Ohio Administrative Code Search

...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...

...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...

...tain 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 . Providers may be nominated for inclusion on the list by provider associations and organizations including but not limited to: deans of Ohio's allopathic a...

...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...