insuring employer may approve and reimburse for various drugs as a part of a...

...ers. 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 the mission and goals of the committee shall be developed and maintained by the chief medical officer. Providers may also be nominated for inclusion on the list by provider associations and organizations including but not ...

...ers. 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 the mission and goals of the committee shall be developed and maintained by the bureau. Providers may also be nominated for inclusion on the list by provider associations and organizations includ...

...cal 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 diversity to the mission and goals of the HCQAAC shall be developed and maintained by the chief medical officer. Providers may be nominated for inclusion on the list by provider associations and organizations including but not limite...

...cal 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 credibility and diversity to the mission and goals of the HCQAAC shall be developed and maintained by the the bureau. Providers may be nominated for inclusion on the list by provider associations and organizations including but not ...

...laim, and are rendered by a health care provider. Payment for services rendered to a claimant shall be paid to a health care provider only when the provider has either delivered, rendered or supervised the examination, treatment, evaluation or any other medically necessary and related services. Provider supervision of services shall comply with the requirements of the provider's regulatory board and the centers for m...

...d worker shall be paid to a health care provider only when the provider has either delivered, rendered or supervised the examination, treatment, evaluation or any other medically necessary and related services. Provider supervision of services shall comply with the requirements of the provider's regulatory board and the centers for medicare and medicaid services (CMS), if applicable, for supervisi...

...s 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, the payor will receive no more than the amount that would have been paid to the health care provider as provided by this chapter. ...

...s 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...

...A provider treating an injured worker may, at any time, make a request in writing, facsimile, or e-mail, in accordance with the bureau's confidentiality and sensitive data requirements, for relevant information concerning conditions, treatment or history for the claim. The request for information shall be accompanied by an appropriate patient release of medical information. A prompt response will be given to this re...

...an of record or other approved treating provider licensed to practice medicine, osteopathy, chiropractic, mechanotherapy, dentistry, podiatry, or nursing clinical nurse specialist, certified nurse midwife, or certified nurse practitioner, or license to practice as a physician assistant. Physical medicine may be provided in the physician's office or referred to another licensed provider. (C) To be eligible for reimbu...

...an of record or other approved treating provider licensed to practice medicine, osteopathy, chiropractic, mechanotherapy, dentistry, podiatry, or a certified registered nurse anesthetist, nursing clinical nurse specialist, certified nurse midwife, certified nurse practitioner, or physician assistant. Physical medicine may be provided in the physician's office or referred to another licensed provid...

...tices when treating injured workers. A provider's failure to comply with the requirements of this rule may constitute endangerment to the health and safety of injured workers, and claims involving lumbar fusion surgery not in compliance with this rule may be subject to peer review by the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) pursuant to rule...

...tices when treating injured workers. A provider's failure to comply with the requirements of this rule may constitute endangerment to the health and safety of injured workers, and claims involving lumbar fusion surgery not in compliance with this rule may be subject to peer review by the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) pursuant to rule...

...32 of the Administrative Code. (B) Providers must indicate the appropriate "International Classification of Diseases, clinical modification" codes for the injured worker's allowed physical condition(s) being treated, and must utilize the applicable codes, from the edition of the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) in effect on the date...

...32 of the Administrative Code. (B) Providers must indicate the appropriate "International Classification of Diseases, clinical modification" codes for the injured worker's allowed physical condition(s) being treated, and must utilize the applicable codes, from the edition of the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) in effect on the date...

...ude, or substitute for, the health care provider's responsibility to exercise sound clinical judgment in light of current best medical practices when treating injured workers. (A) As used in this rule, "concussion" means a type of traumatic brain injury induced by external force, which might include a bump or blow to the head, or a jolt or hit to the body, which causes the brain to bounce around or t...

... 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 ...

...e injured worker, the hospital, and the provider of record that continued use of the emergency room for non-emergent services will not be reimbursed. (E) The bureau may establish the same or different fees for in-state and out-of-state hospitals based on the above reimbursement methodologies. (F) Payment will be made for hospital services in accordance with rule 4123-6-10 of the Administrative Code.

...jured worker, the hospital, and the provider of record that continued use of the emergency room for non-emergent services will not be reimbursed. (E) The bureau may establish the same or different fees for in-state and out-of-state hospitals based on the above reimbursement methodologies.

...dicare and medicaid services' inpatient provider specific file (IPSF). (B) QHP or self insuring employer (non-QHP): A QHP or self-insuring employer may reimburse hospital inpatient services at: (1) The applicable rate under the methodology set forth in paragraph (A) of this rule; or (2) (a) For hospitals the department of health and human services, centers for medicare and medicaid services...

... access hospitals; changes to medicaid provider enrollment; and changes to the medicare shared savings program final rule," 86 Fed. Reg. 44774 - 45615 (2021). (c) The department of health and human services, centers for medicare and medicaid services' hospital-specific cost-to-charge ratio information as of the July 2021 update to the department of health and human services, centers for medicare...

...dicare and medicaid services' inpatient provider specific file (IPSF). (B) QHP or self insuring employer (non-QHP): A QHP or self-insuring employer may reimburse hospital inpatient services at: (1) The applicable rate under the methodology set forth in paragraph (A) of this rule; or (2) (a) For hospitals the department of health and human services, centers for medicare and medicaid services...