Ohio Administrative Code Search

...(A) The bureau shall review all bills received from the MCO pursuant to paragraph (A)(1) of rule 4123-6-10 of the Administrative Code for payment eligibility. The bureau's review may include, but not be limited to, verification of the following: (1) The services were delivered, rendered, or directly supervised by providers who meet bureau credentialing and licensing criteria; (2) The bills conf...

...(A) An MCO shall retain records received from providers and subcontractors that are utilized by the MCO to perform its medical management functions, to substantiate the delivery, value, necessity, and appropriateness of goods and services provided to injured workers, and to develop electronic billings to the bureau. (1) The MCO shall retain records relating to a claim so long as the industrial co...

...(A) Pursuant to division (A)(1) of section 4121.441 of the Revised Code, this rule shall provide procedures for an alternative dispute resolution (ADR) process for medical disputes between an 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 exhaus...

...(A) Pursuant to division (A)(1) of section 4121.441 of the Revised Code, this rule provides procedures for an alternative dispute resolution (ADR) process for medical disputes between an 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...

...(A) Pursuant to division (L) of section 4121.44 of the Revised Code and division (A)(1)(f) of section 4121.441 of the Revised Code, the administrator shall require employees, employers, providers, MCOs, and plans that participate in the workers' compensation system to report data to be used by the administrator to: (1) Measure and perform comparison analyses of costs, quality, appropriateness of ...

...(A) Except as otherwise provided in rule 4123-6-21.6 of the Administrative Code, medication must be for the treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer. The bureau may deny a drug or therapeutic class of drugs as not being reasonably related to or medically nec...

...(A) Except as otherwise provided in rule 4123-6-21.6 of the Administrative Code, medication must be for the treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer. The bureau may deny a drug or therapeutic class of drugs as not being reasonably related to or medically nec...

...(A) Medication must be for treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer. (B) Medication 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 ...

...The bureau, or a self-insuring employer with a point-of-service adjudication system, may establish a coordinated services program (CSP) that requires an injured worker to obtain prescription medications reimbursed by the bureau or self-insuring employer from a single designated pharmacy and/or prescriber. (A) Placement in a CSP. (1) The bureau or self-insuring employer with a point-of-service adjudication system ma...

...The bureau, or a self-insuring employer with a point-of-service adjudication system, may establish a coordinated services program (CSP) that requires an injured worker to obtain prescription medications reimbursed by the bureau or self-insuring employer from a single designated pharmacy and/or prescriber. (A) Placement in a CSP. (1) The bureau or self-insuring employer with a point-of-service adjudicati...

...This rule governs the bureau's reimbursement of opioid prescriptions used to treat acute, subacute, and chronic pain in a work related injury or occupational disease. (A) Definitions. For purposes of this rule: (1) "Acute pain," "chronic pain," "morphine equivalent dose (MED)," and "subacute pain" have the same meanings as defined in rule 4731-11-01 of the Administrative Code. (2) "OARRS" mea...

...(A) When the claimant or any other person making payment on behalf of the claimant, including a volunteer, pays for medical services 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, ...

...(A) When the claimant or any other person making payment on behalf of the claimant, including a volunteer, pays for medical services 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 medica...

...(A) "Physical medicine" is the evaluation and treatment of a claimant by physical measures and the use of rehabilitative procedures, with or without assistive devices, for the purpose of preventing, correcting, or alleviating any work related disability. Physical medicine includes the establishment and modification of physical rehabilitation programs, treatment planning, instruction, and consultative services. "Physi...

...(A) "Physical medicine" is the evaluation and treatment of an injured worker by physical measures and the use of rehabilitative procedures, with or without assistive devices, for the purpose of preventing, correcting, or alleviating any work related disability. Physical medicine includes the establishment and modification of physical rehabilitation programs, treatment planning, instruction, and co...

...(A) Acupuncture. (1) Acupuncture is a recognized method of treatment in Ohio and must be administered by a licensed doctor of medicine, doctor of osteopathic medicine and surgery, or doctor of podiatric medicine who has completed a course of study in acupuncture under the administration of an approved college of medicine, college of osteopathic medicine and surgery, or college of podiatric medicine, doctor of chirop...

...(A) Acupuncture. (1) Acupuncture must be administered by a licensed doctor of medicine, doctor of osteopathic medicine and surgery, or doctor of podiatric medicine a doctor of chiropractic who holds a certificate to practice acupuncture from the Ohio state chiropractic board, or a non-physician acupuncturist licensed pursuant to and practicing in compliance with Chapter 4762. of the Revised Code....

...(A) Acupuncture. Acupuncture is eligible for reimbursement when prior authorized and administered by a licensed doctor of medicine, doctor of osteopathic medicine and surgery, or doctor of podiatric medicine, a doctor of chiropractic who holds a certificate to practice acupuncture from the Ohio state chiropractic board, or a non-physician acupuncturist licensed pursuant to and practicing in compl...

...This rule governs the identification and medical management of claims necessitating supportive care, including medical treatment reimbursement authorization. The objective is to ensure the timely and efficient provision of medically necessary and appropriate treatment reasonably related to the allowed conditions, in order to maintain or improve the injured worker's level of function, minimize or prevent reg...

...Effective January 1, 2018, reimbursement for lumbar fusion surgery for treatment of allowed conditions in a claim resulting from an allowed industrial injury or occupational disease shall be limited to claims in which current best medical practices as implemented by this rule are followed. This rule governs the bureau's reimbursement of lumbar fusion surgery to treat a work related injury or occupational ...

...Reimbursement for lumbar fusion surgery for treatment of allowed conditions in a claim resulting from an allowed industrial injury or occupational disease shall be limited to claims in which current best medical practices as implemented by this rule are followed. This rule governs the bureau's reimbursement of lumbar fusion surgery to treat a work related injury or occupational disease. It is not meant to ...

...This rule governs the bureau's reimbursement for health and behavior assessment and intervention (HBAI) services offered to injured workers who may benefit from an assessment that focuses on identifying behavioral barriers impeding the injured worker's recovery which may be addressed through intervention services. (A) An injured worker shall be eligible for consideration of health and behavior assessment...

...This rule governs the bureau's reimbursement for health behavior assessment and intervention (HBAI) services offered to injured workers who may benefit from an assessment that focuses on identifying behavioral barriers impeding the injured worker's recovery which may be addressed through intervention services. (A) An injured worker shall be eligible for consideration of HBAI services if the injured worke...

...Reimbursement for a spinal cord stimulator for treatment of allowed conditions in a claim resulting from an allowed work related injury or occupational disease is limited to claims in which current best medical practices as implemented by this rule are followed. This rule governs the bureau's reimbursement of a spinal cord stimulator to treat a work related injury or occupational disease. It is not meant t...

...(A) HPP. Except as provided in paragraphs (A)(7) and (A)(8) of this rule, reimbursement for hospital inpatient services with a discharge date of February 1, 2023 or after will be calculated as follows: (1) (a) Reimbursement for hospital inpatient services, other than outliers as defined in paragraph (A)(3) of this rule, services provided by hospitals subject to reimbursement under paragraph ...