Ohio Administrative Code Search

... designation in the medicare outpatient provider specific file in effect implemented by the materials specified in paragraph (A)(10) of this rule. For purposes of this rule, the following hospitals are recognized as "children's hospitals": nationwide children's hospital (Columbus), Cincinnati children's hospital medical center, shriners hospital for children (Cincinnati), university hospitals...

...e appendix to this rule, developed with provider and employer input and effective May 1, 2023. Ambulatory surgical centers determined as of the effective date of this rule by the centers for medicare and medicaid services (CMS) to not meet quality measures for the calendar year 2023 full payment update under the CMS ambulatory surgical center quality reporting (ASCQR) program, established by 42 U.S.C. 1395...

...e appendix to this rule, developed with provider and employer input and effective May 1, 2022. Ambulatory surgical centers determined as of the effective date of this rule by the centers for medicare and medicaid services (CMS) to not meet quality requirements for the calendar year 2022 full payment update under the CMS ambulatory surgical center quality reporting (ASCQR) program, established by 42 U.S.C. ...

...e appendix to this rule, developed with provider and employer input and effective May 1, 2021. Ambulatory surgical centers determined as of the effective date of this rule by the centers for medicare and medicaid services (CMS) to not meet quality requirements for the calendar year 2021 full payment update under the CMS ambulatory surgical center quality reporting (ASCQR) program, established by 42 U.S.C. ...

...e appendix to this rule, developed with provider and employer input and effective May 1, 2025. Ambulatory surgical centers determined as of the effective date of this rule by the centers for medicare and medicaid services (CMS) to not meet quality measures for the calendar year 2025 full payment update under the CMS ambulatory surgical center quality reporting (ASCQR) program, established by 42 U.S.C. 1395...

...me health agencies. Home health agency providers must maintain records which fully document the extent of services provided to each claimant. All records must be maintained in accordance with the conditions of participation required for medicare certification, joint commission accreditation, or community health accreditation program (CHAP) accreditation, or accreditation through an organization that has been granted...

...interdisciplinary group of professional providers led by a physician with a specialty in physical medicine and rehabilitation, orthopedic surgery or vascular surgery knowledgeable in the field of prosthetics and physical disabilities, comprised of members that may include a podiatrist, physical therapist, occupational therapist, kinesiotherapist, prosthetist and other medical specialists that serves individuals requi...

...interdisciplinary group of professional providers led by a physician with a specialty in physical medicine and rehabilitation, orthopedic surgery or vascular surgery knowledgeable in the field of prosthetics and physical disabilities, comprised of members that may include a podiatrist, physical therapist, occupational therapist, kinesiotherapist, prosthetist and other medical specialists that serv...

...(A) Direct payment to a health care provider or other person by the industrial commission, self-insuring employer, bureau of workers' compensation, or their agent, for medical care rendered to a claimant does not imply or create a legal relationship between the provider or person and the commission, self-insuring employer, bureau, or their agent. (B) The services rendered to the claimant are the legal obligation of ...

...(A) Direct payment to a health care provider or other person by the industrial commission, self-insuring employer, bureau of workers' compensation, or their agent, for medical care rendered to an injured worker does not imply or create a legal relationship between the provider or person and the commission, self-insuring employer, bureau, or their agent. (B) The services rendered to the injured ...

...tween the bureau, or its agent, and the provider. Payment will be made either thirty days after the bureau, or its agent, receives a proper invoice for the amount of the payment due, or thirty days after the final adjudication allowing payment of an award to the claimant, whichever is later. (1) A "proper invoice" includes but is not limited to the claimant's name, claim number, date of injury or occupational diseas...

...rom the physician of record or treating provider that includes medical documentation substantiating the continued medical necessity and effectiveness of the unit. (3) To be eligible for reimbursement under this rule, the TENS unit must be prescribed by a physician and furnished by a provider holding a current, valid, license or certificate of registration from the Ohio respiratory care board to s...

