Ohio Administrative Code Search

...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...

...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 claims management...

...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 ...

...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...

...ervices 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 provider in the MCO's ...

...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...

...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...

...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 ...

...ify or recertify or may decertify a provider, MCO, or QHP as provided in this chapter. (B) The bureau will monitor and may investigate a provider, MCO, or QHP, 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 will afford the ...

...(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...

...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...

...ept as provided in this rule, a medical provider shall not assess a fee or charge the bureau, industrial commission, MCO, QHP, self-insuring employer, injured worker, 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 access to all fi...

...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...