...the physician of record or treating provider that includes medical documentation substantiating the continued medical necessity and effectiveness of the unit. (3) To be eligible for reimbursement under this rule, the TENS unit must be prescribed by a physician and furnished by a provider holding a current, valid, license or certificate of registration from the state of Ohio board of pharmacy to s...

...ureau fees for in-state or out-of-state providers will be established by the administrator of workers' compensation with the assistance of the bureau's medical management and cost containment division. The bureau may establish different fees for in-state and out-of-state providers. The methods of payment may include rates based on resource based relative value scale (RBRVS), percent of allowed charges, or usual, cust...

...ureau fees for in-state or out-of-state providers will be established by the bureau. The bureau may establish different fees for in-state and out-of-state providers. The methods of payment may include rates based on resource based relative value scale (RBRVS), per cent of allowed charges, or usual, customary and reasonable fee maximas, as determined by the bureau. Rates will be reviewed at least annually by...

...(A) Providers' patient and billing related records, including but not limited to those records described in rule 4123-6-45.1 of the Administrative Code, may be reviewed by the bureau or the MCO to ensure workers are receiving proper and necessary medical care, and to ensure compliance with the bureau's statutes, rules, policies, and procedures. (1) Based on division (B)(16)(c) of section 4121.121 of the Revised Code...

...(A) Providers' patient and billing related records, including but not limited to those records described in rule 4123-6-45.1 of the Administrative Code, may be reviewed by the bureau or the MCO to ensure workers are receiving proper and necessary medical care, and to ensure compliance with the bureau's statutes, rules, policies, and procedures. (1) Based on division (B)(15)(c) of section 4121...

...(A) A health care provider shall create, maintain, and retain sufficient records, papers, books, and documents in such form to fully substantiate the delivery, value, necessity, and appropriateness of goods and services provided to injured workers under the HPP or of significant business transactions. The provider shall retain such records for a minimum period of five years from the date of paymen...

...(A) A health care provider shall create, maintain, and retain sufficient records, papers, books, and documents in such form to fully substantiate the delivery, value, necessity, and appropriateness of goods and services provided to injured workers under the HPP or of significant business transactions. The provider shall retain such records for a minimum period of three years from the date of payment for said goods or...

...ntialing and recredentialing and use of provider profiling; (3) Utilization management to determine the appropriateness of care; (4) Evaluation of employee and provider dispute resolution procedures and outcomes; (5) Evaluation of outcomes of care based on clinical data; (6) Procedures for remedial action for inappropriate or substandard services; (7) Evaluation of employee satisfaction with the plan; (8) Evalu...

...hall include a list of bureau certified providers in the QHP's provider network. (C) The QHP application for certification shall include, at a minimum, the following provisions, as more fully detailed within the QHP certification application itself: (1) A statement that the application is without misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, ...

...ontainment services shall not require a provider to participate in a workers' compensation network of providers in order to maintain membership in a related health care program. If the QHP utilizes a leased provider network, the QHP shall not apply the discounted payment rates of the leased network to services rendered by the provider in the QHP unless the signed, written consent of the provider has been obtained.

...ement standards of credentialing of providers in the QHP network that meet but may exceed the bureau credentialing requirements in the HPP. (B) An employer that develops a QHP may selectively contract with providers or contract with a vendor that selectively contracts with providers. (C) Only a bureau certified provider is eligible for selection by an employer that develops a QHP, by a QHP as a ...

... and an employer, an employee and a provider, or an employer and a provider. This rule applies to, but is not limited to, reviews of records, medical disputes arising over issues such as, but not limited to, quality assurance, utilization review, a determination that a service provided to an employee is not covered, is covered or is medically unnecessary; or disputes involving individual health ...

... and his or her representative, and the provider. All parties providing or requiring such confidential information for use in the QHP system shall not provide or use such confidential information for any purpose other than to perform duties required under the QHP system, and shall prevent such information from further disclosure or use by unauthorized persons.